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[This is Part 2 of the misc.education.medical FAQ.]

------------------------------

Subject: 4. The Interview Process

4.1) How can I prepare for my interview?

You should do research on the school itself. Learn a little about
the city it is in, the programs offered, grading policies, and
instruction method (Problem Based Learning or traditional or mixed).
Look at the school's information packet and their web site. If
you're interested in doing research in a particular field during
medical school, find out which faculty at the school are doing
research in that area. The more you read about the school, the more
questions you will have to ask your interviewer.

In preparing for the questions you will be asked (cf 4.4),
definitely consult the Medical School Interview Feedback Page begun
by Graham Redgrave: <http://www.interviewfeedback.com>.

4.2) What should I wear to the interview?

Dress professionally in your style. This simply means to dress like
you would if you were a doctor, but do not lose all of your
personality (i.e. if you are a guy with long hair, don't cut it; if
you normally have a mustache, leave it...you are not trying to
produce a standard image, you want to be yourself).

4.3) Should I bring anything to the interview?

Bring a list of any questions you wish to ask (you will probably
forget most of them if you try to memorize them). Always have a pen
and paper on you. Find out what the weather will be like and bring
a coat if necessary. Bring your application to look over between
interviews.

4.4) What will I be asked?

This is largely dependent on the school and on the interviewer (in
other words, on chance). Be prepared to answer questions about
"defining" moments in your life--elaborating on what you do for fun,
what your favorite activity is, what sports you play, and just about
anything that interests you.

Some schools still drill you though, so beware (these interviews can
truly be draining). Stress interviews (empty rooms with phones
ringing, being asked to open windows that are nailed shut) are very
rare. If you've done research, and it's on your application, be
prepared to discuss it.

Many students have recorded their interview experiences at the
Medical School Interview Feedback Page:
<http://www.interviewfeedback.com>.

Some commonly asked questions:

The favorite--Tell me about yourself.
Where do you see yourself in 10 years? (often asked)
What does your family think about this?
What is the biggest problem facing medicine today?
What are the disadvantages/downsides of a career in medicine, besides
no time?
What are you looking for in a medical school?
What do you think about "insert current hot topic here"?
(HMO, PPO, Doctor-assisted suicide, ethical/moral issues of cloning,
other financial issues in health care delivery)
What field of medicine are you interested in?
What do you like to do that isn't science related?
What will you do if you do not get accepted somewhere this year?
What are your strengths/weaknesses?
And, perhaps the most popular...

4.5) "Why do you want to be a doctor?"

If you want to say "to help people," please just make that an
introduction to a much deeper soliloquy! You can tie this answer to
personal experiences (i.e. things you may have seen while
working/volunteering in the medical field, or possibly an illness
that you or a family member went through).

The key is to come across as someone who has genuinely thought
through the decision.

4.6) What questions should I ask?

Ask anything you want about the school. Many times faculty or
students may not know the answer, but will be willing to find out
and get back to you. A good source of questions to ask is the
Association of American Medical Colleges' pamphlet "31 Questions I
Wish I Had Asked," available at
<http://www.aamc.org/students/applying/about/31questions.htm>.

4.7) Should I do anything after the interview?

Sending a thank you note is purely optional, and some consider it an
outdated practice. Others feel that acknowledging time spent on
your behalf is just common courtesy. One suggestion is to follow up
with the admissions office, expressing your interest in the school.

4.8) What does "waitlisted" mean? What does "hold" mean?

The terms "wait list," "acceptance range," "hold," and any others
synonymous with these all mean that the class was full, but you have
been placed on a ranked list. If spots open up, people on the wait
list will be moved up and offered seats in the class. In general a
school will accept twice as many people as its class size when all
is said and done. Also, even though waitlists ARE ranked, they do
not have to pull from them in order, so if something about you
really stands out (such as a follow up letter stating how impressed
you were with the school and how much you would like to become part
of their institution), you can increase your chances of getting in
off the wait list.

4.9) What if I don't get accepted?

Try again. Trying 2 times seems to be the norm these days but after
3 times you might want to consider doing something else (there have
been some people who have finally been accepted after applying 4+
times, but they are the exception rather than the norm). The most
important thing to do is to consult each school as to why you were
rejected or not taken off of the waitlist and ask what you can do to
improve your chances. Follow their advice.

4.10) How should I choose what school to go to?

