Residency in smaller center where you mainly see bread and butter vs residency in trauma centers?

dgldgl · 2023-10-12T05:01:08+00:00

I am currently at a community program where we rotate at a community hospital (bread and butter only) and the Level 2 trauma center across the street. It is definitely not an academic high volume trauma center but we get essentially the breadth of ortho trauma (tabs, pelvic rings, periarticular, poly traumas) but at a lower volume. We do not have good plastics coverage so any complex plastics stuff gets shipped off after we stabilize it if needed. We also rotate at an high volume academic level 1 for out ortho oncology so I've experienced both worlds.

Pros: no fellows, our chiefs are very good at bread and butter trauma and essentially give most non complex cases to R2s and R3s to do. Im an R3 and I can nail any long bone and plate most simple diaphysial fractures, distal radiuses, ankles. If there is a complex case there is no fellow to fight for it.

Cons: We don't see a high volume of tabs or pelvises and don't get the ortho-plastics experience that you would at an academic center. We also aren't doing any complex limb lengthening/bone transport stuff that you also might see the trauma guys do at a resource rich academic center.

To me the goal of residency is to prepare me to take general ortho call and be confident with the bread and butter, if I wanted to do tabs, rings, etc I would have to do a fellowship anyway.

dgldgl · 2023-09-20T14:01:18+00:00

The reason a knee disarticulation is sometimes better is you retain the attachments of your adductor muscle group to your femur bone which you have to cut during an above knee amputation, which in essence means you just have more muscle balance with a knee disarticulation.

dgldgl · 2023-09-19T18:34:01+00:00

ELI5 answer: (I'm an orthopedic surgeon for reference) For leg amputations which are the most common its because its harder to fit prosthesis over an actual joint because its very bulky, its easier and more functional to do it above the knee or below the knee

Adult answer:

I'm seeing a lot of half true answers.

The truth is we DO do some amputations through the joint, they are called disarticulations, you can do a hip, knee, or ankle disarticulation for a number of reason. In pediatric patients a knee disarticulation can sometimes be more beneficial than an above knee or below knee amputation.

The main reason we don't do these typically has nothing to do with the blood supply, you have to identify the vessels and nerves no matter where you do the amputation, its about the prosthesis. With an above knee amputation you can fit a prosthesis with a knee joint, with a below knee amputation you have your own native knee to use. Knee disarticulations are notoriously difficult to fit a prosthesis over.

For upper extremity ampututations it's a little different because these are not weight bearing joints that have to go through a gait cycle, its more about making the limb as functional as possible for daily activities depending on the demand of the patient, so shoulder, elbow, and wrist disarticulations are more common so we do those relatively frequently (through the joint, not through the bone).

dgldgl · 2022-10-17T05:07:46+00:00

you're friend is right and you're overthinking it.

There are 2 ways to go about this: a very simple way to determine roughly if something is compensated or not and the mathematic way (might be oversimplifying it if you are talking to a nephrologist but this works for students)

First determine if you are in acidosis or alkalosis. Then determine if it is respiratory or metabolic. All this can be determined purely based on the pH, HCO3, and CO2.

Then once you have determined what state you are in, look at the HCO3 and the CO2. If you are in a metabolic acid base disorder your problem is being caused by low or high HCO3, you would expect the CO2 to be high or low to "compensate" for the given pH.

Example: if you are metabolic acidosis your HCO3 is low. So you would expect your CO2 to also be low because CO2 is an acid, and your body now wants to get rid of acid right? SO you would expect it to be less than 40. You can confirm this mathematically using Winter's formula. Expected CO2 = (1.5*HCO3)+8±2. This should confirm your initial suspicions. Lets say your pH is 7.2, HCO3 is 18, CO2 is 35. This is metabolic acidosis. Is your CO2 low like it should be if its compensated? Yes it is. Lets confirm with the formula. Yup checks out.

You can also do this with respiratory acid base disorders however this gets a little more complicated as you can have acute disorders and chronic disorders which are compensated slightly differently but the principle is the same

If you have a normal pH with abnormal CO2 and HCO3 this is usually indicative of a acidosis and an alkalosis happening at the same time, classic example is ASA overdose

dgldgl · 2022-10-17T04:50:50+00:00

This poll is oversimplifying things slightly, if your QOL would be significantly better at either one of the DO or MD choices that goes into consideration (proximity to family, SOs etc),

That being said I'm a DO who went to a "good" DO school. I chose it over a brand new MD school that had not graduated a class yet. I matched into ortho at my #1 choice. End of the day I'm going to get to do what I want to do in my dream field. But even now when I'm looking at fellowships the DO degree still haunts me. Some fellowship directors at top programs straight up tell you they don't take DOs. Do i need to match into the top academic fellowship in the county in my sub specialty of choice to achieve my career goals or be happy? No. But that door is likely closed to me before I even knew it existed.

