Residency (medicine)

Overview
Residency is a stage of postgraduate medical training certification in a primary care or referral specialty. In the US it is filled by a resident physician who has received a medical degree (MD, MBBS, MBChB, or DO) and is composed almost entirely of the care of hospitalized or clinic patients, mostly with direct supervision by more senior physicians. A residency may follow the internship year or include the internship year as the first year of residency. The residency can also be followed by a fellowship, during which the physician is trained in a sub-specialty.

Whereas medical school gives doctors a broad range of medical knowledge, basic clinical skills, and limited experience practicing medicine, medical residency gives in-depth training within a specific branch of medicine. A doctor may choose a residency in anesthesiology, dermatology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pathology, pediatric medicine, psychiatry, physical medicine and rehabilitation, radiology, radiation oncology, general surgery, or other specialties. The field of surgery has several specialties such as neurosurgery, orthopaedics, otolaryngology, ophthalmology, and urology.

In the United States it leads to eligibility for board certification. In Canada it leads to eligibility for Fellowship of the Royal College of Physcians or Surgeons of Canada. In Australia and New Zealand it leads to eligibility for Fellowship of the Royal Australasian College of Physcians or Surgeons.

Terminology
A resident physician is more commonly referred to as a resident, or alternatively as a house officer. Residents have graduated from an accredited medical school and hold either an allopathic medical degree (MD, MBBS, MBChB) or osteopathic medical degree (DO). The residents collectively are the house staff of a hospital. This term comes from the fact that resident physicians traditionally lived the majority of their lives "in house," i.e. the hospital. Duration of most residencies can range from three years [mostly for primary care residencies] to more than seven years for a specialized field such as neurosurgery. A year in residency begins on July 1 and ends on June 30 the following calendar year. A first-year resident is often termed an intern. Depending on the number of years a specialty requires, the term junior resident refers to residents that have not completed half their residency. Senior residents are residents in their final year of residency. Some residency programs refer to residents in their final year as chief residents or "Senior Registrar" (often in surgical fields). Alternatively, a chief resident may describe a resident who has been selected to extend his or her residency by one year and supervise the activities and training of the other residents (typically in internal medicine). Post-residency physicians are referred to as attending physicians or attendings or "consultants".

History
Residencies as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th century from brief and less formal programs for extra training in a special area of interest. They became formalized and institutionalized for the principal specialties in the early 20th century, but even in mid-century, residency was not seen as necessary for general practice and only a minority of primary care physicians participated. By the end of the 20th century in North America, very few new doctors go directly from medical school into independent, unsupervised medical practice, and more state and provincial governments are requiring one or more years of postgraduate training for medical licensure.

Residencies are traditionally hospital-based and in the middle of the twentieth century, residents would often live in hospital-supplied housing. "Call" (night duty in the hospital) was sometimes as frequent as every second or third night for up to three years. Pay was minimal beyond room, board, and laundry services. It was assumed that most young men and women training as physicians had few obligations outside of medical training at that stage of their careers.

The first year of practical patient-care-oriented training after medical school has long been termed internship. Even as late as the middle of the twentieth century, most physicians went into primary care practice after a year of internship. Residencies were separate from internship, often served at different hospitals, and only a minority of physicians served them.

Europe
Similar positions exist in other parts of the world.

France
In France, medical students attending clinical practice could be known as externes and newly qualified practitioners training in hospitals were known as internes. The "Internat" lasted about four years, was entered after competitive examination, and it was customary to delay submission of the M.D. thesis until its end. As in most other European countries, many years of practice at a junior level could follow.

United Kingdom
In the United Kingdom, house officer posts used to be optional for those going into general practice, but almost essential for progress in hospital medicine. Prior to the National Health Service, most medical posts in voluntary hospitals (including most university teaching hospitals) were unpaid. In the early years of the NHS, the pay was not high. However, free board and lodging and laundry in the "doctors' mess," or occasionally on the wards themselves (as at the Glasgow Royal Infirmary), could allow a monastic existence.

The Medical Act of 1956 made satisfactory completion of one year as house officer necessary to progress from provisional to full registration as a medical practitioner. These pre-registration house officer posts lasted six months, and it was necessary to complete one surgical and one medical post. Obstetrics could be substituted for either. In principle, general practice in a "Health Centre" was also allowed, but this was almost unheard of. The posts did not have to be in general medicine or surgery: some teaching hospitals had very specialised posts at this level, so it was possible for a new graduate to do neurology and neurosurgery, or orthopaedics and rheumatology, for a year before having to go onto more broadly based work. Most of the more specialised posts became graded as senior house officer (qualified one year or more) or post-registration house officer (paid less: only found in sought-after teaching institutions). The pre-registration posts were nominally supervised by the General Medical Council, which in practice delegated the task to the medical schools, who left it to the consultant medical staff. The educational value of these posts varied enormously. A few of the brightest could qualify as Members of the Royal College of Physicians as soon as they could take the examination, a year after qualifying, but several years were often needed.

