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Residency Training

Overview

Residency training is mandatory training which follows medical school if you desire to practice medicine in the United States. Technically, at least one year of residency training (in some states up to 3 years) is the minimum requirement for obtaining a medical license in most US states, but in order to obtain board certification and employment, the entire residency training has to be completed.

To see where residency training falls in the entire medical education process, check out the overview of medical education and training. To learn more about specific specialties and find one matched to your personality, use SDN's Specialty Selector.

Getting into residency

You "get into residency" by applying at the end of 3rd year and interviewing during the beginning of 4th year of medical school. Many factors are important in being able to get into your residency of choice:

1. Board scores (very important, especially if applying to a competitive specialty or program)
2. Grades & honors
3. Recommendation letters from the Dean and faculty members in the specialty of interest
4. Research (required for some residencies) - ideally within the field
5. The decision makers know you personally (doing an effective rotation there can be key)
6. A good interview

After interviewing all candidates, the residency programs make a "rank list" with the most desirable applicant they want in their program on top and down the list to the least desirable. Students do the same, making a rank list with their "first choice" program in the first spot, listing 5-10 programs (or so) from most desirable to least desirable.

On "Match Day" (middle of March) each year, a computer matches applicants with positions ("The Match" or more officially called the "NRMP") and you find out where you will spend the next few years for training. Most people match in their first choice or at least in the first 2 or 3.



MD and DO residencies

There are roughly 17,000 graduates from US allopathic (MD) medical schools and about 3,000 graduates from US osteopathic (DO) medical schools each year, all of which participate in different residency match programs to get into residency. In addition to these 20,000 US graduates, approximately another 12,000 international medical graduates (IMGs) also participate in the residency match programs each year.

The NRMP (or National Residency Match Program), primarily catering to the MD graduates, but also accessible to DO graduates and IMGs as independent applicants, offers by far the most residency positions - about 21,000 per year. The osteopathic match offers another 1,000 residency spots to DO graduates, although this is insufficient to offer all DO graduates residency positions (more about his below).

So, adding up some numbers, it is apparent right away that there are fewer positions available (roughly about 22,000 spots including MD and DO residencies) than applicants for residency (32,000 total applicants including US graduates and IMGs). If only considering US medical school graduates, including both MD and DO, there is actually a surplus of residency positions since there are only approximately 20,000 total graduates and 22,000 residency spots available each year.

Needless to say, when looking at all the 32,000 or so applicants for residency, many graduates don't match at all - particularly IMGs. In the 2002 NRMP match, 94% of MDs matched, 71% of DOs matched and 52% of IMGs matched. It is also interesting to mention that about 10% of the residency positions of the NRMP Match were not filled that year.

Note, however, that many applicants and some residency programs never go through the match. Applicants can arrange their own residencies without going through the match and some residency programs just don't use the NRMP. Also, there are a few specialty matches for the very competitive residency programs, such as Plastic Surgery, Urology, Ophthalmology, Neurosurgery and a few others, which add more residency spots to the total number of spots available each year.

Training

Most residency training is anywhere from 3-7 years in length, often followed by a fellowship for additional subspecialty training.
For example: Internal medicine residency (3 years) followed by a Cardiology fellowship (3 years) or anesthesia (4 years) followed by a pain management fellowship (1 year) or plastic surgery (5 years) followed by a hand surgery fellowship (1 year). The minimum is 3 years (internal medicine, family medicine, pediatrics) and the maximum is around 7 years (neurosurgery and others with fellowship). Most surgery specialties are about 5 years without additional subspecialization such as thoracic surgery, for example.

Physicians are paid a salary during residency. The salary ranges from about $35,000 to $45,000 per year, depending on specialty, location and years of experience (years in residency).
If you are on a military scholarship, and therefore in a military residency (read more under scholarships in the Loans and Scholarship section) your salary and benefit package can get close to $60,000 per year for residency, depending on various factors.

Residencies and specialties vary greatly in their intensity and time commitment.
Some residencies are 45 hours per week (dermatology, oncology, etc.) with little or no call. Others are brutal, like most surgical, internal medicine, or other inpatient residencies with 80 hours or more a week.

At the end of residency, you take the last board exams (step 3) for board certification in your specialty.

Also, during residency training, the more senior residents are involved in teaching the more junior ones and often some medial students as well. You often hear "see one, do one, teach one" when referring to residency training. So, residency training, most often, includes learning and teaching those who follow behind to some extent.

Schedule

By law, residency programs are officially limited to 80 hours per week, but quite a few programs still ignore that limit and residents in these programs exceed 80 per week. A few years back, there were no limits and residents routinely worked 100-120 hour a week.

