How is doctor formed?

November 7, 2012 12:59 PM

Please explain the American medical educational system to me like I'm a small child. The Wikipedia article isn't very clear.

I don't get this med school/intern/residency thing, and I don't understand the (educational) difference between, say, a psychiatrist, a neurosurgeon, and a family practice doctor. In the US. I realize this is a dumb question.

I'm particularly interested in psychiatry. I know my psychiatrist completed her residency last year. That basically means she's right out of school, right? How much psychology/psychiatry did she really have to tske? She works in a large office with many other mental health people - because she doesn't have the experience to work on her own, or what?

But I'm also interested in the overall American medical educational system, because I'm embarrassed that I don't know. Thanks.

posted by edrnjevich to education (19 answers total)

Medical school is four years. After you graduate, you go into a residency program. You are officially a doctor, but you are still learning. You get paid, but not nearly as much as you will be when you complete residency.

Residency lengths vary depending on your specialty, generally from 3-5 years. First year residents are often called interns. You might also take a year in there do a fellowship-basically a special focused program somewhere.

After you complete residency, you are an attending, and are basically completely finished with your training.

If your psychiatrist finished her residency last year, she is not a newbie. Presumably she chose to work in an office with other folks, rather a separate practice.

[FWIW, my wife is a child psych resident]
posted by Chrysostom at 1:09 PM on November 7, 2012 [1 favorite]

So, it varies. Everyone goes through 4 years of medschool, that generally consist of 2 years of like standard classroom work, and then 2 years where you're rotating through different specialties getting a feel for what they actually do.

Then, it varies a lot. Some specialties (like family practice) have a relatively short residency (~3 years). Some -- like neurosurgery, could have an internship year plus 6-8 years of residency.

Your psychiatrist is probably 4 or 5 years out of school if she just finished her residency -- 1 year of Internship plus 3 or 4 years of residency -- but it varies some.
posted by brainmouse at 1:10 PM on November 7, 2012

Oh, in your specific examples, a family practice doctor would probably have a three year residency. Neurosurgeon probably five.
posted by Chrysostom at 1:10 PM on November 7, 2012

You go to medical school to learn the "basics" of being a doctor.

Internship can occur before or right along with Residency. Think, fresh medical degree but hasn't had any experience. You're supervised in this step.

Residency is when you learn specifics to the different kinds of medicine. It's when you specialize. In your case, you would aim to be a resident of a clinic or psychiatric hospital. You're also supervised in this step.
posted by royalsong at 1:15 PM on November 7, 2012

Admission to medical school in the US generally requires a four-year bachelor's degree or its equivalent.

Obtaining an M.D. through medical school generally takes four years. The first year or two are classroom/lab study, and the following two to three years are clinical training in a teaching hospital or other location under the instruction of a licensed physician. After graduation with the M.D., student cannot practice independently and will practice in a medical residency under supervision of experienced physicians. The length of residency can vary from several to seven years based upon subject area of specialization. A brain surgery residency will be longer than a residency for family medicine.

During this process, students sit for various levels of the United States Medical Licensing Examination (USMLE). The first step is generally taken after the second year of medical school, the second step during the fourth (final) year of medical school, and the third and final step after the first year of residency.

Your psychiatrist is competent to practice medicine unsupervised if she is no longer in residency. Her residency was at least four years long.
posted by Tanizaki at 1:16 PM on November 7, 2012

Also: in college/university, you usually major in "pre-med", which consists of a lot of chemistry and biology courses.
posted by Melismata at 1:17 PM on November 7, 2012

After high school, those wishing to become doctors attend a four year university course. They can major in any subject, but must take certain science, math, and other courses required for admission to medical school and to prepare them to take the MCAT (Medical College Admission Test).

If accepted into medical school, they spend four years in medical school. The classes are a mixture of science courses and more practical hands on training.

After medical school they do an internship. This can be either stand-alone or integrated as part of the next stage of their specialty training. After internship, doctors can practice medicine independently without supervision of a licensed physician, but most continue on to a specialty training program called a residency.

Residency training follows internship training or includes it as part of an integrated program. Its length veries depending on specialty. The shortest residency programs (e.g. family medicine) are three years, the longest, I believe seven years. Or residency in a specialty (e.g. "general surgery" which is a specialty despite having "general" in the name) might be followed by another period of training called a "fellowship" in a subspecialty.

