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How do I tell if a program is malignant?

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Of course if you read what they write on their website and drink their promo Koolaid no program is malignant (think how T cells get fooled by tumor expressing PDL1). Maybe Canadian programs aren't as bad as some US programs, but even if they're not malignant some have at least high grade dysplasia. Here's just my 2c:

- ask how they've responded to COVID and changes in last 2 years. Obviously a lot places have increased workload and disrupted schedule etc. But also see how residents feel about it, for example are increased workload just dumped onto residents? are seniors dumping workload onto juniors? is there admin and other support for the increased workload?

- watch out for places that are shrinking or not hiring additional faculty in face of constantly increasing workload. faculty turnover can be a big red flag for culture of that hospital/admin. if faculty are struggling to cope with work volume no doubt that trickle down economics is gonna get to the residents.

- conversely if there is disruption in lecture, teaching or availability of elective, ask how residents are coping with it. Is it swim or sink? do faculty care about how residents are progressing? also do faculty actually make an effort to help residents progress? watch out for faculty who micro manages resident's progress, but never make meaning contributions (aka your knowledge is deficient, so go memorize this 1500 page book and come back with encyclopedic knowledge)

- ask about exam pass rate and exam support. not enough attention is paid by candidates on this. If you fail your boards it's a huge deal. both formal support by program, as well as support by senior / co-residents are equally important. If a program expects you to pay for your own book or question bank, that tells u something. If co-residents or senior residents are hesitant to share "mock" exam questions with you, that tells u something. If senior residents never teach anything to juniors and just expect juniors to work, that tells u something.

- if a program doesn't mention how many residents are in each year, try to find that out, especially for smaller programs. If a program is supposed to have 2 each year x 5 years, but only has 7 or 8, what happened to the others? if they're on mat leave or something, fine. If they transferred out, that's worth chewing on. 

- if a program is a weird structure, eg they have extra PGY3 but missing PGY4s, it could be due to mat leave, sick leave, grad degree etc. But it could also be that some residents failed a year and are repeating a year. It's very blunt to ask if any residents are struggling in that program so it might need to be asked tête-à-tête / sotto voce.

- a less discussed point, ask what kind of jobs past residents have landed on, especially for smaller programs. If PGY4s are pre approved for a job, that says something about the quality of training and reputation. If PGY5s are scrambling for fellowship with no backup, that says something. If somebody is staying in their own program for fellowship, not because they wanted to, but because they couldn't get fellowship elsewhere or cannot find a job, that tells u something.


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