This depends on several factors. Important ones include location
and what the school "typically" produces. In other words, if you
want to specialize, it may not be in your best interest to go to a
state school where most of the class goes into family practice.
Financial issues are also a factor, as state-funded schools are
often much less expensive than private schools.

Going to a school with an established reputation may be of benefit,
especially when applying for residencies, fellowships, and positions
in academic medicine. If you feel that you may end up in an
academic position, or are considering a very competitive specialty,
you may consider going to a "name" school.

If you narrow it down to two schools which are virtually identical,
go to the one that feels right--that might be your best choice. How
do the students at the school feel? Are they treated well?

4.11) What should I do during the summer before medical school?

Nothing at all. Take a deep breath.

------------------------------

Subject: 5. Medical School Curricula

5.1) How long is medical school?

In the United States, medical school is generally four years in
length. You spend the first two years predominantly in the
classroom and lab, and the last two years predominantly in the
hospital.

5.2) What classes are there in medical school?

The classes in medical school vary from place to place. But there
are some that everyone takes in their first two years, no matter
where they are:

Gross Anatomy
Biochemistry
Pathology
Behavioral Science
Pharmacology
Physiology
Microanatomy/Histology
Microbiology
Physical Diagnosis (or some kind of intro to the patient class)
Medical Ethics

The amount of lab work varies from class to class and school to
school, although some classes (like gross anatomy) feature as much
lab work as you have time for.

5.3) How are students graded/evaluated in medical school?

Again, depends on the school. Many schools still have the standard
A/B/C/D/F scale of grading. The rest go on the pass/fail scale or
some variation of it. Many schools have an "honors" grade which
reflects performance in an upper percentile of the class for that
course.

The grading scale can change as you advance in your studies. For
example, some schools have letter grades the first two years and
then pass/fail grades the last two (or letter grades the first three
and pass/fail the last year only).

The grades themselves are objective the first two years - based
almost entirely on written exams, oral exams, and practical (or lab)
exams. In the third and fourth years, grades depend in large part
on evaluations by other members of your hospital team - the
attending physician(s), the resident(s) and/or the intern(s). There
are also written/oral exams in the last two years, and the relative
importance of exams vs. evaluations varies greatly from rotation to
rotation.

5.4) What are "rotations"?

Rotations are the blocks of time you spend on the different services
in the hospital. Most schools have a set of required rotations and
let you choose from a vast field of elective rotations to fill out
the rest of your third and/or fourth year. The required rotations
everywhere:

Surgery
Internal Medicine
Psychiatry
Pediatrics
Obstetrics and Gynecology (Ob/Gyn)

Generally you will spend a total of about 10 months doing these five
rotations. Some schools make you take all required rotations in the
third year, and some let you spread them out so that you can take
electives in the third year, thereby allowing you to take some
electives that may help you narrow down your possible choice of
specialty for residency.

There are some rotations that are required at all but a few schools:

Family medicine
Neurology
Orthopedics

A typical third year might look something like this:

Surgery - 2 months
Pediatrics - 2 months
Neurology - 1 month
Family Medicine - 1 month
Ob/Gyn - 6 weeks
Psychiatry - 6 weeks
Internal Medicine - 3 months

As far as electives go, generally there are several ways you can go.
You can take "away" rotations - rotations arranged to spend at other
hospitals (ideally the hospitals where you think you might like to
do your residency). Generally, schools will let you do a month or
two away. When considering away rotations, keep the following
tidbits in mind:

1) Most residency applications are due by October or November, and
most residency committees start making decisions on who to interview
by the end of November at the very latest. Therefore, for an away
rotation to really help you sway the people at the hospital you
visit, it must be done in the first few months of the fourth year
(keeping in mind that USMLE Step II is usually at the end of August
of that year). September and to a lesser extent October tend to be
the most popular months to schedule away rotations.

2) At most schools, there are a lot of hoops to jump through to get
an away rotation approved. You have to determine that the hospital
you want to go to actually has an open slot in the rotation you want
during the month you want to be there. Once you've gotten that
info, there are lots of forms and signatures needed--deans and
chairmen from both schools, grading papers, course content papers,
etc. The point of all this is: once you decide to take an away
rotation, get started on planning it because it takes a month or two
to get everything straightened out.

