How Medical Residency is Like in the USA
Mar 14, 2022
Published by Kathrin O'Neill
A general perception among aspiring doctors is that getting accepted to a medical program is the final step in their quest to become certified healthcare professionals. That perception changes quickly as they start attending medical school and realize this is just the beginning of a long journey to become a doctor. In the United States (USA), residency training is a crucial and defining part of every medical student's journey. It occurs when you obtain your MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine) degree. Do you have any idea what residency is like in the USA? No?
Don't worry. This article contains valuable insights into USA medical residency. You will learn all the necessary details you need to know to understand residency training in the USA. You will learn what to expect during this postgraduate training program and the overall residency experience.
In the USA, medical residency is a training period every medical graduate has to undergo after completing medical school. During the training, graduates have to perform the same duties as professional doctors, but the difference will be that a certified and experienced physician will supervise them. Residency is a postgraduate program to help fresh medical graduates learn to apply their knowledge and skills in the practical world under the mentorship of their peers. St. Mark's Hospital in Salt Lake City, Utah's General and Trauma Surgeon, Dr. Buck Parker said:
"The only way you're going to learn medicine is through experience and mentorship."
During and after graduation, doctors in the US and those immigrating to the US for residency must take the US Medical Licensure Exam (USMLE), which has three parts. Before receiving registration or licensure, which the individual states offer when their eligibility requirements are met, early doctors must complete a minimum of two years of postgraduate or residency training.
Therefore, during their fourth year of medical school, students start applying to their desired residency training programs and wait for the Match Day to identify where they will be training for the next 1-6 years. Candidates who do not get matched have to participate in a mad scramble through which they are selected for unfilled positions. Very few doctors change their residency programs, and mostly they perform the entire residency training at the same hospital or complex.
The Association of American Medical Colleges (AAMC) researched American doctors' demographic and racial makeup in training and disclosed the findings in the 2020 Report on Residents. The AAMC analyzed aspects like characteristics of medical school graduates/residents such as test scores and demographic comparisons, and professional activities after completing residency.
According to the report, around 140,000 medical residents were working in health care systems in the USA in 2020. Thus, making this community just as large as the entire population of Dayton in Ohio. Moreover, females outnumbered males by a ratio of 2 to 1 in some groups such as radiologists and pediatrics.
As per the same report, when trainees reach the end of their residency program, about one-quarter of these early-career doctors choose to practice in MUAs (medically underserved areas). The number of early-career doctors serving in MUAs has dramatically increased in the past decade, and a majority of these doctors were practicing in Alabama, Louisiana, Nevada, and Iowa.
The organization also noted that the 2020 report covered more active residents than 2019, with 134,951 residents covered in 2019 and 139,848 in 2020.
As far as race and gender comparison is concerned, AAMC reported that whites accounted for the largest share of residents with 50.8% in 2020, followed by Asians with 21.8%, and Hispanics with 7.5%. There is immense racial diversity observed in medical residency in the USA. Black/African-Americans accounted for 5.5%, and American Indian or Alaska Native represented 0.6% of all residents during 2019-2020. However, it is worth noting that this figure doesn't include 16.5% of residents who do not possess permanent US residency.
Gender-wise, females make up a more significant percentage of medical residents in gynecology and obstetrics, with 83.8% of all residents in these specialties being females. Moreover, in pediatrics, 72.4% and in family medicine over 53% of residents were females. On the other hand, Males were more dominant in diagnostic radiology with 73%, emergency medicine with 64.1%, and anesthesiology with 66.9% of all residents being males.
It is important to note that the path to residency is more complex than you think. Most residents opt to change their routes along the way. According to AAMC's survey, almost half (48.7%) of students who graduated in 2019-2020 reported that they changed their specialty at least once after entering medical school. They entered the medical school with a different specialty in mind, but they had switched to another specialty by the time of their graduation.
AAMC observed that around 88.5% of medical graduates had shifted their focus to child neurology after beginning their studies, while 74.4% switched to vascular surgery and 63.1% opted for plastic surgery. On the other hand, just 26.1% of students claimed that they graduated with the same specialty they had opted for at the start of medical school. The report revealed that the continuity rate was highest for the following four specialties.
Residency is essentially postgraduate training, and its length entirely depends on your chosen specialty. Generally, residency may last from 3 to 7 years, but physicians opting for highly specialized fields like female pelvic medicine, pediatric radiology, or reconstructive surgery will have to complete fellowship training after completing residency. Some specialties like anesthesia otolaryngology or urology don't offer an integral postgraduate year 1, also called PGY-1, on internship. Hence, applicants must do surgical or categorical training before PGY-2 and later in the final specialty.
Those who change their minds or leave the program for educational or other reasons may apply to other specialty residencies after their issues are resolved and expect to be accepted based on their previous training experience. For family medicine, internal medicine, and pediatrics, residency length is three years, whereas, for general surgery, the length is 5 to 6 years.
For subspecialties lie transplantation surgery, the length for general surgery is 6 years and an additional 2 to 3 years for chest surgery fellowship, after which at least 3 years of transplant surgery fellowship. Keep in mind that medical subspecialty training, for instance, for gastroenterology or nephrology, is obtained via fellowships following pediatric or internal medicine residencies.
Matching is the process through which medical graduates are assigned their respective residencies. Students start applying for the match during the last year of medical school to secure a residency. This process involves extensive research and an understanding of the medical residency basics. Ideally, students should first decide which specialty they are most interested in, and after that, they should research and apply for the feasible program.
Once their applications are received, residency programs evaluate them and usually invite candidates for an interview. The candidates are interviewed by a panel comprising senior residents and attending physicians. Sometimes, they may offer the candidates a tour of the facility.
