When my friend opened her email and saw the words “Mayo Clinic” on the screen before her, she was shocked. She was going to be a trainee at one of the most exalted of elite institutions. Those who do not work in medicine are less aware that every institution — whether associated with a college, university, or privately-funded — varies in its prestige. People often assume the Harvards and Yales are the best at everything, not necessarily realizing that the top hospitals for orthopaedics or heart bypasses, to name just two examples, are affiliated with neither. But for those of us within medicine, we generally recognize the well-recognized from the obscure, and may even secretly judge people based on the caliber of their training institutions. 

As someone who was a middle-of-the-road medical student and attended state schools, I always wondered what the elite experience in medicine was like. Did statisticians walk out of the walls the second you had a research question? Did things magically happen more easily when you wanted to coordinate something to improve patient care? Was the coffee slightly better and the peanut butter and cracker supply endless? 

Both my friends and I have trained at elite institutions, and together, we have been fortunate enough to compare experiences, evaluating elite medical institutions and their community counterparts. After sharing and discussing our experiences, this is what I’ve discerned:

Elite Institutions Focus on Teaching

This may seem obvious, but for bright-eyed medical students interviewing at various places, it isn’t always as clear. Personally, as someone who has seen six different residency training programs, and worked with the trainees in each in some capacity, I’m aware that though some institutions are labeled as residency programs, they seem to value service over education. 

In speaking to my friends and colleagues who worked at elite institutions, the common thread is that such institutions truly value teaching. Educating trainees also occurs as a result of robust patient care through multidisciplinary conferences, subspecialist-run clinics, rigorous chart reviews, and expansive plan-of-care discussions. There are residency programs piloted by private institutions that claim to emphasize education — but with the dark subtext of developing a cheap labor workforce with improved reimbursement by federal institutions (by virtue of association with a training program). 

A focus on teaching can be manifested in various ways, whether it's regimented reading, frequently assigned presentations, or malignant pimping.

Elite Institutions Set the Bar High (in the Best and Worst Way)

My friend, in training at one of the best children’s hospitals in the country, told me that her institution was hosting a mortality and morbidity conference regarding a 30-minute delay in addressing anemia. She was astounded. At her previous training site, this time interval would’ve been the standard of care; no one would’ve batted an eye at forcing the patient to wait slightly longer for a blood transfusion. On the one hand, my friend was frustrated that they were nitpicking over such a minor occurrence, and that she’d been chastised for something so seemingly small. On the other hand, she recognized that her institution was obsessed with refining the process to its best possible endpoint. 

In my estimation, high expectations from elite institutions can be both good and bad. While they certainly do improve patient care by addressing every detail of the process, they also place significant strain on their clinicians, which ultimately leads to burnout. There was a noticeable difference between my friends at elite institutions and those at community programs, namely in the amount of pressure the elite trainees felt to never err. It’s difficult for an elite institution to say every single detail matters (and to be critical of its trainees for errors) without spreading them thin and incurring negative self-esteem and depression in those same trainees. It's a fine line, but if you push it too far, you produce robotic trainees who struggle to demonstrate the empathy necessary to practice medicine well.

Elites Have the World-Renowned Experts, and You’ll Rely On Them

Elite institutions may have many resources a community institution does not: subspecialty clinics with experts in a specific area of disease, multidisciplinary teams who have dealt with your very rare condition before, a new electronic preoperative education system, case conferences involving many specialties, or evidence-based protocols. 

I can certainly see why someone would want to go to an elite institution — when I was employed at an elite institution, there was a world-renowned radiologist; we joked that her reads were so accurate, she made surgery unnecessary, as she knew the culprit without us entering the abdomen. The promise of having specialists is reassuring. The resources that specialists bring with them can make or break a diagnosis. That said, a friend of mine once remarked how difficult it is to change the process at an elite institution compared to its community counterpart. “When we read a study that showed a marked difference in patient outcomes with minimal downsides,” she said, “we could implement that change the very next day on rounds. At [ELITE] institution, it would have had to go through various committees and approval processes before potentially being enacted. The process can be frustrating, at best, and demoralizing at worst.”

The availability of resources within an elite system are unparalleled. Again, this is a double-edged sword. If you have the world’s best radiologists, your physicians stop looking at scans and their ability to read their own scans becomes a vestige. If you consistently call a subspecialist regarding a condition or surgery, your non-subspecialists become less comfortable managing those conditions. Some of the most accomplished, well-developed surgeons I’ve ever seen are at community hospitals. The environment, and the lack of access to refined tools, has led to personal development of surgical skills they wouldn’t otherwise have had in various fields. (Of course, the key is that these surgeons also sought out learning to hone their skill set, which is not true of every practitioner.) 

Elite Clinicians Put Their Pants on One Leg at a Time, Same As You

Before my first day at an elite institution, I felt significant impostor syndrome. I couldn’t possibly be smart enough, hardworking enough, skilled enough to be there. They’d recognize immediately that I wasn’t “one of them.” But, time passed and I came to realize that “elite” individuals are no different than anyone else, and as your friends join the ranks of elite institutions across the country, you soon realize that the metrics that divide elites from non-elites are much smaller than you might have believed. I expected the junior-level trainees to be harder working (how did they get into such well-known institutions in the first place?), but their work ethics weren’t significantly better than mine. I expected them to know more, and have an encyclopedia of surgical anatomy prepared at all times — but their medical students got the same questions wrong that all medical students get wrong (Sampson’s artery is the one found in the round ligament). Whatever the circumstances that led to these individuals’ positions at [ELITE] institution, they were hardly the savants I expected them to be. 

Infamy Doesn’t Always Mean Better Care

When I rotated at an institution that was infamous for having its own way of doing things, I expected to see magic. Here it was — the [ELITE] WAY. I was scrubbed into a surgery and couldn’t wait to see what the fanfare was about. I watched as a technique was performed ... and it was very similar to the routine, medically-accepted technique used at every other institution. Yes, there were times when I was astounded by an individual’s surgical skill, but there were other times when I was dismayed. Just because something has a name doesn’t make it better, nor does the absence of one make it worse. 

Elite Coffee Is Definitely Worse

Look, I’ve spent this whole article avoiding specifics about institutions, but I’m willing to come clean and say that the best coffee is always at the community hospitals. I did my residency at an institution that went from community to academic, and the food and drink definitely declined during the transition. One of the community hospitals I worked at in Las Vegas had massage chairs in the doctor’s lounge, served salmon with eggs and fresh smoothies every morning, offered a sushi bar once weekly (with a chef from the Vegas strip), and had a latte/mocha machine. [ELITE] hospitals, you can’t win them all. But maybe you could up your coffee game on behalf of your world-renowned subspecialists?

Where did you train? Did your training institution have a reputation (and did it match your experience)? Share your stories in the comments section.

Dr. Muldoon is a minimally invasive gynecologic surgery fellow, a mother to the world’s tallest one year old and a 7-year-old Labrador, a wife to a kind Canadian, and an avid reader and fridge magnet collector. Dr. Muldoon is a 2020–2021 Doximity Op-Med Fellow.