Residents are so called because they used to live in the hospital where they were working, as opposed to their teachers/supervisors, the attending physicians who did not reside at the hospital. Residency training formerly involved extremely insane working hours. Recently these conditions have been somewhat ammeliorated.
posted by Jahaza at 1:17 PM on November 7, 2012

When your psychiatrist did her residency, she was only doing her psychiatry specialty. So no, she's not just out of school. From my observation though, physicians (at least all the ones I know, incl my husband) tend to downplay their residency (and fellowships, if they choose to further specialize) as it's still a training position, even though they are getting paid.
posted by gaspode at 1:26 PM on November 7, 2012

A big difference between the US and many other countries is that med school starts after the bachelor's degree, not as part of it.

So to give a friend's career as an example, she first earned a BA in history. Then she decided to become a doctor, so she went back to school and took undergraduate courses in science (biology, physical chemistry, organic chemistry, etc.). Then medical school. Then a year of internship. Then two years of residency (when she finally got paid a tiny salary). Then two years of fellowship (with a slightly larger salary).
posted by Sidhedevil at 1:35 PM on November 7, 2012

Thanks, it's making sense!

Where do students split off into their specialties? On, say, Gray's Anatomy, they imply the residents do rotations through different things.

(I like this psychiatrist just fine, I'm just using her as an example. I was Googling her and was surprised to learn that maybe she was only my age.)
posted by edrnjevich at 1:55 PM on November 7, 2012

I've never seen Grey's Anatomy, but they are surgical residents right? So presumably they are doing rotations through different types of surgery (cardiothoracic, orthopedic etc)?

For pathology for example, residency is full of rotations in that you move from breast pathology to gastrointestinal pathology to blood bank to neuropathology etc etc etc. Most people futher specialize in fellowships (my husband did a fellowship in liver pathology and works with a liver transplant team for example).

Psychiatrists I'm not sure about, maybe would specialise in for example child psychiatry or forensic psychiatry fellowships? I have a couple of psychiatrist friends and they went straight into private practice after their residencies. That was about 10 years ago though.
posted by gaspode at 2:01 PM on November 7, 2012

Also: in college/university, you usually major in "pre-med", which consists of a lot of chemistry and biology courses.

Many universities do not have a "pre-med" major. Instead, undergraduates can major in any subject, which may be something in the biological sciences, or may be something totally different like music. The essential thing is to take courses that are prerequisites for medical school admission and that teach essential knowledge for passing the MCAT. Many students also take additional private classes targeted just at the MCAT.

On, say, Gray's Anatomy, they imply the residents do rotations through different things. Would my psychiatrist's residency been all psychiatry, all the time, or would she have been rotating through other things too?

If she did a psychiatry residency, it's going to be all psychiatry all the time. For some fields the residency may be broader—a number of what lay people regard as specialties (such as cardiology) are sub-specialies of internal medicine, and will require a residency in internal medicine to start with. In other specialties the internship year might have rotation through various sub-specialties that most lay people will lack familiarity with. For example, a friend of mine is a pathology resident and had to do rotations in blood banking, laboratory medicine, autopsies, and others, in her first year. But now she does blood bank work all the time.

Students engage in clerkships, rotations through any area of medicine, in the third and fourth year of medical school. They usually get a broad exposure to lots of specialties in this time period.
posted by grouse at 2:02 PM on November 7, 2012

Mostly but not all right so far:

Four years of college is the accepted normal although some programs may or may not waive all four years if you have 90 credits. I've never seen this, but allegedly it happens.

Four years of medical school, although a few schools in the US combine either college & medical school, allow you to graduate in three years, or combine MD/PHD (six years, I believe, not certain).

Internship is no longer the word used for the first year of residency, but it was formerly used to refer to the post-graduate year 1 (PGY-1).

So internship is an outdated term that refers to the first year of residency.

Residency ranges from three years (Family Medicine, Internal Medicine) to 7 or 9 years for some surgical subspecialties such as neurosurgery. Sometimes residents will stay on an extra year as chief resident, which can either be an honor or just a matter of being in charge of paperwork. Sometimes the final year is an automatic promotion of the resident to chief resident, but not always.

