Whereas medical school teaches medical practitioners 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 medical practitioner may choose a residency in anesthesiology, sports medicine, dermatology, emergency medicine, family medicine, internal medicine, internal medicine/pediatrics, neurology, obstetrics and gynecology, pathology, pediatric medicine, psychiatry, physical medicine and rehabilitation, radiology, radiation oncology, or other specialties (e.g., surgery).
In Canada it leads to eligibility for Certification by and Fellowship of the Royal College of Physicians and Surgeons of Canada.
In the United States it leads to eligibility for board certification and membership/fellowship of several specialty colleges and academies.
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.
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 needed reform. On call time was unpaid until 1975 (the year of the interns' one-day strike), and for a year or two depended on certification by the consultant in charge - a number of them refused to sign. On call time was at first paid at 30% of the standard rate. Before paid on call was introduced, there would be several house officers "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. Outpatients were not usually a junior house officer's responsibility, but such clinics formed a large part of the workload of more senior trainees, often with little real supervision.
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.
Research fellows and PhD candidates are often clinical assistants, but a few were senior or specialist registrars. A large number of "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 a junior or middle grade practitioner or with a consultant.
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.
Some subspecialties hold interviews in a more competitive format. In certain surgical subspecialties, for example, applicants have been asked to whittle a nose from a bar of soap and to tie suture in a timed fashion. The purpose of these tasks is to force an applicant into a pressure setting and less to test his or her specific skill set.
As an attempt to defray the cost of residency interviews, social networking sites have been devised to allow applicants with common interview dates to share travel expenses. Nonetheless, additional loans are often required for "residency and relocation".
International medical students may participate in a residency program within the United States as well but only after completing a program set forth by the Educational Commission for Foreign Medical Graduates (ECFMG). Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG) assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).
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. The same applies to the programs; they are obligated to take the applicants who matched into them.
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 radiology, dermatology, ophthalmology, orthopedics, otolaryngology, radiation oncology, and urology.
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 Medical Doctor (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.
Critics of long residency hours trace the problem to the fact that a resident 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 healthcare workers: ward clerks, nurses, laboratory personnel (urinalysis), phlebotomists (blood ailments e.g. atherosclerosis). This may include the non-patient care facets of medicine typically referred to as scut work.
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 filed by the Committee of Interns & Residents/SEIU, a national union of medical residents, the American Medical Student Association, and Public Citizen that sought to restrict medical resident work hours. OSHA instead opted 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. Fear of their program losing accreditation sometimes leads residents to underreport hours worked.
Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care.
Recently, there has been talk of reducing the work week further, to 57 hours. In the specialty of neurosurgery, some authors have suggested that surgical subspecialties may need to leave the ACGME and create their own accreditation process, because a decrease of this magnitude in resident work hours, if implemented, would compromise resident education and ultimately the quality of physicians in practice AANS News. .. It should be noted, however, that in other areas of medical practice, like internal medicine, pediatrics and radiology, reduced resident duty hours may be not only feasible but advantageous to trainees because this more closely resembles the practice patterns of these specialties. In addition, there are no "outcomes studies" or other substantive data to support either conclusion.
Many changes have occurred in postgraduate medical training in the last fifty years: