How are doctors trained, anyway? (Part 2 — the process)

So how does one train to be a physician? The first step is to obtain a four-year undergraduate degree at a college or university. This was the most fundamental change in post-Flexner medical training; before that time, many medical schools had little or no requirement for previous education, some not even demanding a high school diploma. Today the prospective physician’s baccalaureate degree can be in anything (mine happens to be in history and religion), but all medical schools require premedical course work in biology, chemistry, biochemistry, physics, and often mathematics. As a result of these science-heavy requirements, most premedical students choose to major in one of the sciences.

The next step is to gain admission to medical school. This traditionally has been a difficult thing to accomplish, although admission statistics for individual schools are hard to interpret because virtually all students apply to several schools, often more than ten. In general, a medical school applicant’s overall chances of being admitted to medical school has fluctuated between 25 and 35 percent over the last several decades. One thing that has changed is drop-out rate. Fifty years ago, many students did not complete the course; these days, drop-out rates are extremely low.

Medical school generally lasts four years, at the end of which time the graduate is properly addressed as “doctor.” However, the new doctor is one in name only, because no state will allow her to practice medicine independently without further training. Medical licenses are in fact granted by the individual states, and their requirements vary, but all demand at least one year of supervised on-the-job training beyond medical school. Fifty years ago, many physicians stopped their training after doing that single year of training — called an internship — because that was all a physician needed to obtain a medical license and begin working as a general practitioner. These days virtually no one stops after one year, because nearly all physicians require more training just to find a job. You will still hear doctors in their first year out of medical school referred to as interns, but the term does not mean much now.

Medical students receive a standard training curriculum that varies little between the various medical schools; this is enforced by the organization that accredits medical schools. Toward the end of their four years, however, students generally do get some freedom to select courses geared toward what specialty they choose for their residency, the term for the several years of practical training they get after medical school. The usage comes from the fact that medical residents once actually lived in the hospital; these days, even though resident workweeks average eighty hours or so, no one literally lives in the hospital.

Residencies come in the standard broad categories of areas of expertise like internal medicine, pediatrics, surgery, and obstetrics and gynecology, as well as specialties like radiology, neurology, dermatology, and psychiatry. There are in total twenty-four recognized medical specialties, each of which sets its own requirements for the residents training in their respective fields. (You can read more about each individual specialty here.) Medical science has expanded sufficiently that a medical student who wishes to specialize in not being a specialist — that is, who wants to take care of all sorts of patients — must do a residency in family practice.

Residency lasts from three to five years after medical school, depending upon the specialty. At the end of training, the resident takes an examination. Passing it makes her “board-certified” in the field; someone who has completed the residency requirement but has not yet passed (or has failed) the examination is called “board-eligible.” Some physicians choose to continue their training even further beyond residency, to subspecialize in things like cardiology, infectious diseases, or hematology.

The person you encounter when you bring your child to her doctor’s appointment has thus spent at least eleven years getting ready to meet you: four years in college, four years in medical school, and three to five years in residency. That person has also spent much of that time being initiated, perhaps indoctrinated, into a culture, a worldview, that is shared by most physicians. It is a culture foreign to that of many nonphysicians. Its attributes come primarily from the way physicians have been trained since Flexner’s reforms of medical education a century ago. Knowing about this time-honored system will help you understand your child’s physician, and understanding improves communication. More about that in later posts.