The first year of residency (often still called the "Internship" year) is crazy. Don't plan to see your family. Almost regardless of specialty you have a heavy call schedule (every 4th night you stay at the hospital - for up to 36 hours at a time) and lots of hours. You are again (or still) at the bottom of the hill and it all rolls downhill.

Usually things improve somewhat after the 1st year of residency and it gets better. Some people say that it is during the first year of residency where you learn 90% or more of all you'll ever need to know - a very intense experience. It is also after the 1st year or residency that you can get licensed in most US states, and, depending on specialty, you can start moonlighting (working outside of residency) to earn some extra money on the side. Of course, this is not true for all specialties. Moonlighting is not possible after completing just the first year of most surgical residencies, for obvious reasons.

Again, the 80 hour limit, imposed a few years ago, is not necessarily followed by all residency programs, yet. Also, programs can file for an exemption to raise hours from the 80 hour work week, which some programs have done. It pays to check out the hours residents put in at a residency program you are interested in. Things are likely to improve with time and perhaps hours will be reduced to some number under 80, eventually.

DO Residency considerations

Most of the available residency positions in the United States are ACGME-approved for MDs, while only very few residency positions are funded and approved by the AOA (American Osteopathic Association) for DOs alone.

There are about 3,000 DO graduates per year, compared to only about 1,000 AOA (DO) available residency positions. This creates a problem for DO graduates and most of them will have to enter MD residency programs for training each year. Military residencies are also approved for DOs by the AOA, so this presents another alternative to stay with AOA residency programs.

So, what's the fuss about AOA approved residencies and why would a DO graduate really care? Well, the ACGME (for MDs) and the AOA (for DOs) handle physician licensing in each state and the AOA does not like DO physicians to train outside of its approved programs. The AOA may prevent you from getting a medical license in some states if you have completed a non-AOA-approved internship (first year) program.

To prevent this from happening, DOs can enter AOA-only accredited internships, AOA-ACGME programs with dual accreditation or military residency programs, which are typically accredited by both. Also, the AOA can approve additional residency programs which are currently not AOA-accredited on a case by case basis.

Also note, that it is very difficult for DOs to compete in some of the specialties with MDs.

Quoting from "Iserson's Getting Into A Residency", 6th ed, p. 362,
(see the recommended books list - I highly recommend this book):

"ACGME-approved training in some specialties is almost completely off-limits to Osteopaths. Chief among these are General Surgery and various surgical specialties, such as Colon and Rectal Surgery, Neurosurgery, Orthopedic Surgery, Otolaryngology, Pediatric Surgery, Thoracic Surgery, and Urology. Even in the military, it is nearly impossible for an Osteopathic medical school graduate to obtain a position in, and be allowed to finish, a Surgical residency program. This is controlled by the 'powers' granting accreditation to residency programs."

Military Residency

All graduates of the Uniformed Health Services University (UHSU) medical school have to go through the military match. Also, generally speaking, all graduates of any other medical school who participated in the military "HPSP" scholarship are required to go through the military match. If you don't know what these programs are, you can read more about both of these in the Loans and Scholarship section.

In the case of HPSP, the military is more lenient in allowing graduates to complete civilian residencies in some cases and then returning to the military to serve the payback period, afterwards. Also, for a few limited specialties, the military does not offer any residency positions at all. Neurosurgery is an example. In this case, only civilian residencies are an option and the military allows individuals to pursue civilian residency training in this case.

The results of the military match are announced in December, instead of March. If you are interested in a particular specialty, you can rank both military residencies and civilian residencies at the same time. However, if you match in the military residency, you are required to accept that residency position and to withdraw from the civilian match.

Note that the actual time spent in the military residency does NOT count as your service payback time. So, here are a few quick examples:

If you were on the HPSP program for 4 years during medical school, you owe the military a 4-year active duty commitment and a 4-year reserve duty commitment after residency. However, if your residency training takes longer than 5 years, you will owe one additional year of active duty service and one additional year of reserve duty service for each year over the 5 year limit.

So, let's assume you're residency and fellowship training take 6 years to complete, combined. You would owe the military 5 years of active duty payback and 5 years of reserve duty payback instead of 4 years each in this case. If your residency training only takes 3 years to complete, you still owe 4 years each in payback.

If you have attended the UHSU, the minimum payback is 7 years. Any additional time is added to this as well.

As already mentioned in previous discussions, military residencies are most often accredited by both ACGME (for MDs) and AOA (for DOs), although there are some disparities in the competitive surgical specialties, which are almost off-limits to DOs, as also discussed previously.

Other info

The FREIDA website is the official site for most residency and fellowship program information. You can find all types of great info, including average weekly work hours, resident salaries,

Another interesting site with residency reviews is Scutwork.com.


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