The electives you do at your home school tend to fall in these
categories:

1) Electives in what you think will be your residency specialty
2) Electives in things you think will help you in residency (a lot of
people take things like cardiology, radiology or emergency medicine
because they provide valuable training for the intern year)
3) Electives in things that interest you
4) Electives your friends are taking
5) Electives that are easy (generally includes things like
ophthalmology, dermatology, and lots of odd little electives that
will turn up on the list at your school; at my school we could do a
month sitting in the blood bank drawing blood from people, or do a
month learning what the different lab tests are and what they mean)

5.5) What are the "must have" textbooks?

The only absolutely essential, "must have" textbook is the "Atlas of
Human Anatomy," by Frank H. Netter, M.D. (now in its 2nd edition).
Beyond that, your textbook purchases should reflect:

a) the recommended texts of your school - not all texts cover the
same subjects to the same depth, and you might miss out on a
professor's pet area that he loves to test heavily because it's so
insignificant that a different book barely touches on it (thus a
gentle reminder to try to learn what your professors consider
themselves to be experts in, because those things will always be on
the tests). Also, remember that your required texts will all be on
reserve in the library (usually in multiple copies) - so if you
really feel you need to read one chapter, you can always just borrow
the library copy and read it.

b) the course materials given out in each class - some classes
feature thick, comprehensive syllabi that cover each lecture
specifically and that make the purchase of an outside textbook
pointless. And some schools have note-taking services that "can"
lectures - basically giving you a typed transcription of the entire
lecture, complete with copies of overhead materials. As with the
syllabi, a good set of cans renders a textbook moot. Not all
schools allow the canning of lectures, but if they are offered you
should absolutely sign up and get them.

c) your personal study preferences - how do you study best? Some
people love to read the texts. Some people like lectures and don't
read much at all. Determine where you fall in the scheme of things
and plan your purchases accordingly. Even if a text is great
(example - the Robbins pathology text), generally the book will be
dry reading and very long, and if you are not the kind of person who
learns well from books like that, then your money is better spent
elsewhere.

5.6) What is PBL?

PBL stands for "Problem Based Learning." Basically, there are two
basic types of curricula in medical schools today: PBL and so-called
"traditional" learning. Traditional learning is the basic stuff you
had in college--lectures and plenty of 'em, labs, classes taught as
discrete entities (gross anatomy, pathology, pharmacology, etc.).
PBL represents a more integrated way of presenting the materials.
Lectures are kept to a minimum; instead, the emphasis is on small
group learning, teamwork and problem solving. Groups meet and are
given clinical situations in keeping with the current subject
material. These situations can involve anatomy, pathology,
pharmacology, etc. all at the same time. The group then solves the
problems using available resources (library, computers, etc.) and
discusses their solutions. In this way they learn the body as it
is--a set of interrelated systems--instead of in discrete chunks.

That said, PBL is not for everyone. Some people prefer the
lectures. Some schools offer only PBL, some only traditional, and
some give you an option of which you would prefer. Contact the
schools you are interested in and ask them about their curricula.

5.7) Is there any free time in medical school?

There is as much free time as you want there to be. In spite of
what you might hear, medical students don't study ten hours a night
AND go to every lecture AND go to every lab AND read journals just
for interest AND work on a cure for cancer. At the beginning, sure,
you'll feel this overwhelming fear that everyone is ahead of you and
you will make the lowest grade and somehow people will find out and
point and laugh at you. So you'll study like crazy right up until
that first gross anatomy test that you'll take on no sleep in some
caffeine-induced trance. After that, though, you'll learn what your
best study methods are and how best for you to use your time. After
that, you'll discover that there is plenty of free time to have a
family life, have friends, go to parties, form a bowling team in
your second year and win the league championship after defeating the
five-time defending champions in the playoffs (which a group of
students from my school - myself included - did).

In the clinical years, your free time depends on your rotation.
Surgery tends to lend itself to hospital work and sleep only.
Psychiatry tends to give you more free time than you could possibly
fill. The others fall someplace in the middle.

5.8) What is the USMLE?

In spite of its resemblance to the words "U SMILE," it's not a happy
thing. USMLE stands for United States Medical Licensing
Examination, and the website may be found at <http://www.usmle.org>.
There are three parts to it (the first two parts consisting of a
one-day, eight-hour exam and the third part consisting of a two-day
exam), and in virtually every state you must pass the parts in order
to get licensed. The examination is now offered on computer at
testing centers, and may be taken whenever the student wishes. See
the USMLE web site for more information.

