Scott Dulebohn, MD; Associate Professor of Neurosurgery, East Tennessee State University
While medical school provides the foundation, residency creates the building! A physician's long-term ability to be a successful clinician is developed during internship and residency when you learn the skills and responsibility necessary to practice medicine safely. Residency training is completed in private and public teaching hospitals throughout the United States and is similar to an apprenticeship, although you may feel more like an indentured servant. Doctors in training typically earn a little more than $50,000 a year in developed countries, and you will normally work at least a 60-hour workweek. Often you will work seven days a week with rare weekends off. Depending on the program and schedule, you may be on call every second, third, or fourth night, or you may work several night shifts.
To become a great clinician requires a combination of studying and seeing thousands of patients. As Sir William Osler, MD, noted, “To see patients without reading is like a ship without a rudder; to read and not see patients is like never having gone to sea.”
The first year of training post-medical school is often referred to as the “internship,” “first-year resident,” or “R-1”. Virtually all specialties require a basic year of training. Some call it a “transitional” year or a “rotating” year. This is where doctors fine-tune their basic understanding of medicine and learn to apply it to patient care before they typically follow with specialty training. For some programs, it often includes 2-3 months of medicine, surgery, pediatrics, surgery, and sometimes obstetrics and gynecology and psychiatry with an elective. Others are more focused; for example, a general surgery first-year resident might expect to do six months of general surgery and then six months assigned to subspecialty areas such as urology, thoracic surgery, plastic surgery, trauma surgery, vascular surgery, and critical care. An internal medicine or pediatrics resident might expect six months of general medicine and then six months of subspecialty training in gastroenterology, hematology, oncology, nephrology, cardiology, and critical care.
In most programs, the first year is the most demanding of your time. Usually, with the exception of some surgical programs, residency training time and the amount of call or overnight shifts decrease each year. While it is great to find out indirectly, questions about time commitment should be avoided in interviews as it may be misinterpreted that you will not put in as much time as it takes to care for your patients safely.
With experience and time comes more responsibility. After the first year, you are no longer the low person in the program, but your patient care and independent decision-making increases. You have a much greater expectation of your attendings and seniors that you know the basics and are quickly expanding your knowledge of your chosen specialty area.
Most specialties require daily time spent in clinics or the operating theater taking care of patients and early mornings and late evenings rounding on patients, checking their progress, and evaluating their need for further treatments or discharge. Other specialties, such as radiology, radiation oncology, dermatology, pathology, anesthesiology, and emergency medicine, tend to provide care in 8-12 hour shifts, some 7-days a week, while others Monday through Friday. Some programs have home call, while others require residents to stay in the hospital overnight.
As an intern or resident, you are never completely alone. Hospital training programs typically have a hierarchy, and while several interns may be on-call, a senior resident is also quickly available for life-threatening emergencies or more complex decisions. If the resident feels they cannot make a good decision, a fellow or attending typically may be called in from home for help or guidance.
Medicine has multiple specialties. Most require a minimum of three to six years of initial training, which in some cases may be followed by a fellowship. Some are easier to obtain a training position, while others are extremely difficult. The following outlines the basics of the most common residency training programs:
Anesthesiology typically requires a one year internship followed by an additional three years of residency training. Several fellowships are available, such as critical care, pain, pediatrics, and cardiothoracic. Other than emergency surgery and procedures at night, there are fewer patient care responsibilities in the evenings and weekends. This specialty requires relatively above-average USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores.
Dermatology is normally a one-year internship followed by three years of residency training. Most of the training is done in clinics. This may be followed by optional fellowships in dermatopathology, pediatrics, or procedural based training. Dermatology residents may take call, but after the first year, it would not be in-house, and it would be uncommon to be required to go to the hospital. Competition for the dermatology match is high, and students need to achieve very high USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores.
Emergency medicine is normally a one-year internship followed by 2-3 years of residency training. More than half of the training is spent taking care of patients in the emergency department. This may be followed by fellowships in toxicology, EMS, or critical care. Rather than taking call, residents typically work a set number of 8- or 12- hour shifts each month. Emergency medicine requires relatively above-average USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores to match.
