Medical School FAQ

Residency and Beyond

7.1 What are the different medical specialties?

A good source for learning about the different medical specialties is the American Board of Medical Specialties http://www.abms.org, an organization that coordinates and approves changes in board certification policy in the different medical fields. A complete list of the certifying boards and the general and subspecialty certificates that they offer can be found on their web site. A list of the major medical specialties can be found below. No effort has been made to list subspecialties. Click on any of the specialty to see a list of colleges offering that specialty.

7.2 What is a residency?

Upon graduation from medical school, you become a "doctor" having earned the M.D. or D.O. degree. However, this isn't the end of formal medical training in this country. Many moons ago, back when almost all physicians were general practitioners, very few physicians completed more than a year of post-graduate training. That first year of training after medical school was called the "internship" and for most physicians it constituted the whole of their formal training after medical school; the rest was learned on the job. As medical science advanced and the complexity of and demand for medical specialists increased, the time it took to gain even a working knowledge of any of the specialties grew to the point where it became necessary to continue formal medical training for at least several years after medical school. This training period is called a "residency," earning its moniker from the old days when the young physicians actually lived in the hospital or on the hospital grounds, thus "residing" in the hospital for the period of their training.

During residency, you and your classmates practice under the supervision of faculty physicians, generally in large medical centers. Many primary care specialties, however, are based in smaller medical centers. As you grow more experienced, you assume more responsibilities and independence until you graduate from the residency, and you are released to practice on your own upon an unsuspecting populace.

The length of residency programs varies considerably between specialties and even a little within individual specialties. In general, the surgical specialties require longer residencies, and the primary care residencies the least time.

The AMA maintains a database of almost all of the residency programs in the United States, called the Fellowship and Residency Electronic Interactive Database Access (FREIDA) system. It is available at http://www.ama-assn.org/ama/pub/category/2997.html.

Recently a new type of residency has emerged, the so-called "combined residency." These residencies train physicians in two medical fields, such as internal medicine-pediatrics, or psychiatry-neurology. As these types of residencies are new, they are relatively few in number; they provide an opportunity for the physician to become "double-boarded" and receive board certification in each of the two specialties. Usually these residencies last one or two years less than the total years that would be spent doing both residencies.

In the old days, all physician completed a one year "rotating internship" after graduating from medical school. Such an internship consisted of all the major subdivisions of medical practice: Internal medicine, surgery, obstetrics and gynecology, etc. The idea was to provide a broad spectrum of training to allow the new physician to work in the community as a "general practitioner."

Today, the closest thing we have to the rotating internships of old is the "transitional year," also completed after graduating from medical school. For a few specialties, a year of post-gradute training is required before beginning a residency in that field. Many who want to go into these fields fill that requirement with a transitional year. Fields that require a year before beginning residency include radiology, neurology, anesthesiology, and ophthalmology.

In the current lingo, the first year of post-graduate training is called "internship," and any medical school graduate in the first year of post-graduate training is called an "intern" regardless of what that first year of training consists. Most specialties do not require a transitional year, but instead accept medical school graduates straight out of medical school.

An alternative to the transitional year for some is the "preliminary year." Preliminary years come in two flavors, internal medicine and surgery. Each of these preliminary years somewhat resembles the rotating internships of old, but with a focus on either internal medicine or surgery. Those programs that require a year of post-graduate education before beginning residency may accept either a transitional year or a preliminary year. Obviously, surgical residencies will require that you do a preliminary surgery year while some other specialties will prefer a preliminary medicine year.

The other reason that a new M.D. would go into a preliminary year or transitional year would be because he didn't match into the specialty of his choice. The hopeful applicant then takes a preliminary or transitional year in the hopes of improving his chances and qualifications for the next year's residency match.

The term "categorical" is used largely to distinguish between the interns who are doing a preiminary year and those who are already accepted into the residency program. For instance, a general surgery program may have 6 interns every year, but two of them may doing surgery as a preliminary year. Those positions that are already accepted into the whole surgical residency program are called "categorical."

The Match (also 7.4) is a way to bring together residency applicants and residency programs in an organized fashion. After applying to and interviewing at various residency programs in their specialty of choice, students submit a "rank order list" which specifies their preferences for programs in numerical order. Residency programs submit similar lists. After all of the lists have been received, a computer matches applicants and programs. At noon Eastern time, on a fateful day in March of each year, all applicants across the country receive an envelope telling them where they will spend the next several years.

Controversy has surrounded the Match algorithm in recent years, due to a slight preference for residency programs in a very small percentage of cases. The algorithm has since been changed to favor applicants' preferences.

There are several books about residency and the Match. "First Aid for the Match" by Tao Le, et al., and "Getting into a Residency: A Guide for Medical Students" by Kenneth Iserson, MD, provide insights about how to prepare for the Match.

The National Resident Matching Program (NRMP) is the official name of the Match, which is run by the Association of American Medical Colleges (AAMC). Its home page may be found at http://www.nrmp.org/.

Several specialties have their own matching programs. Neurology, Neurosurgery, Ophthalmology, Otolaryngology, and Plastic Surgery, along with several subspecialty fellowship programs in these fields, have their matches coordinated through the San Francisco Matching Program http://www.sfmatch.org.

Urology has its own matching program, coordinated by the American Urological Association at http://www.auanet.org/students_residents/residency_match/index.cfm?categoryid=8.