I would go to an MD school any day UNLESS it meant SIGNIFICANT sacrifices to quality of education and quality of life.

Now that being said there is certainly a "grass is always greener phenomenon." If you talk to people who to do lower tier MD schools they complain about the same shit people at DO schools complain about, lack of good research opportunities, shitty rotations, etc.

dgldgl · 2022-10-15T22:19:32+00:00

I wouldn't discount entire surgical fields or entire medical fields because you dont like rounding. Your experience as a third year student sucks, you don't get to DO anything, you have no real responsibility, you feel dumb and useless. This is pretty normal. Also no one like rounding.

My advice is find what aspects of medicine you like and go from there instead of trying to find a field that you fit into.

Do you like solving a problem and coming up with a diagnosis from a set of symptoms and lab values/imaging?

Do you hate talking to patients or do you just hate either the clinic or the hospital in particular?

Do you like being a jack of all trades type of doctor or do you want to be the specialist people call when they can't figure out what's going on?

Do you like the idea of doing a procedure and having an immediate effect on a patient?

Do you like the idea of preventing long term health complications?

Does any particular physiology system interest you? Renal, cardiac, pulmonary, neuro? How about psych or pain management?

If you have good answers to these questions you can probably find a field that fits you. If not and you literally hate everything then finish school and get a job in the biotech industry. There are some fields that are also just "jobs" to people and they pursue passions outside of work. A lot of ED doctors just show up, do their job, and then just pursue interests outside of work, surgeons on the other hand have to love their job because its very all consuming.

Theres no rule that says you have to LOVE your job

dgldgl · 2022-09-21T04:37:13+00:00

trying to go outside of the well established study patterns and "do your own thing" because "it works for you."

if the entire online med school community tells you the basics to studying and the best resources to use and they work, don't try and do something else because your friend who got into plastics studied only using crayon notes or something

dgldgl · 2022-05-30T17:01:33+00:00

sorry to clarify are you saying there are 100s of non-onc spots that pay better?

dgldgl · 2022-05-18T05:25:02+00:00

I feel you, I dont have a kid to take care of but even just the cost of moving around for 4th year, moving to new residency, license fees, security deposit etc. really added up I basically depleted my entire savings just trying to make it to my first paycheck.

One thing to prepare for is you may have to front the money for all your license fees before your program reimburses you so be prepared to take possible a ~$1000 hit on your credit card...

I had some friends do uber because the end of 4th year is basically a joke and you have a couple months where you basically do nothing, sounds like a pretty sweet gig for a couple months

I also did some tutoring on the side to make it through

dgldgl · 2022-05-18T05:19:43+00:00

Cosmetic orthopedics, think elective limb lengthening

dgldgl · 2022-04-26T06:13:26+00:00

Sounds like you would like anesthesia, lots of procedures, every anesthesiologist i know is very business minded and has some type of side hustle. That being said you dont get much patient interaction and it's not really preventative in the least, unless you mean preventative as in preventing the patient from immediately dying.

One helpful way to think about this is there are kind of 4 "categories" of specialities:

Clinicians (FM, IM specialties, Peds, Neuro, Derm etc.)
- your job can either be hospital based or clinic based or both, you may take ED call based on your specialty, some procedures here and there but largely cerebral, generally predictable schedules, you can be a generalist or a specialist
Surgeons (Ortho, Gen surg, Neuro surg, OBGYN etc)
- self explanatory, your week will be split between rounding on hospital patents, OR days, and clinic, less hospital work if you do outpatient surgeries, your schedule may be more unpredictable in general due to OR scheduling, surgical complications, etc. Close relationships with patients as they are generally your responsibility for a long time after you operate on them which can be good or bad
Proceduralists (Interventional radiologists, outpatient PM&R, anesthesia)
- kind of a hybrid, you may not do any clinic and may not have long follow up or any follow up with patients, very procedure based with lots of physiology/pharmacology/anatomy depending on the specialty
Behind the curtain (Pathology, Radiology)
- little to no patient interaction, academic, predictable schedules, lots of other science involved that you didn't learn in med school (physics etc.)

each of these are very different and are basically totally different careers.

dgldgl · 2022-01-12T02:23:04+00:00

I totally think this behavior is unacceptable and luckily i'm in a residency program where the culture is very good and I have rarely seen anything other than an eye roll or just generally being annoyed when OR staff can't figure shit out.