These interviews are exceptionally helpful in helping you learn more about the program you have applied to. Therefore, you must remember to give your best shot and, in return, get as much information as possible about the program. It isn't just an opportunity for the residency to determine whether or not you are suitable for their program but also for you to check if you have made the right choice. You may consider asking about the program accreditation, faculty, and resident benefits accepted candidates are entitled to, such as health insurance.
After the interview process is over, you will submit a rank order list of your preferred residencies and send the list to the National Resident Matching Program. The residency programs are also required to submit the list of their preferred candidates in order of acceptance. The information is entered into a computer program. Using an algorithm, the program matches students to residencies.
The rank list submitted by candidates remains confidential, so a residency program will never know their ranking in your list. Also, there's no restriction on the number of residency programs you can rank. You may change the rank of a program or add more programs to your list even after submitting the rank order list. The only condition is that you should submit the final list before the rank list deadline. Visit the National Resident Matching Program website to know the deadline to submit your rank order list.
FREIDA™ is the American Medical Association's (AMA) comprehensive residency & fellowship database. It includes information on over 12,000 Accreditation Council for Graduate Medical Education-accredited residency programs. You can check out this list to find critical data and information about different residency programs.
Since thousands of medical school graduates apply for residency in the USA every year, it is unlikely that all candidates will be matched. A small percentage of students fail to match with any program. One of the main reasons you may fail is that you applied to a few programs. Or else, you applied to a very competitive residency program. If your performance at medical school wasn't too good, even then, you may not be accepted by a residency. You can seek a position for residency through SOAP (Supplemental Offer and Acceptance Program) if you fail to match. This is the mechanism developed for eligible unmatched candidates. You can consider it another opportunity to secure a residency for yourself. Since 2017 Match, this program included three offer rounds, but a fourth rounded was later added to SOAP.
If you don't get matched even through SOAP, there is no need to feel hopeless because those who don't match can avail other options. The residency program may have some unfilled resident spots, and you may be found eligible for one of them. So, please consult your medical school's dean as they usually receive the list of programs with open residency options after the matching process is complete. Additionally, you can apply for a 1-year research fellowship. Alternately, you can take a year off and apply the next year again for residency.
Residency is all about gaining specialized training in your desired area of focus. Therefore, the skills and procedures that you will learn will vary as per the requirements of your chosen specialty. For instance, the procedures and skills would differ for an emergency medicine resident compared to a urology resident.
As a general rule, all residents are responsible for patients' assessments. They will perform physical examinations, order appropriate drugs and diagnostic tests, and consult with other specialists if needed. Also, part of a resident's job description is attending patient rounds, specialty appropriate diagnostic procedures, and prescribing/performing treatment.
In some specialties, the provision of patient education and writing discharge summaries are also part of their job. Residents are required to assist their peers/supervisors/senior physicians during surgical procedures as well as respond to emergencies like trauma pages or codes.
But all of these responsibilities aren't put on a resident's shoulders right from day one. During the residency's first year, you will most likely be supervised by senior residents and attending physicians, while your job won't include as many responsibilities. As you gain experience, you will be supervised less, and seniors will allow you to conduct patient care on your own, as per the requirements of your specialty.
So, as you progress into residency years, your responsibilities increase along with your independence. Every year will bring more responsibilities and independence. Such as, in your second year as a resident, you will supervise medical students. By the time of your third residency year, you will be supervising 1st-year medical residents and may have most of the responsibilities of an attending physician.
Well, to be honest, it IS hard but not as hard as you might not be able to make it through. Every resident's experience is different, but most would agree that postgraduate training is a huge challenge, and that's what it is supposed to be. According to an Austin, Texas-based orthopedic surgeon Dr. Barbara Bergin, residency was more grueling than she expected.
"I expected residency to be grueling, and it was that and more. Each step along the process of becoming a physician supersedes the previous one in terms of physical and mental stress and degree of difficulty."
Dr. Buck Parker said postgraduate training was a much bigger challenge than his initial anticipation.
"I expected to work a lot and I expected to be super tired. I sorely underestimated all that."
That's because, during his residency, which Dr. Parker completed in Detroit, Michigan, he found himself in unexpected situations quite often. Such as encountering medical issues that he had never heard of. On his very first day, 7 individuals were admitted to the hospital for gunshot wounds. Gradually, he became accustomed to such incidents.
"The speed at which you improve is really impressive, because in your first week you don't even know where the bathroom is. By the end of the first year, you're functioning as a real doctor," Dr. Parker said in an interview.
Here's a rough budget estimation for early doctors in the USA and IMGs (international medical graduates) alike. However, IMGs should add the cost of visa and traveling expenses to these expenses as per their nationality and the program's individual requirements.
So, you see each month's cost can go up to $1200. But it may become more cost-effective if you co-habit with your friends or have family around.
While your working hours can vary as per the specialty, you can expect to have a long, grueling work schedule. Some residents can work 45 hours per week, while others work for more than that. For instance, dermatology is a field where residents are not required to be on call, so their working hours are relatively less than other, more demanding specialties like surgery where one has to be on the call. The first year as a resident is the worst when it comes to working hours as you will be required to work more on-call hours than 3rd and 4th year residents.
Besides tending to patients, residents also need to attend lectures and conferences, so the entire process becomes too time-consuming. After the changes in laws governing residents' work hours in 2003, a resident can work no more than 80 hours per week. But, it is still a lot. They are also entitled to get one free day from patients’ responsibilities in a week, in-hospital call to no more than every 3rd night, and between duty periods, they must get a 10-hour duty free period.
The benefits and rewards outweigh the challenges one faces as a medical resident. So, brace yourself for utterly busy and chaotic 3 to 6 years as a medical resident in the USA because the future will be brighter than you think.
