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Internship, Residency and Fellowship

Residency is a 3+ year training program in a medical specialty. The first year of training after medical school is called internship, or more commonly it is called first year of residency or PGY-1 (PostGraduate Year-1). The following years are called PGY-2, PGY-3, etc. The training that is done after a residency (in a subspecialty) is usually called a fellowship. Much of what you will learn in your chosen specialty will be learned in your residency.

It's hard to believe that, after 12 years of school, 4 years of college and 4 years of medical school, there is still so much to learn. The first 20 years of school are the foundation and the tools you will need to learn your specialty. During your residency you will learn medicine by caring for patients with a variety of diseases. The more patients you care for, and the more disease and variations of disease that you see and treat, the more proficient you will become. The knowledge obtained from patient care is supplemented with lectures and conferences.

There are so many different residencies, but generally the first year of residency (internship or PGY-1) is spent either rotating through different specialties or rotating to different areas within one specialty. In my case I spent the year rotating, in 1 month intervals, to the ER, General Surgery, Internal Medicine, Intensive Care Unit, Orthopedics, Pediatrics and OB/GYN. After the first year much more emphasis is placed on your own specialty.

A typical day in residency starts around 7AM. First you see your patients prior to "rounds" to check on the results of diagnostic tests, to see how they are responding to therapy. Next are "rounds" with your team. A team usually consists of several interns, a upper level supervising resident, and an attending or teaching physician. They take care of a specific group of patients. "Rounds" mean you walk around to each patient to discuss his or her care. Suggestions on further diagnostic tests and treatments are the usual topics of discussion. After rounds you may return to see some patients in more depth, do whatever procedures need to be done, talk to the patient's private physician, etc.

Usually there is a lecture or conference at some point in the day. After lunch new patients are often admitted to your team. You will need to do a history and physical exam. Then write their admitting orders. These are written instructions about which tests, medications, etc. are to be given for this patient. At the end of the day you "sign out" to the team that is "on call" that night. This is done to tell them about either all your patients or the ones that may run into trouble that night. At home it is important to continue to read about medicine, especially at this point in your career. However, fatigue plays a big role and you often need recovery sleep from your night on call.

On Call

Being on call while in residency means that you stay in the hospital over night and care for the patients on your team and the other teams, and care for the new admissions. This means you will be working up to 30-36 hours with little or no sleep. This is done every 2nd, 3rd, or 4th night depending on the institution and specialty you are in. This is a long-standing tradition in medicine. Many people outside the medical field see this as an unnecessary, perhaps dangerous tradition. The argument on the other side goes that the more experience you have treating patients and their diseases the better you will be as a physician. In order to see the same number of patients from 9AM-5PM, the length of training programs would need to be considerably longer. Also, someone needs to care for patients after hours. An old saying in medicine goes - the only thing wrong with being on call every other night is that you only get to see half the patients.

An intern is at the bottom of the food chain at a teaching hospital. Any unpleasant, menial task (called "scut" work) is the intern's job.

Another medical tradition during internship is the phenomenon of "see one, do one, teach one". In other words when a procedure needs to be performed you see someone do it. Next time it needs to be done you do it. The following time, now that you are an expert, you teach someone else to do it. This is how some medical knowledge gets passed on.

At this point you are finally being paid for your services. The mean salary for a first year resident in 1998-99 was $34,104. For each additional year of residency the mean salary increase was $1,451 see this page for details).

Medical License

After completing a residency or fellowship, you must obtain a medical license so that you can practice medicine. Each state has its own individual rules. For graduates of U.S. medical schools this is a relatively straightforward procedure. Generally you have to have graduated from an approved medical school in the U.S. Medical schools are approved or accredited by the Liaison Committee on Medical Education (LCME), which is a joint committee of the Association of American Medical Colleges (AAMC) and The American Medical Association (AMA). Many states require only 1 year of training after medical school (internship) in an approved residency program as the bare minimum for obtaining a license. Residency programs are accredited by the Accreditation Council of Graduate Medical Education (ACGME) through the Residency Review Committees (RRC). You need to have passed one of several exams to prove that you are competent (such as the USMLE). Letters of reference are usually required. A check of your malpractice history will also be obtained. The rules for graduates of foreign medical schools are more complex and can be obtained from each state medical licensing board.

Board Certification
Becoming a board certified physician in a specialty involves the completion of a residency in a given specialty, then completing a comprehensive exam (often a written and oral exam). When you have satisfied the requirements of that particular board you are now Board certified and are called a Diplomate of that board (e.g. Diplomate of the American Board of Emergency Medicine). There are 24 approved medical specialty boards in the U.S. (seewww.abms.org, the American Board of Medical Specialties). Many boards require recertification every 7-10 years.

Now it is time to find a real job. You can join a group practice, start your own private practice, join a clinic or join an H.M.O. Some physicians are hospital based (emergency physicians, radiologists, pathologists, anesthesiologists) but can be part of a private practice or an employee.

I hope you have enjoyed our long journey on the road to Becoming a Doctor. It has been a long and fruitful one for myself and many others.

About the Author:
Dr. Carl Bianco, M.D. is an Emergency Physician practicing at Dorchester General Hospital in Cambridge, MD, located on the Eastern Shore of Maryland. Dr. Bianco attended Medical school at Georgetown University School of Medicine and he received his undergraduate degree from Georgetown University majoring in nursing and pre-med. He Completed an internship and residency in Emergency Medicine at Akron City Hospital in Akron, Ohio.

Dr. Bianco lives near Baltimore with his wonderful wife and two wonderful children.