Residency (medicine)

Residency is a stage of postgraduate medical trainingin North Americaand leads to eligibility for board certification in a primary care or referral specialty. It is filled by a resident physician who has received a medical degree (M.D.or D.O.) and is comprised almost entirely of the care of hospitalizedor clinic patients, mostly with direct supervision by more senior physicians. A residency may follow the internshipyear or include the internship year as the first year of residency.

Where as medical schoolgives doctors 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, such as anesthesiology, dermatology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pathology, pediatric medicine, psychiatry, physical medicine and rehabilitation, radiology, radiation oncology, general surgery. The field of surgery has several specialties such as neurosurgery, orthopaedics, otolaryngology, ophthalmology, and urology.

Terminology

A resident physician is more commonly referred to as a resident, or alternatively as a house officer. The residents collectively are the house staff of a hospital. The duration of most primary care residencies is three years for primary care, with the year beginning on July 1 and ending on June 30, though it could be more than seven years for a specialized field. A first year resident is often termed an intern. Third year residents are also called senior residents in a 3 year residency. The supervising physicians past residency are referred to as attending physicians or attendings.

History

Residencies as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th centuryfrom brief and less formal programs for extra training in a special area of interest. They became formalized and institutionalized for the principal specialties in the early 20th century, but even in mid-century, residency was not seen as necessary for general practice and only a minority of primary care physicians participated. By the end of the 20th century in North America, very few new doctors go directly from medical school into independent, unsupervised medical practice, and more state and provincial governments are requiring one or more years of postgraduate training for medical licensure.

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 intership, often served at different hospitals, and only a minority of physicians served them.

Changes in postgraduate medical training

Many changes have occurred in postgraduate medical training in the last fifty years:

1. Nearly all doctors now serve a residency after graduation from medical school. In many states, full licensure for unrestricted practice is not available until graduation from a residency program. Residency is now considered desirable preparation for primary care (what used to be called "general practice").
2. The internship has been subsumed into residency for most physicians. It is now uncommon for a physician to take a year of internship before entering a residency, and the first year of residency training is now considered equivalent to an internship for most legal purposes. Physicians who graduate from osteopathic medical schools (receiving the D.O. instead of M.D. degree) are still encouraged (and in five states required) to take an internship before applying for residency.
3. The number of separate residencies has proliferated and there are now dozens. For many years the principal traditional residencies included internal medicine, gynecology, pediatrics, general surgery, ophthalmology, orthopedics, neurosurgery, otolaryngology, urology, physical medicine and rehabilitation, and psychiatry. Family practice residencies have been available for many years.
4. Pay has increased and residents now make a wage which can support a family. Few residents live in hospital-supplied housing anymore, but unlike most attending physicians (that is, those who are not residents), they do not take call from home; they are usually expected to remain in the hospital for the entire shift.
5. Call hours have been greatly restricted. In July of 2003, strict rules went into effect for all residency programs in the US, known to residents as the "work hours rules". Among other things, these rules limited a resident to no more than 80 hours of work in a week, no more than 30 hours at a stretch (with no new patients in the last six), and call no more often than every third night. In-house call for most residents these days is typically one night in four; surgery and obstetrics residents are more likely to have one in three call. A few decades ago, in-house call every third night or every other night was the standard.
6. For many specialties an increasing proportion of the training time is spent in outpatient clinics rather than on inpatient care. Since in-house call is usually greatly reduced or absent on these outpatient rotations, this also contributes to the overall decrease in the total number of on-call hours.

United States

In some of the United States, doctors can obtain a general medical license after completing one year of internship. Many residents have medical licenses and do legally practice medicine without supervision ("moonlight") in settings such as urgent care centers and rural hospitals. However, in all residency-related medical settings, residents are supervised by attending physicians who must approve their decision-making.

Matching

Access to graduate medical training programs such as residencies is competitive. Applicants apply to programs, are selected for interview, and submit a rank-order list to a centralized matching service (currently the National Residency Matching Program). Residency programs submit a list of applicants in rank order as well. The two parties' lists are combined by an NRMP computer which (theoretically) creates optimal matches of residents to programs. On a certain day in March each year ("match day") these results are announced. A similar but separate osteopathic match exists which announces its results in February, before the NRMP. Osteopathicphysicians(D.O.s) may participate in either match, filling either traditionally allopathic(M.D.) 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.).

On match day, candidates find out if they have matched into a program. If they have not, they typically "scramble" into a program the next day. This means calling unfilled residency programs directly to secure a position. This frantic, loosely structured system often forces would-be residents to choose new specialties and geographic locations with little or no time for consideration. The scramble is widely considered to be an unfavorable way of obtaining a residency position.

In 2000-2004 the matching process was attacked as anti-competitive by class-action lawyers. Congress reacted by requiring that antitrust cases cannot make this argument.

Work hours

Medical residencies traditionally required brutally long hours of their trainees—classically, 36-hour shifts separated by 12 hours rest, and 100+ hour weeks. The American public (though not some physicians trained under the same circumstances) is increasingly recognizing that such long hours are counter-productive; sleep deprivation increases rates of medical errorsand motor vehicle accidents. The Accreditation Council for Graduate Medical Education(ACGME) and the American Osteopathic Association(AOA) have recently limited the number of work-hours to 80 hours weekly, overnight call frequency to no more than one overnight every third day, 30 hour maximum straight shift, and 10 hours off between shifts.

See also

• Physician training
• Junior doctor

External links and sources

• Resident Manual
• Match anti-trust suit dismissal
• The Accreditation Council for Graduate Medical Education in the United Staes
• The American Osteopathic Association Accredidation for osteopathic residencyde:Ärztliche Weiterbildung

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