The parts are:

Step I, taken after your second year
Step II, taken in your fourth year
Step III, taken at the end of your internship year

5.9) What is a good USMLE score?

A good score is one that is (a) passing and (b) passing, a fact that
the USMLE apparently realized because rumor has it they are going to
make the exams pass/fail in the near future. For now, keep in mind
that the national average (which has been rising, probably through
artificial means) has been around 215 in 1997-98. The cut-off for a
"good" score once was 200 (when 200 was set as the statistical mean,
or 50th percentile score). Now, though, "good" scores start around
215 and go up from there. And yes, it is sad but true that some
residency programs use USMLE Step I scores as a preliminary cut-off
point for sending out secondary applications and/or interview
requests. Generally the programs that do this tend to be the more
competitive ones - surgery, orthopedics, ENT, neurosurgery, etc.

5.10) What is AOA?

Alpha Omega Alpha, or "AOA," is a national medical honor society that
was founded in 1902 to promote and recognize excellence in the medical
profession. Most, although not all medical schools have a chapter of
AOA. Each school's chapter selects a small group of students to join
the society, generally in their junior or senior years. "Junior AOA
status," or being selected as a junior, is considered superior to
"senior AOA status."

In order to meet the minimum requirements of the national society,
students must be in the top 15% of their class academically, and
possess leadership and community service attributes. Academic
activities such as research, performance in clerkships and electives
and extracurricular program participation are generally included in
the selection criteria.

Individual chapters may also elect to induct outstanding alumni,
faculty and house staff to AOA. Induction ceremonies are generally
held just before graduation and are highly specific to the
individual chapters.

Having AOA on your curriculum vitae is considered an asset when applying
in the very competitive post-graduate programs such as dermatology and
surgical subspecialties.

[Maintainer's note: Stanford, the University of Connecticut, and
Harvard are the schools that do not have AOA. If you are aware of
other schools that do not have a chapter, please let me know.]

------------------------------

Subject: 6. Paying for Medical School

6.1) How expensive is medical school?

Very. According to the AAMC's Medical School Admissions
Requirements, the range of tuition and student fees for 1996-1997
first-year students was:

Range Median Mean
Private, Resident: 8,152-31,925 24,925 23,835
Private, Nonresident: 16,403-31,925 25,224 25,407
Public, Resident: 2,908-20,129 9,107 9,921
Public, Nonresident: 10,680-51,669 21,129 22,153

Keep in mind that these figures represent only tuition and
fees. Other expenses include room and board, books, equipment,
transportation, insurance, and personal expenses. In all, these
additional expenses can easily be up to $15,000 per year.

6.2) How can I pay for medical school?

The first consideration is to reduce your expenses. The less
expensive schools tend to be public schools within your state. If
you don't have a medical school in your state, you may be eligible
to attend other state schools as an in-state resident through an
exchange program such as WICHE, the Western Interstate Commission
for Higher Education, which allows students from Alaska, Montana,
and Wyoming to apply to and attend any western medical school as a
state resident (with the exception of the University of Washington).
Another major expense that can be reduced, if you qualify, is the
cost of application. Be sure to apply for an AMCAS fee waiver (if
you qualify), which can save you hundreds of dollars.

Unfortunately, reducing expenses still leaves, in most cases, tens
of thousands of dollars to pay. The most common way to pay this is
via loans, particularly federal Stafford loans and private
alternative loan programs. While some Stafford loans may be
subsidized (the government will pay the interest while you are in
school), there is a limit to the amount you can borrow. Other loan
programs are often offered by the various schools.

Grant aid (aid you don't have to repay) is not common. Most schools
offer a minimal amount of merit- and/or need-based grant aid. There
are also two programs that will cover the entire cost of school plus
give you a stipend. The first, the Medical Scientist Training
Program, is a highly competitive government-subsidized program
designed to recruit students interested in earning both an M.D. and
a Ph.D. The second, the Uniformed Services University of the Health
Sciences, is the military's medical school. In return for years of
service to the military, your education is paid for in addition to
your receiving a commission in the military and the concomitant
salary and benefits.

Another possibility for covering your expenses is to obligate
yourself to later service. Two examples of this type of program are
the Armed Forces HPSP and the Public Health Service program, both of
which provide payment for medical school in return for a commitment
to serve in either the military or in underserved public health
regions, respectively.

