- What part does residency play in medical training in the United States?
- What is the basic structure of a residency?
- What specific rotations constitute a residency?
- What are the duties of an intern?
- What are the duties of a resident?
- What procedures do interns and residents perform?
- What knowledge and skills should I bring to my training program?
- What demands does residency place on the trainees?
- What do residency program selection committees look for in a successful candidate for training?
- How do residencies view foreign medical graduates?
- What is the residency application process?
Residency is fundamental and indispensable. In the United States, a student of medicine completes two years of classroom study and two years of clinical rotations in hospital and clinic. This, however, does not qualify him for medical practice in any specialty, nor are there distinct specialty tracks in medical school, and all students are graduated with a similar set of medical knowledge and skills, which is not sufficient to allow them to practice medicine independently. It is residency, therefore, that ultimately makes you a physician and specialist.
The first year (internship), usually a year of general clinical work, is followed by several years of specialty training (residency proper). For Internal Medicine and Family Practice, the total duration of training is three years. Medicine subspecialties require a fellowship of, usually, two or three years after completion of Internal Medicine residency. Examples are Cardiology, Endocrinology, Gastro-enterlogy, Hematology and Oncology, and Nephrology. Other specialties, such as Dermatology and Otolaryngology, require only the preliminary (internship) year before direct specialty training.
This varies somewhat among programs. In Internal Medicine, general medicine service (the floors), medical (ICU) and cardiac (CCU) intensive care, outpatients clinic, night coverage, and various medical subspecialties are usual. Rotations usually last either four weeks or a month.
An intern is the lowest-ranked member of the hospital team of physicians, although he may be responsible for supervising medical students. His own duties include all aspects of patient care and medical documentation, including History and Physical examination, follow-up examination and management of diagnostic testing, co-ordination of medical care, and dismissal from hospital. His work is supervised by residents, fellows and ultimately by attending physicians.
Common procedures in Internal Medicine are venipuncture, arterial blood gas collection, EKG recording and interpretation, basic X-ray interpretation, placement of central vein lines, and some specialized procedures. In most of these, direct supervision by senior medical personnel is provided. House staff also provides Advanced Cardiac Life Support (ACLS) in cases of cardio-pulmonary arrest.
It is neither expected nor required that you be proficient in the practice of medicine as you begin residency. This is the goal of your training. Nonetheless, you should be skilled in obtaining medical history and performing a physical examination, in formulating a reasonable differential diagnosis and in making appropriate suggestions of diagnostic evaluation and treatment, as well as in performing and interpreting the pertinent diagnostic tests, some of which are noted above.
In addition to scientific and clinical competence, you are expected to demonstrate an ability to work as part of a team, to function well under pressure, to provide effective communication to patients and to other medical professionals, to assume the appropriate level of responsibility, and to act as a teacher and role model to your colleagues.
There is no question that medical training often places great demands in terms of time, effort and stress on program participants. It may at times feel overwhelming. Nevertheless, training programs represent probably the most controlled and predictable medical practice situation that you are likely to encounter. There is plenty of support and all your activities are supervised by qualified physicians. Moreover, in the last few years several laws have been implemented that limit the amount of work, including time on duty, that a resident may perform. Very long duty shifts are now rare, although you may still have to work as much as 24 hours at a time, through the night and on week-ends and holidays. This may interfere with your personal, family and social life, and we advise you to consider this as you prepare yourself for residency.
First, a certain minimal level of clinical competence is of course required. Performance during and completion of medical school education, United States medical board scores, references and clinical experience in the United States are used to establish this. For foreign medical graduates in particular the last two are especially important. Although you can prepare for the boards by studying on your own, supervised clinical experience in the United States is required to complete a strong candidacy profile.
Secondly, and very important, the candidate must possess excellent interpersonal and communication skills, be able to effectively interact and get along with other house staff, nursing staff and attending physicians, as well as with patients and their families. This depends in part on the candidate’s personality, but also on his understanding of and familiarity with American society and medicine. These are hard to obtain except by personal experience.
All in all, American graduates are viewed more favorably, although there are more and more programs that consider and accept FMGs. American programs feel the obligation to train their own country’s graduates primarily, as one would expect. Whether a foreign graduate has the requisite clinical and social skills is often an important question for residencies. Administrative matters, including visa processing, put additional burden on the program that is considering FMGs. Success of a foreign medical graduate in getting into an American residency depends on his recognition of these considerations and on his addressing them effectively during the application process.
Certain general groups of FMGs may be distinguished. The two extremes are very young recently graduated physicians and older and more experienced persons, either those who have had a career before medicine or those who previously have been practicing physicians. Each of these offers both favorable and unfavorable considerations in the view of residency programs. A wise candidate will emphasize the strengths of his situation and will demonstrate that the possible ‘weaknesses’ of it have been considered and addressed or do not in fact apply in his particular case.
The younger physicians are seen as energetic and eager and easier to direct. They are in general less burdened with family obligations and may more easily adjust to new situations. Their weakness is the obvious relative lack of personal and professional experience and of some social skills that one acquires through experience.
The older physicians may have clinical skills and experience that far exceed those of recent graduates. They tend to be more adept also at establishing and maintaining professional interactions and at finding efficient ways of completing the task at hand and of organizing themselves. Still, they may have established certain habits and practices that may be undesirable in the setting of medical training and that may be hard to change. They may find it difficult to adapt to their new position of being the lowest ranked member of the health team. Family and other personal affairs may distract them from their residency duties. They may have less energy and motivation than the younger physicians.
We suggest that you carefully assess your particular candidacy in view of the foregoing considerations, in order that you may best present yourself to the residency programs of your choice.
Currently, most residency placement is done by means of a computer match once the application process itself is complete. Likewise, most application is now done electronically. In addition to details of your personal and professional activities, curriculum vitae and personal statement constitute an important part of the application, as do letters of reference.
Details of the application process are easily obtained from the internet or from the applicable administering organization.