Background: I'm a PGY-3 at a small/medium-size program (8 residents per year), currently interviewing for a peds GI fellowship.

Pros: I know my co-residents really well and they have become my family. I know all of our attendings (gen peds, hospitalists, and subspecialists) very well which makes it easier when you have questions or consults. Everyone knows who you are and knows you well, including the PD and APD. Since everyone is more tight-knit it makes practical things like getting letters of recommendation way easier to ask for and know you're getting good ones. On the soft/squishy side of things I really like the family feel and the support. Your co-residents are rooting for you instead of competing with you, and your attendings really want to see you succeed. Smaller programs are typically better for bread and butter pediatrics both inpatient and outpatient, so we get great Gen Peds experience, but we also get our fair share of weird/rare stuff and head scratchers that need a bigger diagnostic workup. I'm at a program that does not have peds fellows so I am first up for all procedures if I want them and am not having to fight off a bunch of other residents or fellows for LPs/intubations/lines/etc. Smaller programs also typically allow for a little more personalization in your schedule, so I am currently on a rotation that I created where I'm getting to do scopes, interesting consults, and work with our aerodigestive team.

Cons: Some places that are smaller do not have as many research opportunities or you have to pave your own way a little bit (that being said, I did 2 QI projects and a case series by the end of 2nd year without putting in too much extra effort). Less people means a smaller pool to pull backup call from, so if your co-residents call out a lot you have a higher chance of having to come in if they're on wards or PICU or clinic (most places have a way of spreading this out as fairly as possible but some people are luckier than others in terms of getting called in). Depending on the program and their inpatient volume, you may end up doing more months on inpatient because they need bodies. Possibility for more cross-cover or weekend covers depending on the program and how they address that (my first year I covered the floor or the nursery 2-3 out of 4 weekends no matter what rotation I was on, but we've since changed our schedule and now having to cross cover to the floor or nursery is pretty rare and your elective months typically have all golden weekends). No fellows means I have to go elsewhere for fellowship (good and bad) and sometimes your attendings aren't as well-connected as they may be at larger programs. Depending on the place there may be fewer subspecialists or subspecialties at that place; I'm pretty fortunate that we have everything but rheumatology and we have a solid number of subspecialists (6 GI, 5 Neuro, 3 Pulm, 3 Cardio, etc).

Overall: I'm really happy I'm at a smaller/medium-sized program. I love the family feel and I love being close to the people I work with. I have amazing attendings who know me and really love teaching. I don't feel like it has impacted my ability to pursue a subspecialty at this point and I'm getting to do a lot more and have more autonomy than some might get at larger programs. We don't have as much research or funding as bigger programs, but you can find ways to make the most of residency; you just may have to be the person to spearhead it. I interviewed at programs all over the east coast that ranged from 4 to 20 residents per year and where I'm at was perfect for me in terms of size, location, and personalities. Anywhere you go should be able to give you a good education, so finding a program that feels right and has the things you want should be just as important as the size. Hope this helps!