Finally, be sure to search the Web and other sources for private
scholarship sources. You may be eligible for free money or favorable
loans due to your extracurricular activities, ethnicity, religion,
heritage, or any number of other factors. Your school's financial aid
office will be happy to suggest sources to you as well as discuss means
of payment.

6.3) Can you tell me about Armed Forces scholarships?

The Armed Forces Health Professions Scholarship Program (HPSP) is a
scholarship between two to four years in length offered to students
in schools of medicine, osteopathic medicine, dentistry, and
optometry. HPSP students receive full tuition, school-related
expenses, and a stipend as benefits. The stipend is currently (as
of 8/98) around $912/month, paid in two parts on the 1st and 15th
days on each month by direct deposit. Expenses are reimbursed by
the submission on an itemized form with receipts and a signed
approval letter from your school stating that the expenses you claim
are reasonable ones for your curriculum; typically, most texts and
equipment (i.e., stethoscopes, lab coats) are paid without any fuss.
Tuition is paid directly to your school.

Basic requirements for the HPSP are that you are a U.S. citizen and
meet the qualifications for commissioning as a military officer.
There is an application and interview process which takes place at
about the same time as med school apps. (Of course, you do have to
actually get into med school in order to receive it.) The HPSP is
offered through the Navy, Army, and Air Force (the Marine Corps is
part of the Department of the Navy and is served by Naval docs, and
the Coast Guard is staffed by docs from the Public Health Service).

In return, you owe as many years of service to the military as you
received in support. Residency does not count towards this payback
time. What you actually wind up doing, of course, varies according
to your specialty; there isn't a huge need for pediatric
neurosurgery about the average aircraft carrier, for example.

What are the advantages to this little Faustian bargain? Well, for
starters, there are the financial benefits. The more frugal
students will emerge from med school debt-free, and those who live a
little higher on the hog will owe relatively small student loans.
Salary during residency is about $10,000/yr greater in the military
(in the neighborhood of $40,000 for interns, $50,000 for more senior
residents). Even post-residency, you won't starve; average
attending salaries vary by specialty, rank, and years of service,
but most wind up in the neighborhood of $100,000/yr as junior
attendings (typically O-4 in rank: a lieutenant commander in the
Navy, a major in the other two). You are automatically commissioned
as an O-1 while a med student (ensign in the Navy, 2nd lieutenant in
the other two) and are promoted to O-3 on graduation
(lieutenant/captain). There are some pretty entertaining places to
work in the military that you might not the chance to work near in
the future: Europe, Asia, and so forth. And of course, medicine is
medicine: patients can be much the same no matter where you work,
and in any case the majority of patients in the military system are
not actually active duty troops but retirees and dependents.
Benefits can be nice as well: 30 days paid vacation each year, no
overhead, and full medical/dental coverage.

Military residencies, by the way, are generally quite good. When
considering your training site come application time, you do want to
think about issues like patient volume, didactics, and so forth,
just as in any residency, but board pass rates for military
residency grads have been uniformly excellent, and people have
gotten into fine fellowships with minimal difficulty.
(Incidentally, if you do a civilian fellowship as an active duty
officer, the military will still pay you as an attending. Which is
pretty sweet.)

Now for the downside. You are sacrificing a few years of your life,
in a sense. Although a flexible mindset and a willingness to
compromise will help you get a good posting, not everyone in the
Navy gets to go to Italy or San Diego. Internship and residency are
relatively separate entities and require separate applications, not
only for fields like anesthesia but even for fields with categorical
internships like internal medicine or general surgery. Not only
that, there is a risk that you will have to spend a couple of years
away from training between your R-1 and R-2 years as a general
medical officer, or GMO. This risk is greatest in the Navy overall
but present in the Army and Air Force; it is also greater if you
plan on pursuing a more specialized field like neurosurgery or
anesthesia. Medicine, peds, and family med residents are more
likely to complete their training uninterrupted. GMO tours vary
between one to three years in length.

(A brief proviso on the whole GMO thing. An anesthesiology
attending at the National Naval Medical Center in Bethesda spent
three years as the medical officer aboard the USS Belknap in the
Mediterranean, and he loved it. After finishing his tour, he went
on to his residency at Mass General. So it's not the kiss of death.
Also, GMOs are a dying breed. The DoD is currently working out a
plan to abolish GMOs and staff those positions with
residency-trained docs. So stay tuned.)