Fellowships are slightly higher paid advanced residency, done after residency, where you can further specialize in a branch of your field, such as internal medicine -> nephrology.

In some fields like radiology your PGY-1 year may be done at a completely unrelated field like internal medicine or surgery for reasons that totally escape me.

Some residency spots are considered allotted to Doctors of Osteopathy and some spots are allotted to allopathic (MD) graduates, and depending on who you ask there is or is not rampant bias when a DO applies to an MD residency and vice versa.

DO students take the COMLEX which includes some aspects of their philosophy as well as their massage stuff, and if they want to apply to an allopathic residency they are generally required to take the US Medical Licensing Exams in addition to their COMLEX.

The residency match algorithm recently won a noble prize for its advanced and arcane mathematics. Students begin applying in their fourth year starting in September, interview with programs for a few months, and then are notified of the lottery results in mid-March. Residency begins July 1st every year.

Residents are paid between 30,000 (Puerto Rico) to 65,000 out of a general pool from the Medicare fund for graduate medical education, where 100,000 are given to each institution for their troubles.

In 2015 residency spots are projected to hit the fan as the number of American Medical Graduates is going to hit parity with the amount of residency spots.
posted by hobo gitano de queretaro at 2:06 PM on November 7, 2012 [1 favorite]

It is not true that psych residents only do psych. Their first year may require up to six months of stuff like general internal medicine.

The whole point of medical training is to ostensibly recognize when something else outside your specialty may be going on so you can refer them to the proper people.

This is considered one reason why medical training of doctors is considered superior to mid-levels (physician assistants and nurse practitioners) because they are not required to gain exposure to other fields and thus may not always know the limits of their knowledge.
posted by hobo gitano de queretaro at 2:09 PM on November 7, 2012 [1 favorite]

Medical students during their third year are required to take at least one month (up to three) of surgery, internal medicine, psychiatry, OB-GYN, pediatrics, and family medicine. Their fourth year ends up as mostly vacation and interviews, but many schools also require a re-do of internal medicine as well as optional stuff like emergency medicine, in addition to electives. This would be when students do subspecialty rotations of their choice; pathology, cardiology, radiology, the more arcane medical fields.

Residents sometimes but not always rotate through subspecialties during their residency, that is more dependent on where they are training. Sometimes there may not be any subspecialists at that hospital so there's no way to gain experience in organ transplantation during your surgical residency without doing a fellowship.
posted by hobo gitano de queretaro at 2:12 PM on November 7, 2012

hobo gitano de queretaro: "It is not true that psych residents only do psych. Their first year may require up to six months of stuff like general internal medicine.
"

Yes, this is exactly right.
posted by Chrysostom at 2:12 PM on November 7, 2012

I missed this part of your question originally, but the majority of american physicians now work for other people or larger organizations because they do not want to run an increasingly complicated small business. You can't just hire a receptionist and call it a day anymore.

Medical billing is an absolute nightmare, so it's nice to have that taken care of, even if the true cost is mostly shifted onto the patients. Fraud in medical billing is rampant right now, due to equal parts of poor training in medical billing, shady behavior by insurance companies, and simple greed. Nobody is doing anything about it, either. I don't mean in hospitals, I mean in private practice.

Medicare's punishment for blatant and outright fraud (billing for far more visits than would be literally possible in a 24 hour period) is generally, at worst, just a warning and an empty threat to suspend payments at some undefined point in the future.
posted by hobo gitano de queretaro at 2:22 PM on November 7, 2012 [1 favorite]

Medical school: The first 2 years are preclinical classes (biochem, anatomy, physiology, pathology, etc.). Medical students may have a little contact with patients during this time, but it will be minimal and most of their time will be spent in the classroom.

The second 2 years are spent in the clinical setting, doing 1-2 month long clinical rotations in a very wide array of specialties. The 3rd year is spent doing core rotations (the ones everyone has to do) usually include surgery, pediatrics, OB/GYN, internal medicine, neurology, family medicine, psychiatry, and may include time in anesthesia, ophthalmology, dermatology, radiology, pathology, etc. 3rd year students ("clerks") are actively involved in patient care but work under the supervision of both the senior attending physician and one or more more senior residents.

