The Anatomy of Residency in the U.S.
Now that I have written about Pursuing Residency in the U.S., I realized that not all of us were familiar to the structure of residency training. There are some aspects of residency training that you will find similar almost everywhere in the world, but residency trainings in different countries also do some things differently.
So let’s go through the anatomy of residency in the US that hopefully will provide some illustration for those of you who are thinking about pursuing residency here. Just a little reminder, residency is specialty training, while fellowship is subspecialty training. I will only discuss about residency in this article. We may talk more about fellowship in the near future.
Q: I have finished medical school and do not want to pursue any specialties. Can I just take USMLE and apply for a medical license to practice as a general practitioner in the US?
A: No. Everyone who has completed his/her medical degree needs to go into residency to be able to obtain a medical license and practice in his/her area of interest.
Q: Then, who provide primary care in the US?
A: There are 3 specialties that are definitely considered as primary care in the US: family medicine, internal medicine, and pediatrics. In addition, obstetrics and gynecology are sometimes considered as primary care for women.
Family medicine is probably the closest US equivalent to what we know as general practitioner in Indonesia, since family physicians provide comprehensive health care for people of all ages.
Q: Do different specialties require different lengths of training?
A: Yes. Here is the concise table showing the length of training for different specialties. Of note, I will explain about transitional/preliminary year in the next question.
|Specialty||Length of residency training (in years, not including transitional or preliminary year)||Transitional/preliminary year needed|
|Plastic Surgery *||6||N/A|
* = Specialties that need specific number of years in surgery residency, but not the completion of the whole surgical residency, as a prerequisite
Q: What is transitional/preliminary year?
A: Transitional year is a one-year position with rotations through various disciplines (Internal Medicine, Surgery, etc.) preceding training in another specialty. Preliminary year is a one-year position in a given field (mostly Internal Medicine or Surgery) usually preceding training in another specialty. As you can see, the transitional year is similar in structure to the last two years of medical school, in terms of rotating through various specialties; while preliminary year is only in one specific specialty. Transitional/preliminary year is required by certain specialties as described in the table above.
Q: What is the clinical schedule like in residency?
A: Residency training is structured into blocks of rotation, which can be 2-week blocks or 4-week blocks depending on individual programs.
Just as what you would expect with residency training everywhere, the first year is usually the hardest one in terms of schedule. A first year resident is often called an “intern”. You will do a lot of inpatient care, have more in-house calls compared to your second and third year, and usually only have one or two blocks of elective. During inpatient rotations, you work in a team with a senior resident (2nd or 3rd year), (an)other intern(s), and an attending physician. Sometimes, a fellow (subspecialty trainee) is also a part of the team.
In second or third year, you will have more elective blocks where you can do rotations in subspecialties of your interests. For those interested in pursuing fellowship after residency, they usually choose the respective subspecialty as one (or more) of their elective blocks. Although the call schedule tends to get lighter in 2nd and 3rd years, the level of attached responsibility increases. Senior residents are expected to be able to lead the team when they are in inpatient services, formulate management plans for patients, and participate in teaching for interns and medical students. In other words, they are learning to be ready for the real world.
Some residency programs provide opportunities for the residents to do international electives, which usually take place in developing countries.
One of the interesting things about residency training in the US is that there are duty hour rules that have to be followed by residency programs in order to maintain their accreditation status. Residents are only allowed to work maximum 80 hours per week with 1 day per week allocated as a day off from all clinical duties, averaged over a 4-week period. Don’t worry, they also have vacation time, 3-4 weeks per year depending on the programs.
Q: What is the educational experience like in residency?
A: Residency programs are responsible in providing educational experience for the residents. However, just like everywhere else, the quality of educational experience in residency will be determined by the commitment of the individual program to resident education.
The structure of daily educational experience has some similarities to how it works in Indonesia. Generally, residents have morning report/conference for about an hour and noon conference for another hour everyday. In between, there is teaching round with their respective teams. The contents of these conferences may differ between programs, but usually include case report, didactic teaching on core topics in the specialty (by attending physicians, chief residents, or fellows), and journal club. It is important to note that this is the typical daily educational experience for non-surgical specialties. In surgical specialties, the schedule may be different given the fluidity of their day (e.g. they may have early surgeries scheduled etc.). In addition, non-surgical residents (e.g. Internal Medicine, Pediatrics, etc.) on emergency and intensive/critical care rotations do not usually follow the same schedule for the same reason as those in surgical specialties.
There is also a weekly grand round where distinguished speakers from the institution or outside are invited to give a talk, and quality improvement conference (or what is known as morbidity/mortality conference) once every few months depending on the programs. Some programs also have board preparation sessions for residents to prepare for their board certification exam.
Q: How about the exams and evaluations?
A: For most specialties, especially non-surgical, the formal written (or computerized) exam is once yearly, which is called in-training exam. There is no formal oral exam; however, residents will be evaluated by their peers, seniors/fellows, and attending physicians on every rotation they do based on their performance. In a lot of programs, the patients or patients’ caregivers and supporting staff are also given the opportunity to evaluate residents.
Each resident is assigned (or chooses) a mentor/advisor during his/her training, who is expected to provide guidance on career plans and/or personal development. In addition, he/she also needs to meet with the program director twice in a year to discuss about progress that have been made, areas that need improvement, and future career plans.
Q: Is research a component of residency training?
A: The short answer is yes. However, it is actually scholarly activity that is required during residency; which may range from a quality improvement project, case report, chart review, up to clinical, translational, or bench research. In other words, don’t be intimidated by the word “research” or “scholarly activity”. It is feasible to fulfill.
Q: What is a chief resident?
A: There are two meanings of chief resident. In primary care specialties, a chief resident is 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. In other specialties, a chief resident may refer to a resident in his/her final year of residency. A chief resident, especially in primary care specialties, usually coordinates the clinical and educational activities of the residents. In some programs, they may also function as “junior” attendings. Although it may seem like additional training with a lot of responsibility, being a chief resident for a year gives a significant weight in the resume, especially for those interested in pursuing a career in academics.
Q: What is board certification exam?
A: Once a resident completes his/her training, he/she will be eligible to sit for board certification exam to demonstrate through either written, practical, and/or simulator based testing, a mastery of the basic knowledge and skills of his/her respective specialty. A physician can still practice without being board certified because medical/surgical licensing is a separate process from board certification. However, most hospitals/medical centers require their physicians to be board certified. In addition, more fellowships (subspecialty trainings) expect the fellows to be board certified in their specialty (e.g. a fellow in Pediatric Neonatology is expected to be board certified in Pediatrics), at least during their subspecialty training.
I hope this gives some illustration on how residency works here in the US. As always, I can be reached at firstname.lastname@example.org if you have any questions.
Nurul Itqiyah Hariadi is currently a fellow in Pediatric Infectious Diseases University of Michigan. She received her M.D. degree from Universitas Indonesia in 2004. Prior to her current training, she completed her residency at Children's Hospital of Michigan (2007-2008) and UCLA Pediatric Residency Program (2008-2010). She lives in Ann Arbor, Michigan, with her husband, a 6-year old daughter, and a baby son.