The "Match Day" for these specialties occurs in January, instead of March as for the NRMP. Consult the matching programs' web sites for schedules.

A fellowship is a period of training that you undertake following completion of your residency, as a means to subspecialization. For instance, a general surgeon can do a number of different fellowships (e.g. cardiothoracic surgery, plastic surgery), a pediatrician can complete a fellowship in pediatric endocrinology, etc. The list of possible subspecialties is almost endless. A fellow is considered somewhere in the hierarchy between residents and faculty. They are paid like advanced residents, but nothing close to what a private physician makes. People take fellowships for a number of different reasons: The subspecialty may be what they've always wanted to do in the first place, they may develop an interest in that field along the way, and it's often a path to a faculty position in a residency program and medical school. The length of fellowships also varies some, but usually lasts three years or less.

Intern and resident hours vary very widely depending on specialty, hospital, and within hospitals between different departments. Some specialties are well-known for their less demanding hours during residency (and often afterwards as well). These "lifestyle" fields include radiology, anesthesiology, and physical medicine and rehabilitation (physiatry). Specialties whose residencies are reputed for difficulty and lack of sleep are general surgery and obstetrics and gynecology. Most of the other specialties fall somewhere in between.

Surgical interns and often internal medicine interns routinely work 100+ hours a week, with some months requiring a brutal every other night call schedule. This means, for instance, that you go to work on Monday morning (around 5-6 am) work all day, stay in the hospital all night (with varying amounts of sleep but usually < 2-3 hours), work the following day as well (hoping that you may get out early), then go home for around 6 pm only to repeat the whole cycle again the next day. On months such as these, if you have a spouse, children, or pets, you won't see them. You can do the math to figure out how many hours per week that amounts to. Most call schedules for intern years run either every third or every fourth night on call.

There are a few states that limit the number of hours that a resident can work. Perhaps the most prominent state with a such a law is New York.

New York's law, limiting residents to 80 hours per week, came about largely due to the Libby Zion case. Libby Zion was a young woman whose death in a NYC teaching hospital sparked an investigation into the large amount of hours that residents work.

Nevertheless, many hospitals in New York still do not follow this law and the state has performed "spot inspections" to attempt to verify compliance. For an excellent discussion of this issue, read the book "Residents: The Perils and Promise of Educating Young Doctors" by David Ewing Duncan.

Generally, to become certified by one of the boards recognized by the American Board of Medical Specialties http://www.abms.org, a physician must meet several requirements:

After certification, a physician is given the status of "diplomate" in that specialty. Many boards require recertification at regular intervals.

Before discussing this, it may be useful to delineate the differences between organizations that physicians may be associated with. Some definitions:

Association or Academy - A group for physicians in a particular field, that often sponsors meetings and publishes journals. Example: American Academy of Family Physicians.

Board - Organization that conducts periodic examinations for physicians in a particular field, and offers "certification" (cf 7.8). The overseeing organization for all specialty boards is the American Board of Medical Specialties http://www.abms.org. Example: American Board of Internal Medicine.

College - Similar to an association, but membership is often tied to board certification and experience. More of an honor than simple association membership, doctors are often elected to "fellowship" after recommendation by their colleagues. Example: American College of Surgeons.

After a physician has received board certification in his/her field, and has gained a set amount of experience in that field (usually a specified number of years of practice), that physician can be recommended for fellowship status in their specialty college. After approval, the physician can then use their fellowship status on stationery and business cards, i.e. Susan M. Avery, M.D., F.A.C.S. signifies that Dr. Avery has received fellowship status in the American College of Surgeons.

Those who have graduated from medical schools outside of the United States and Canada are called International Medical Graduates (IMGs) or Foreign Medical Graduates (FMGs). Sometimes, US citizens who have attended foreign schools are called USFMGs to distinguish them from non-citizens.

There has been a move of late among some members of Congress, the Accreditation Council for Graduate Medical Education (ACGME), and the AAMC, in light of a perceived surplus of physicians in the US, to reduce the number of Medicare-funded residency positions to 110% of the number of graduating US medical school seniors. As of yet, this has not been implemented.

The Educational Commission for Foreign Medical Graduates (ECFMG) http://www.ecfmg.org/ is an organization sponsored by the Federation of State Medical Boards, the AAMC, the AMA, the American Board of Medical Specialties, and others, that coordinates certification of graduation, passing grades on the United States Medical Licensing Examination (USMLE), and other information about FMGs. Prior to applying to residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME), an FMG must hold a certificate from the ECFMG.

7.11b The CSA?

CSA stands for "Clinical Skills Assessment," a new requirement for foreign-trained physicians seeking to obtain ECFMG certification. Applicants face 10 simulated patients and be evaluated on their ability to take a history, perform a physical exam and record a written note. More information can be found on the ECFMG web site at http://www.ecfmg.org/.

A physician's education does not end with medical school and residency. Continuing Medical Education, or CME, allows physicians to keep up with new developments in all medical fields. Physicians earn "credits" for hours spent in various learning activities.

The American Medical Association (AMA) offers the Physician Recognition Award (PRA) for doctors who complete 50 hours of CME credit per year. The AMA's classification of CME is as follows:

Organizations that receive the nod from the Accreditation Council for Continuing Medical Education (ACCME) http://www.accme.org, as well as state medical societies and other groups recognized by the AMA can provide "category 1" CME courses.