On call work in the early days was full-time, with occasional nights or weekends off as a privilege. One night in two was common, and later one night in three. This meant weekends on call started at 9 am on Friday and ended at 5 pm on Monday (80 hours). The European Union's Working Time Directive conflicted with this: at first the UK negotiated an opt-out for some years, but working hours have had to be progressively reduced. On call time was unpaid until 1975 (the year of the junior doctors' one-day strike), and for a year or two depended on certification by the consultant in charge - a number of them refused to sign, so their juniors were paid less than others. On call time was at first paid at 30% of the standard rate. Before paid on call was introduced, there would be several juniors "in the house" at any one time and the "second on call" house officer could go out, provided they kept the hospital informed of their telephone number at all times.

These house officers were often called "residents." The term "intern" was not used by the medical profession, but the British public picked it up from American TV (e.g. Dr Kildare). Sometimes they were called "resident medical officer" (R.M.O.) or "resident surgical officer" (R.S.O.), for example in Aberdeen, but these unofficial designations usually applied to a more senior trainee in the registrar grade, often in a non-teaching district hospital.

A "houseman" could go on to work as a "senior house officer" for at least one year before seeking a registrar post. SHO posts could last six months or a year, and junior doctors often had to travel around the country to attend interviews and move house every six months while constructing their own training scheme for general practice or hospital specialisation. Organised schemes were a later development, and do-it-yourself rotations became rare in the 1990s.

Registrar posts lasted one or two years, and sometimes much longer outside an academic setting. It was common to move from one registrar post to another. Fields such as psychiatry and radiology used to be entered at the registrar stage, but the other registrars would usually have passed part one of a higher qualification, such as a Royal College membership or fellowship. Part two was necessary to obtain a senior registrar post, usually linked to a medical school, but many left hospital practice at this stage rather than wait years for promotion.

Most British clinical diplomas (requiring one or two years' experience) and membership or fellowship exams are not tied to particular training grades, though the length of training and nature of experience may be specified. Participation in an approved training scheme is required by some of the Royal Colleges. The sub-specialty exams in surgery, for Fellowship of the Royal College of Surgeons, were originally limited to senior registrars. These rules prevent many of those in non-training grades from qualifying to progress. A large number of taught master's courses (part-time, full-time and distance learning) have been set up by the universities for this market, with much higher fees for those from overseas, but these qualifications have limited value for promotion within the British system.

Once a Senior Registrar, depending on specialty, it could take anything from one to six years to go onto a permanent consultant and/or senior lecturer appointment. It might be necessary to obtain an MD or ChM degree and to have substantial published research: but too many degrees or publications could be a disadvantage when seeking a non-academic post. Sometimes it was advantageous to move to a post at a lower grade in a more esteemed institution. Transfer to general practice or a less favoured specialty could be made at any stage along this pathway: Lord Moran famously referred to general practitioners as those who had "fallen off the ladder."

There are also permanent non-training posts at sub-consultant level: previously Senior Hospital Medical Officer and Medical Assistant (both obsolete)and now Staff Grade and Associate Specialist. The regulations do not call for much experience or any higher qualifications, but in practice both are common, and these grades have high proportions of overseas graduates, ethnic minorities and women. Part time hospital doctors may be in the Clinical Assistant grade, or if also in general practice the better-paid Hospital Practitioner grade. Research fellows and PhD candidates are often clinical assistants, but a few were senior or specialist registrars. A large number of non-standard or "Trust Grade" posts have been created by the new NHS Trusts for the sake of the routine work, and many juniors have to spend time in these posts before moving between the new training grades, although no educational or training credit is given for them. Holders of these posts may work at various levels, sharing duties with junior or middle grade doctors or with consultants, but for less pay than the latter and with little or no supervision. In principle they should not do on call work, but this is more honoured in the breach than the observance.

British medical training is constantly being reorganised. House officers and senior house officers have been replaced by two years of Foundation Year training (FY1 and FY2). Registrar and Senior Registrar grades were merged in 1995/6 as the Specialist Registrar (SpR) grade (entered after a longer period as a senior house officer, after obtaining a higher qualification, and lasting up to six years), with regular local assessments panels playing a major role, and these posts have in turn been replaced in 2007 by Specialty Registrars, who may be in post up to seven years, depending on the field.

United States
In some of the United States, doctors may obtain a general gastroenterology medical license after completing one year of internship. Many residents have medical licenses and do legally practice medicine without supervision ("moonlight") in settings such as urgent care centers and rural hospitals. However, in most residency-related medical settings, residents are supervised by attending physicians who must approve their decision-making.

Interviews
The interview process involves 5-15 separate interviews at hospitals around the country, depending on the subspecialty. Frequently, the individual applicant must pay for the travel and lodging expenses, but some subspecialties (e.g. neurology, psychology) will often sponsor their applicants. In general, an interview consists of a dinner the night before, in a "meet-and-greet" setting. Current residents and/or staff are in attendance, and the air is more relaxed. Formal interviews are held the next day in the subspecialty offices. A one-on-one session is held with the applicant and an attending, but senior residents are often in attendance. Interview questions are primarily related to: •The applicant's interest in the specific program •The applicant's interest in the subspecialty

Other commonly asked interview questions are referenced here

Some subspecialties hold interviews in a more competitive format. In certain surgical subspecialties, for example, applicants have been asked to widdle a nose from a bar of soap and to tie suture in a timed fashion. The purpose of these tasks is to force you into a pressure setting and less to test your specific skill set.

As an attempt to defray the cost of residency interviews, social networking sites, such as MyInterviewTrail.com and StudentDoctor.net have been devised to allow applicants with common interview dates to share travel expenses. Nonetheless, additional loans are often required for "residency and relocation". A common provider may be found here.

Matching
Access to graduate medical training programs such as residencies is a competitive process known as "the Match." Senior medical students usually begin the application process at the beginning of their (usually) fourth and final year in medical school. After they apply to programs, programs review applications and invite selected candidates for interviews held between October and February. After the interview period is over, students submit a "rank-order list" to a centralized matching service (currently the National Residency Matching Program, abbreviated NRMP) by February. Similarly, residency programs submit a list of their preferred applicants in rank order to this same service. The process is blinded, so neither applicant nor program will see each other's list. Aggregate program rankings can be found here, and are tabulated in real time based on applicants' anonymously submitted rank lists.

The two parties' lists are combined by an NRMP computer, which (theoretically) creates optimal matches of residents to programs using an algorithm. On the third Thursday of March each year ("Match Day") these results are announced in Match Day ceremonies at the nation's 125 U.S. medical schools. By entering the Match system, applicants are contractually obligated to go to the residency program at the institution to which they were matched.

On the Monday prior to Match Day, candidates find out from the NRMP if (not where) they matched. If they have matched, they must wait until the Match Day (Thursday) to find out where. If they have not secured a position through the Match, the locations of remaining unfilled residency positions are released to unmatched applicants the following day. These applicants are given the opportunity to contact the programs about the open positions. This is what is known as "The scramble." This frantic, loosely structured system forces soon-to-be medical school graduates to choose programs not on their original Match list. Occasionally and unfortunately, this sometimes requires students to choose entirely new specialties. The scramble is widely considered to be an unfavorable and highly stressful way of obtaining a residency position.

Inevitably, there will be discrepancies between the preferences of the student and programs. Students may be matched to programs very low on their rank list, especially in the competitive specialties like dermatology, ophthalmology, orthopedics, radiology, and radiation oncology.

A similar but separate osteopathic match exists which announces its results in February, before the NRMP. Osteopathic physicians (DOs) may participate in either match, filling either traditionally allopathic (MBBS,MD,MBChB,etc) positions accredited by the Accreditation Council for Graduate Medical Education (A.C.G.M.E.), or osteopathic positions accredited by the American Osteopathic Association (A.O.A.).

In 2000-2004 the matching process was attacked as anti-competitive by class-action lawyers. See, e.g., Jung v. Association of American Medical Colleges et al., 300 F.Supp.2d 119 (D.D.C. 2004). Congress reacted by requiring that antitrust cases cannot make this argument. See Pension Funding Equity Act of 2004 § 207, Pub. L. No. 108-218, 118 Stat. 596 (2004) (codified at ).

The USMLE score is just one of many factors considered by residency programs in selecting applicants. The median USMLE Step 1 scores for graduates of U.S. Medical Schools for various residencies are charted in Figure 4 on page 11 of "Charting Outcomes in the Match" available at http://www.nrmp.org/matchoutcomes.pdf. Program rankings are calculated in real time by aggregate rank lists posted anonymously to MyInterviewTrail.com

History of long hours
Medical residencies traditionally require lengthy hours of their trainees. Early residents literally resided at the hospitals, often working in unpaid positions during their education. During this time, a resident might always be "on call" or share that duty with just one other doctor. More recently, 36-hour shifts were separated by 12 hours of rest, during 100+ hour weeks. The American public, and the medical education establishment, recognized that such long hours were counter-productive, since sleep deprivation increases rates of medical errors. This was noted in a landmark study on the effects of sleep deprivation and error rate in an intensive care unit. The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one overnight every third day, 30 hour maximum straight shift, and 10 hours off between shifts. While these limits are voluntary, adherence has been mandated for the purposes of accreditation.