During the 4th year of medical school the student chooses a field to specialize in (like surgery, dermatology, radiology, psychiatry, internal medicine) and does a 1-2 month "sub-internship" where he/she is basically an acting first-year resident. THe rest of the year is spent doing more elective rotations in (usually) a wide variety of specialties including some that will have nothing to do with their future specialty and are taken for general education/interest. They also spend quite a bit of time applying for residency positions at hospitals, going on interviews, and doing rotations at hospitals where they think they might like to do residency as a kind of audition.

The process by which applicants are matched to a residency program is complicated but is basically done by computer algorithm. Everyone gets their match and finds out where they're going on the same day.

PGY-1 (Post Graduate Year) residents (interns--and everyone still calls them that) are MDs, and are able to do a lot of work independently (like order tests for patients) but not licensed to practice and subject to a lot of supervision by both attending physicians and more senior residents. Residents continue to do 1-2 month long rotations through specific specialties or activities, although this is usually more focused (e.g., an internal medicine resident would do a month of general hospital work, a month of hepatology (liver medicine), a month of cardiology, a month of outpatient primary care, etc. A surgery resident would do a month of general surgery, a month of plastic surgery, a month of trauma surgery, etc. A pathology resident would do a month of surgical pathology, a month in the blood bank, etc.

In most places you can apply for your license after the PGY-1 year, which means you can prescribe medications independently. Residency programs often have very different approaches to whether they encourage their residents to become licensed early or not.

PGY-2 and after--residents get increasingly more autonomy and independence although they are still not allowed to practice fully independently. As others have noted residencies are usually 3-7 years in total.

After residency the doctor takes a specialty board exam which certifies that they have attained a reasonable mastery of the knowledge expected of their specialty. These aren't strictly required to practice, and some solo practitioners don't bother to get board certified, but it's almost impossible to get hired by a hospital or a group practice without board certification.

After residency doctors have a choice--to practice or to go for further training in a subspecialty fellowship. A fellowship is like a continuation of residency but with further narrowing of the specialty rotations and a further increase in autonomy. At the end of fellowship there is usually another board exam.

After that you are an attending physician and are allowed to practice fully independently and bill for your services, which residents can't do.

A psychiatric residency is usually 4 years in total, of which half the first year is spent doing non-psychiatric things (usually internal medicine, neurology, and emergency medicine). So your psychiatrist has at least completed 8 years of medical training and no longer requires supervision to practice.

I wouldn't be concerned about the group practice thing. Most physicians now are joining group practices, mostly due to issues around negotiating reimbursement rates and centralizing billing, (it's easier for a 100-doctor group to negotiate with Aetna or Blue Cross than for a single MD), sharing support staff, and for lifestyle reasons like sharing responsibility for after-hours emergencies or wanting to practice part-time. It's also reassuring for a relatively new attending physician to have other people in the same specialty around to answer questions and bounce ideas off of--although they may feel perfectly comfortable most of the time, there will always be cases where you're not quite sure what the best plan is.
posted by The Elusive Architeuthis at 2:40 PM on November 7, 2012 [2 favorites]

We attend a pediatric practice that is the med school practice and they always have two Third Year students who are rotating through, usually for a month at a time. They are adorable, they all look twelve, and I want to eat them all up because they are so cutely nervous. Generally the first few days of the month they follow the doctors around; in the latter half of the month, they come in, do a solo exam just like the regular doctor and give some advice and patient education to me, and then go out and report to the attending doctor. Then the attending doctor (our actual pediatrician) comes in and redoes the whole thing while the student watches.

It is very interesting for me as a patient parent, but it makes our appointments very long!

The hospital in our network is the teaching hospital for the med school so I've had student doctors in various stages of their process, including a student anesthesiologist for my second c-section. They actually always explain a lot about the who's supervising and how far along the student is and so on. Mostly I do not mind being a practice patient, you get a pretty high standard of care because the supervising doctor spends an extra long time with you. If your psych didn't have the experience to work on her own, I think she'd have to tell you who was supervising her.
posted by Eyebrows McGee at 2:53 PM on November 7, 2012