Family medicine training is three years. Considered general practice specialists, these doctors focus on internal medicine, surgery, obstetrics and gynecology, and psychiatry. They learn to evaluate and treat a wide range of problems. Call is usually every 3rd or 4th night. Training is spent about half in the hospital and half in clinics. Fellowships are available in geriatric medicine, sports medicine, and obstetrics.
Getting into a general surgery internship is typically reasonable. However, getting a guaranteed five-year training slot may be more difficult. Many general surgeons pursue fellowships in critical care and trauma.
Internal medicine is three years of residency training, including a one-year internship. The training is spent in a combination of the hospital and clinics. Almost half of internists pursue fellowship training in oncology, hematology, geriatrics, nephrology, gastroenterology, endocrinology, infectious diseases, cardiology, critical care, pulmonary, and rheumatology.
Neurosurgery is considered one of the most demanding surgical specialties and consists of one year of general surgery followed by five years of neurosurgery. The fellowships are usually one year and available in pediatrics, pain, critical care, stereotactic, spine, tumor/skull based, and vascular.
Obstetrics and Gynecology
Ob/gyne training starts with an internship followed by three years of residency training. It is a moderately hard match, requiring above average USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores. Fellowships are available in high-risk obstetrics, fertility, and oncology.
Training in ophthalmology is four years. One of the most challenging matches in medicine, it requires very high USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores. Fellowships are available in vitreoretinal, glaucoma, neuro-ophthalmology, oculoplastics, and pediatrics.
Training to become an orthopedic surgeon requires five years. Matching requires very high USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores. Fellowships are available in hand, spine, oncology, sports medicine, joint, and pediatrics.
Otolaryngologists, also known as ear, nose, and throat surgeons, training is usually a general surgery internship followed by four years. Matching requires very high USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores. Fellowships are available in pediatrics, oncology, and plastic surgery.
Pathology generally requires four to five years of residency training. It recently has not been a challenging match. Fellowships are available in hematology, pediatrics, blood banking, genetics, and forensics.
Pediatrics is a three-year residency. Matching in this specialty is slightly easier than most. Many pursue fellowship training in oncology, hematology, geriatrics, nephrology, gastroenterology, endocrinology, infectious diseases, cardiology, critical care, pulmonary, emergency medicine, or rheumatology.
Physical Medicine and Rehabilitation
Training to become a PM&R physician is typically 4 years. Recently it has been a slightly easier match. Fellowships are available in sports medicine, spine, and spinal cord injury.
Being selected for plastic surgery training is extraordinarily difficult. Training typically lasts six years. Very high USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores are needed to match.
Generally requires a one-year internship followed by two years of training. Matching is less competitive. Most specialize in aerospace, occupational, or public health.
Psychiatry generally requires four years of training. Matching recently has been getting more difficult. Fellowships are offered in pediatrics, forensics, and consultative services.
Radiation oncology typically requires four years of training. Matching is difficult and requires very high USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores.
Radiology is usually an internship followed by three years of residency training. Call is usually in the hospital and often several nights per month. Multiple fellowships are available in ultrasound, CAT scan, MRI, nuclear medicine, breast, pediatrics, and interventional radiology. Radiology requires above average USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores to match.
Typically a surgical internship followed by four years of urology training. High USMLE® Step 1 and USMLE® Step 2 or COMLEX® Step 1 and COMLEX® Step 2 scores are required to match. Fellowship training is available in pediatrics and oncology.
The road to selecting a residency, matching, and then becoming a fully trained physician is challenging. Being on call several times a week is hard on you and your family. Spouses and children will find it difficult to accept the demands the medical profession puts on your time. You will often arrive home fatigued and burned out, only to get called back in for yet another emergency. Additionally, much of your free is spent reading journal articles and learning new techniques and skills. Despite great sacrifices, in the end, most doctors feel a great reward for their work and the accomplishment of a lifelong dream to choose their profession, train to meet the goal, and then be rewarded by a long-career of applying your learning to the sick and injured.