The military is a startlingly bureaucratic organization which has
little ways of reminding you that it is, in fact, a branch of the
federal government. For physicians, though, military medicine is
actually not really different than working for a good HMO. Research
in military medicine is quite impressive, incidentally, although its
work is often very practical in orientation. There are good
research ties with the NIH and CDC, and most residencies are very
supportive of research (and may in fact require it of residents).

There are a certain number of people each year in the HPSP who defer
their commitment in order to do civilian residencies. The exact
number varies depending on the year, the specialty, and the needs of
the service. If you want to defer, it helps to have a good reason
(i.e., spouse's job) and to not be rude (e.g., "I want to defer
because military residencies are inferior").

If you want to postpone the decision about military service, there
is a financial assistance program (FAP) available to residents in
most specialties, wherein you get about $30,000/yr on top of your
civilian salary to repay loans (or buy a new car, possibly) in
exchange for an equivalent number of years of service.

6.4) Can you tell me about Public Health Service scholarships?

The Public Health Service offers a scholarship (The National Health
Service Corps, <http://bphc.hrsa.gov/nhsc/>) paying full tuition,
books, and supplies, and a monthly stipend, with the following
requirements:

1) You must enter a primary care-type of residency (medicine,
family med, peds) or at least something that's close (OB/GYN,
psych), or a residency combining two of the above fields. A main
limitation is that the residency not take more than 3 or 4 years.
After serving your commitment you can undergo further medical
training (i.e., fellowships).

2) You must serve one year in a federally-designated underserved
area of your choice for each year the NHSC paid your tuition
(minimum two years), be it an inner city (30% of sites) or a rural
cow town (70% of sites).

3) As of December 1998, the IRS has deemed ALL parts of the NHSC
scholarship as taxable, including tuition. So, if you go to a
school that costs $28,000 per year, taxes will leave you with about
$350 from your monthly $950 stipend. The NHSC has been trying to
get Congress to reverse the IRS's reading of the law, but to no
avail as of yet.

There are similar programs available through various state
governments and the Indian Health Service, some funded by the NHSC.

Physicians who have completed training in a primary care field are
eligible for Public Health Service positions, with opportunities for
loan repayment. Some feel that this may be a better choice, as you
are not locked into a primary care field without first going through
your medical school rotations. See the NHSC web site for more
information.

6.5) Can I really borrow more than $10K/yr in Unsubsidized
Stafford Loans?

With the phaseout of the HEAL program at all schools, the Department
of Education has now authorized increased unsubsidized Stafford loan
limits for Health Professions Students. This limit is now $30K/yr.

The Student Financial Aid Handbook section detailing these limits
may be found at:
<http://ifap.ed.gov/sfahandbooks/attachments/0102Vol8Ch3loanperiodamts.pdf>.

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Subject: 7. Residency and Beyond

7.1) What are the different medical specialties?

A good source for learning about the different medical specialties
is the American Board of Medical Specialties <http://www.abms.org>,
an organization that coordinates and approves changes in board
certification policy in the different medical fields. A complete
list of the certifying boards and the general and subspecialty
certificates that they offer can be found on their web site. A list
of the major medical specialties can be found below. No effort has
been made to list subspecialties.

Allergy & Immunology
Anesthesiology
Colon & Rectal Surgery
Dermatolology
Emergency Medicine
Family Practice
Internal Medicine
Medical Genetics
Neurological Surgery
Neurology
Nuclear Medicine
Obstetrics & Gynecology
Ophthalmology
Orthopaedic Surgery
Otolaryngology
Pathology
Pediatrics
Physical Medicine & Rehabilitation
Plastic Surgery
Preventive Medicine (including Occupational Medicine)
Psychiatry
Radiation Oncology
Radiology
Surgery
Thoracic Surgery (including Cardiothoracic Surgery)
Urology

7.2) What is a residency?

Upon graduation from medical school, you become a "doctor" having
earned the M.D. or D.O. degree. However, this isn't the end of
formal medical training in this country. Many moons ago, back when
almost all physicians were general practitioners, very few
physicians completed more than a year of post-graduate training.
That first year of training after medical school was called the
"internship" and for most physicians it constituted the whole of
their formal training after medical school; the rest was learned on
the job. As medical science advanced and the complexity of and
demand for medical specialists increased, the time it took to gain
even a working knowledge of any of the specialties grew to the point
where it became necessary to continue formal medical training for at
least several years after medical school. This training period is
called a "residency," earning its moniker from the old days when the
young physicians actually lived in the hospital or on the hospital
grounds, thus "residing" in the hospital for the period of their
training.

