7) Residency and Beyond

7.1) What are the different medical specialties?
7.2) What is a residency?
7.2a) What is an internship?
7.2b) What is a "preliminary" year? A "categorical" year?
7.3) What is the Match?
7.4) What is the NRMP?
7.5) Are there specialties that don't use the NRMP?
7.6) What is a fellowship?
7.7) How many hours do interns/residents work?
7.7a) Aren't there limits on this?
7.8) What does "board certified" mean?
7.9) What does FACP/FACS/FACOG/etc. mean?
7.10) What is an IMG/FMG?
7.11) What is the ECFMG? The CSA?
7.12) What is CME?
7.13) How do a choose a residency program? I need to declare a medical specialty before long, but I have so many conflicting feelings and thoughts about various clinical areas. How can I make the right choice?

Subject: 7. 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 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.

Allergy & Immunology
Anesthesiology
Colon & Rectal Surgery
Dermatolology
Emergency Medicine
Family Practice
Internal Medicine
Medical Genetics
Neurological Surgery
Neurology
Nuclear Medicine
Obstetrics & Gynecology
Ophthalmology
Orthopaedic Surgery
Otolaryngology
Pathology
Pediatrics
Physical Medicine & Rehabilitation
Plastic Surgery
Preventive Medicine (including Occupational Medicine)
Psychiatry
Radiation Oncology
Radiology
Surgery
Thoracic Surgery (including Cardiothoracic Surgery)
Urology

7.2)

What is a residency?

A:  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.

Lengths of Some Residencies:

All surgical specialties - 5+ years
Obstetrics and Gynecology - 4 years
Family medicine - 3 years
Pediatrics - 3 years
Emergency Medicine - 3-4 years
Psychiatry - 3 years

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.

7.2a)

What is an internship?

A:  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.

7.2b) What is a "preliminary" year? A "categorical" year?

A:  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."

7.3) What is the Match?

A:  The Match 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.

7.4) What is the NRMP?

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.aamc.org/nrmp/ http://www.aamc.org/nrmp/ .

7.5) Are there specialties that don't use the NRMP?

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 http://www.sfmatch.org .

Urology has its own matching program, coordinated by the American
Urological Association at
 http://www.auanet.org/students_residents/ .

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

7.6) What is a fellowship?

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.

7.7) How many hours do interns/residents work?

A:  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

7.7a) Aren't there limits on this?

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.

7.8) What does "board certified" mean?

A:  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:

1) Possess an MD or DO degree from a recognized school of medicine
2) Complete 3 to 7 years of specialty training in an accredited residency
3) Some boards require assessments of competence from the training director
4) Most boards require the physician to have an unrestricted license
5) Some boards require experience in full-time practice, usually 2 years
6) Pass a written examination, and sometimes an oral examination

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

7.9) What does FACP/FACS/FACOG/etc. mean?

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.

7.10) What is an IMG/FMG?

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.

7.11) What is the ECFMG? The CSA?

The Educational Commission for Foreign Medical Graduates (ECFMG)
 http://www.ecfmg.org 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.

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/csahome.htm .

7.12) What is CME?

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:

Category 1: Formally organized and planned educational meetings,
e.g., conferences, symposia. Also includes residency.
Category 2: Less structured learning experiences, e.g.,
consultations, discussions with colleagues, and
teaching.
Other: Reading "authoritative" medical literature, e.g.,
peer-reviewed journals, textbooks.

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

7.13) How do a choose a residency program? I need to declare a medical specialty before long, but I have so many conflicting feelings and thoughts about various clinical areas. How can I make the right choice?

A: It's time for fourth year students to get serious about choosing their specialty area. Some of you are lucky, and everything lines up: you know which clinical area interests you most, your board scores and grades/letters are all in the correct range, and you have helpful professors on your side. For you, it's just a matter of doing the paperwork on time. You can stop reading here.
But I know there are many others of you out there who aren't sure what specialty to choose. Or, you're torn between 2 or 3 specialties. Or you know what you don't want but aren't sure what you do want. Or you know what you want, but aren't sure if your qualifications are strong enough. Read on!
If you're stuck, here's a decision tree to follow:

 
1. Find or make a list of all the specialties available directly after medical school (ie, skip fellowships).
2. Cross off the ones you definitely don't want. You don't need a string of reasons beyond the fact that you simply can't see yourself doing it long term.
3. Perform a Google search with the phrase "choosing a medical specialty." When I tried it, I got about 89,800,000 entries. Set a timer for no more than 1 hour and browse through the first several pages. Take some of the "what specialty are you?" quizzes. If nothing else, they will give you some ideas and possibly make you think about specialties you haven't explored. You can safely avoid making an exact ranking of specialties at this point. Just see which specialties you seem to be most suited to and which you should rule out.
4. Now, list several specialties you can see yourself doing long term, no more than 6.
5. Research those specialties in your institution. Go to the departments and make friends with the residency program coordinators. If you haven't already done so and haven't rotated in the program, arrange to shadow a faculty member for a day. Talk with 1 or 2 residents and check out the pros and cons of the specialty. Finally, ask the program coordinator if your board scores would be in a competitive range. Most program coordinators won't share their board score cut-off, but they likely would tell you if your scores are within range.
6. Narrow your list to 2 or 3 specialties. Now, and only now, talk with family and friends. Tell them you're thinking of these specialties, and get their opinions. Listen hard, and get them to articulate the basis for their opinions.
7. Delete any reasons related to job shortages or oversupply of physicians in a specialty. You don't need 200 jobs, you only need 1, and you should be prepared to relocate somewhere less attractive if you choose a specialty that's overcrowded or not in much demand. Plus, demand can change by the time you finish training.
8. Delete any reasons related to lifestyle or money, unless those concerns come from your significant other.
9. Delete heritage reasons ("Your father is a surgeon; you should be one, too").
10. Now, write down your own pros and cons, independent of all the advice and aptitude testing and board scores. Be honest here. If your priorities are lifestyle, having children during residency, income, opportunities for foreign travel, or avoiding rough circumstances, then rank them appropriately. What fascinates you, what could you be passionate about? Don't be at all logical here.
11. But do be logical in this next step. And brutally honest with yourself: Did you barely pass the boards? Internal medicine might not be for you, even if you really enjoy outpatient medicine. Do you tend to avoid or dislike patient contact? Don't consider family medicine or pediatrics. Do you have high board scores, want a benign lifestyle, but aren't very visual? Don't pick radiology.
12. If you follow all these steps, combining thoughtful reflection on what makes you happy with an objective look at your strengths and weaknesses, one option should start singing out louder than the others. And that's your specialty.

Note that you should take other people's views of your strengths and weaknesses into account, but not necessarily follow their advice. Spouses are a special case because you are making a joint life together. Still, the final decision should be yours, informed by some actual data that help you determine "the best fit" between you and your specialty-to-be.
You can do this in a week; don't procrastinate and don't make the problem bigger than it is. If you choose a specialty that turns out to be a bad fit, you can still change after the first year.
Be practical, but don't limit yourself. I know a physician who started medical school at age 38, one who had to take the boards several times, one who barely passed one of her steps by 1 point, and another who doesn't like patient care. The first one is now practicing radiology in a large private clinic, the second is a fellow in a high-risk obstetric anesthesia program at a very prestigious academic medical center after switching from surgery because of physical limitations, the third is a fellow in a neonatal intensive care unit after completing a successful pediatrics residency, and the last is working for a large drug company doing information technology, his real love.
Even if you are "nonstandard," you can find a specialty you will love and which will value you. Good luck!