Critics of long residency hours trace the problem to the fact that resident physicians have no alternatives to positions that are offered, meaning residents must accept all conditions of employment, including very long work hours, and that they must also, in many cases, contend with poor supervision. This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours.

Graduates of the old system (100+ hour work-weeks) postulate that shorter work hours may lead to residents gaining less clinical experience. Those who straddled both formats during training oft report the shorter work week did not reduce the amount of work to be completed. The 80-hour week simply ensured that one would have to be awake and working for the entirety of their time at the hospital, rather than having occasional time to sleep. Current data has now shown that there has been no reduction in medical errors since the institution of the 80-hour week, perhaps reflecting the increased intensity of the work.

Some of the clinical work traditionally performed by residents has been shifted to non-physician personnel. This may include some of the non-patient care facets of medicine typically referred to as "scut work."

Adoption of an 80 hour work week
Regulatory and legislative attempts at limiting medical resident work hours have been proposed, but have yet to attain passage. Class action litigation on behalf of the 200,000 medical residents in the US has been another route taken to resolve the matter.

Dr. Richard Corlin, president of the American Medical Association, has called for re-evaluation of the training process, declaring "We need to take a look again at the issue of why the resident is there."

The U.S. Occupational Safety and Health Administration (OSHA) rejected a petition seeking to restrict medical resident work hours, opting to rely on standards adopted by ACGME, a private trade association that represents and accredits residency programs. On July 1, 2003, the ACGME instituted standards for all accredited residency programs, limiting the work week to 80 hours/wk averaged over a period of four weeks. These standards have been voluntarily adopted by residency programs.

On November 1, 2002, the 80-hour work limit went into effect in residencies accredited by the American Osteopathic Association (AOA). The decision also mandates that interns and residents in AOA-approved programs may not work in excess of 24 consecutive hours exclusive of morning and noon educational programs. It does allow up to six hours for inpatient and outpatient continuity and transfer of care. However, interns and residents may not assume responsibility for a new patient after 24 hours.

Though re-accreditation may be negatively impacted and accreditation suspended or withdrawn for program non-compliance, the amount of hours worked by residents still varies widely between specialties and individual programs. Some programs have no self-policing mechanisms in place to prevent 100+ hour work-weeks while others require residents to self-report hours.

Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care.

Changes in postgraduate medical training
Many changes have occurred in postgraduate medical training in the last fifty years:
 * 1) Nearly all doctors now serve a residency after graduation from medical school. In many states, full licensure for unrestricted practice is not available until graduation from a residency program. Residency is now considered desirable preparation for primary care (what used to be called "general practice").
 * 2) While physicians who graduate from osteopathic medical schools complete a one-year rotating clinical internship prior to applying for residency, the internship has been subsumed into residency for allopathic physicians. It is now uncommon for an allopathic physician to take a year of internship before entering a residency, and the first year of residency training is now considered equivalent to an internship for most legal purposes. Certain specialties, such as ophthalmology, radiology, anesthesiology, and dermatology, still require prospective residents to complete a separate internship year, prior to starting their residency program training.
 * 3) The number of separate residencies has proliferated and there are now dozens. For many years the principal traditional residencies included internal medicine, gynecology, pediatrics, general surgery, ophthalmology, orthopaedics, neurosurgery, otolaryngology, urology, physical medicine and rehabilitation, and psychiatry.
 * 4) Pay has increased, but residency compensation continues to be considered an educational stipend and is not sufficient as a "living wage". Additionally, few residents live in hospital-supplied housing anymore, but unlike most attending physicians (that is, those who are not residents), they do not take call from home; they are usually expected to remain in the hospital for the entire shift.
 * 5) Call hours have been greatly restricted. In July of 2003, strict rules went into effect for all residency programs in the US, known to residents as the "work hours rules". Among other things, these rules limited a resident to no more than 80 hours of work in a week (averaged over 4 weeks), no more than 30 hours of clinical duties at a stretch with an additional 6 hours for transferring patient care and educational requirement (with no new patients in the last six), and call no more often than every third night. In-house call for most residents these days is typically one night in four; surgery and obstetrics residents are more likely to have one in three call. A few decades ago, in-house call every third night or every other night was the standard.
 * 6) For many specialties an increasing proportion of the training time is spent in outpatient clinics rather than on inpatient care. Since in-house call is usually greatly reduced or absent on these outpatient rotations, this also contributes to the overall decrease in the total number of on-call hours.

External links and sources

 * Match anti-trust suit dismissal
 * The Accreditation Council for Graduate Medical Education in the United States
 * The American Osteopathic Association Accreditation for osteopathic residency
 * FindArticles.com - 'Medical education's dirtiest secret - use of medical residents', Humanist, M.H. Klaiman (November-December, 2003)

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