During residency, you and your classmates practice under the
supervision of faculty physicians, generally in large medical
centers. Many primary care specialties, however, are based in
smaller medical centers. As you grow more experienced, you assume
more responsibilities and independence until you graduate from the
residency, and you are released to practice on your own upon an
unsuspecting populace.

The length of residency programs varies considerably between
specialties and even a little within individual specialties. In
general, the surgical specialties require longer residencies, and
the primary care residencies the least time.

Lengths of Some Residencies
---------------------------
All surgical specialties 5+ years
Obstetrics and Gynecology 4 years
Family medicine 3 years
Pediatrics 3 years
Emergency Medicine 3-4 years
Psychiatry 3 years

The AMA maintains a database of almost all of the residency programs
in the United States, called the Fellowship and Residency Electronic
Interactive Database Access (FREIDA) system. It is available at
<http://www.ama-assn.org/go/freida>.

Recently a new type of residency has emerged, the so-called
"combined residency." These residencies train physicians in two
medical fields, such as internal medicine-pediatrics, or
psychiatry-neurology. As these types of residencies are new, they
are relatively few in number; they provide an opportunity for the
physician to become "double-boarded" and receive board certification
in each of the two specialties. Usually these residencies last one
or two years less than the total years that would be spent doing
both residencies.

7.2a) What is an internship?

In the old days, all physician completed a one year "rotating
internship" after graduating from medical school. Such an
internship consisted of all the major subdivisions of medical
practice: Internal medicine, surgery, obstetrics and gynecology,
etc. The idea was to provide a broad spectrum of training to allow
the new physician to work in the community as a "general
practitioner."

Today, the closest thing we have to the rotating internships of old
is the "transitional year," also completed after graduating from
medical school. For a few specialties, a year of post-gradute
training is required before beginning a residency in that field.
Many who want to go into these fields fill that requirement with a
transitional year. Fields that require a year before beginning
residency include radiology, neurology, anesthesiology, and
ophthalmology.

In the current lingo, the first year of post-graduate training is
called "internship," and any medical school graduate in the first
year of post-graduate training is called an "intern" regardless of
what that first year of training consists. Most specialties do not
require a transitional year, but instead accept medical school
graduates straight out of medical school.

7.2b) What is a "preliminary" year? A "categorical" year?

An alternative to the transitional year for some is the "preliminary
year." Preliminary years come in two flavors, internal medicine and
surgery. Each of these preliminary years somewhat resembles the
rotating internships of old, but with a focus on either internal
medicine or surgery. Those programs that require a year of
post-graduate education before beginning residency may accept either
a transitional year or a preliminary year. Obviously, surgical
residencies will require that you do a preliminary surgery year
while some other specialties will prefer a preliminary medicine
year.

The other reason that a new M.D. would go into a preliminary year or
transitional year would be because he didn't match into the
specialty of his choice. The hopeful applicant then takes a
preliminary or transitional year in the hopes of improving his
chances and qualifications for the next year's residency match.

The term "categorical" is used largely to distinguish between the
interns who are doing a preiminary year and those who are already
accepted into the residency program. For instance, a general
surgery program may have 6 interns every year, but two of them may
doing surgery as a preliminary year. Those positions that are
already accepted into the whole surgical residency program are
called "categorical."

7.3) What is the Match?

The Match (also cf 7.4) is a way to bring together residency
applicants and residency programs in an organized fashion. After
applying to and interviewing at various residency programs in their
specialty of choice, students submit a "rank order list" which
specifies their preferences for programs in numerical order.
Residency programs submit similar lists. After all of the lists
have been received, a computer matches applicants and programs. At
noon Eastern time, on a fateful day in March of each year, all
applicants across the country receive an envelope telling them where
they will spend the next several years.

Controversy has surrounded the Match algorithm in recent years, due
to a slight preference for residency programs in a very small
percentage of cases. The algorithm has since been changed to favor
applicants' preferences.

There are several books about residency and the Match. "First Aid
for the Match" by Tao Le, et al., and "Getting into a Residency: A
Guide for Medical Students" by Kenneth Iserson, MD, provide insights
about how to prepare for the Match.

7.4) What is the NRMP?