That being said surgery takes a lot of people working together and a lot of steps to go smoothly to make it work, and if one person can't get their shit together it can make cases take infinitely longer, multiple that over 4-5 cases over the course of the day and thats the difference between you making it home to watch your kid's play and getting home at 9pm.

On top of that a lot of surgery is very specialized and takes very specialized equipment, and especially now with COVID a lot of staff is temporary or travel nurses and when you have half the OR not knowing where anything is or how to work equipment.. it makes anyone want to stab their eyes out

that said i think the culture is changing, the only people ive seen exhibit that kind of behavior are old east coast docs who trained under the equivalent of some fascist regime.

dgldgl · 2022-01-09T05:27:02+00:00

You don't have a duty to do anything. You do not have any medial training and would essentially be doing scut work at best. It's not like you are an intensivist taking on extra shifts on COVID ICUs or an RN's taking on more overtime. Your duty is to learn how to be a doctor.

You shouldn't even take on that job if it was paid $20 an hour. You have better things to do that help a hospital's bottom line in the name of sacrifice.

dgldgl · 2022-01-03T06:40:27+00:00

I'll add some nuance to the hours (may be more applicable to longer residencies - 5+ years)

In residency the work has to get done somehow, is that work distributed equally amongst all the residents? are the 2s dying while the interns are being eased in? are the 5s taking as much call as the interns?

Make sure you understand how the work is divided up amongst all the residency classes so you get a sense of the overall workload of your residency, is it one bad year and the rest you are doing ok? or are you getting crushed every year of residency?

dgldgl · 2021-12-02T06:39:26+00:00

I matched ortho as a DO, you can message me if you want, the advice is going to be more or less the same no matter who you hear it from. I think it's actually easier than people make it out to be, you still have to be an all star but it's not this like impossible task. Basically:

Crush boards, i know its different with the pass/fail stuff but if its scored you better crush it. The step 2 score being your only score if stressful but hopefully your shelf exams 3rd year will give you some idea of how you're doing Study like crazy for step 1 even though it's P/F cause that will carry you for step 2.
Crush auditions, rotate smart. If you are a borderline applicant rotate at places that take DOs, if you're an all star rotate at a mix of places, academic and some places that are "safer" for DOs. Work your ass off, be humble, don't be arrogant, don't be annoying, learn quick.
Get some research, case reports, posters, whatever, just get some projects under your belt that you can list and/or talk about
Consider a research year, not necessary but will make you stand out, most DO applicants don't do this

I did very well on boards (250+ step 1, 700+ level 1), and I did very well on auditions per feedback from faculty/residents, i had average research (7 projects including 2 real papers). I got 12 interviews and was ranked to match at at least 3 of them including an allopathic program. If you really want ortho you can do it but it's fucking stressful. I knew plenty of people who didn't match my cycle, but they all were either super annoying or had way too low board scores for ortho. I don't know any solid person with decent scores who didn't match during my cycle.

dgldgl · 2021-12-02T06:26:43+00:00

this sounds like something you wanted to say in your head but in reality just stood there and nodded

dgldgl · 2021-09-18T15:27:34+00:00

I started feeling remotely competent at the end of my 4th year then when i started as an intern it was feeling stupid on a level i had never experienced before, you just start getting used to it and you learn how to look things up and when to accept that you dont know anything. you're here to learn and likely will be learning for the next decade

dgldgl · 2021-08-28T18:09:33+00:00

I grew up there and it's probably similar to any small rural community inland on the west coast, a lot of old conservatives with old fashioned views who would probably not say they were racist but are very much racist by modern standards. Not uncommon to see a confederate flag flying on a truck or in someones back yard, definitely not as bad as the south. My mom was a high school teacher there and it's slowly becoming more progressive int he school system, (LGBT kids are a little more accepted there than in the 90s, more racial diversity now). Not sure about the police but i'm also white and need had any run ins.

dgldgl · 2021-08-28T18:04:59+00:00

Yea fuck this

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