The National Resident Matching Program (NRMP) is the official name
of the Match, which is run by the Association of American Medical
Colleges (AAMC). Its home page may be found at
<http://www.aamc.org/nrmp/>.

7.5) Are there specialties that don't use the NRMP?

Several specialties have their own matching programs. Neurology,
Neurosurgery, Ophthalmology, Otolaryngology, and Plastic Surgery,
along with several subspecialty fellowship programs in these fields,
have their matches coordinated through the San Francisco Matching
Program <http://www.sfmatch.org>.

Urology has its own matching program, coordinated by the American
Urological Association at
<http://www.auanet.org/students_residents/>.

The "Match Day" for these specialties occurs in January, instead of
March as for the NRMP. Consult the matching programs' web sites for
schedules.

7.6) What is a fellowship?

A fellowship is a period of training that you undertake following
completion of your residency, as a means to subspecialization. For
instance, a general surgeon can do a number of different fellowships
(e.g. cardiothoracic surgery, plastic surgery), a pediatrician can
complete a fellowship in pediatric endocrinology, etc. The list of
possible subspecialties is almost endless. A fellow is considered
somewhere in the hierarchy between residents and faculty. They are
paid like advanced residents, but nothing close to what a private
physician makes. People take fellowships for a number of different
reasons: The subspecialty may be what they've always wanted to do in
the first place, they may develop an interest in that field along
the way, and it's often a path to a faculty position in a residency
program and medical school. The length of fellowships also varies
some, but usually lasts three years or less.

7.7) How many hours do interns/residents work?

Intern and resident hours vary very widely depending on specialty,
hospital, and within hospitals between different departments. Some
specialties are well-known for their less demanding hours during
residency (and often afterwards as well). These "lifestyle" fields
include radiology, anesthesiology, and physical medicine and
rehabilitation (physiatry). Specialties whose residencies are
reputed for difficulty and lack of sleep are general surgery and
obstetrics and gynecology. Most of the other specialties fall
somewhere in between.

Surgical interns and often internal medicine interns routinely work
100+ hours a week, with some months requiring a brutal every other
night call schedule. This means, for instance, that you go to work
on Monday morning (around 5-6 am) work all day, stay in the hospital
all night (with varying amounts of sleep but usually 2-3 hours),
work the following day as well (hoping that you may get out early),
then go home for around 6 pm only to repeat the whole cycle again
the next day. On months such as these, if you have a spouse,
children, or pets, you won't see them. You can do the math to
figure out how many hours per week that amounts to. Most call
schedules for intern years run either every third or every fourth
night on call.

7.7a) Aren't there limits on this?

There are a few states that limit the number of hours that a
resident can work. Perhaps the most prominent state with a such a
law is New York.

New York's law, limiting residents to 80 hours per week, came about
largely due to the Libby Zion case. Libby Zion was a young woman
whose death in a NYC teaching hospital sparked an investigation into
the large amount of hours that residents work.

Nevertheless, many hospitals in New York still do not follow this
law and the state has performed "spot inspections" to attempt to
verify compliance. For an excellent discussion of this issue, read
the book "Residents: The Perils and Promise of Educating Young
Doctors" by David Ewing Duncan.

7.8) What does "board certified" mean?

Generally, to become certified by one of the boards recognized by
the American Board of Medical Specialties <http://www.abms.org>, a
physician must meet several requirements:

1) Possess an MD or DO degree from a recognized school of medicine
2) Complete 3 to 7 years of specialty training in an accredited
residency
3) Some boards require assessments of competence from the training
director
4) Most boards require the physician to have an unrestricted license
5) Some boards require experience in full-time practice, usually 2
years
6) Pass a written examination, and sometimes an oral examination

After certification, a physician is given the status of "diplomate"
in that specialty. Many boards require recertification at regular
intervals.

7.9) What does FACP/FACS/FACOG/etc. mean?

Before discussing this, it may be useful to delineate the
differences between organizations that physicians may be associated
with. Some definitions:

Association or Academy - A group for physicians in a particular
field, that often sponsors meetings and publishes journals.
Example: American Academy of Family Physicians.

Board - Organization that conducts periodic examinations for
physicians in a particular field, and offers "certification" (cf
7.8). The overseeing organization for all specialty boards is the
American Board of Medical Specialties <http://www.abms.org>.
Example: American Board of Internal Medicine.

College - Similar to an association, but membership is often tied to
board certification and experience. More of an honor than simple
association membership, doctors are often elected to "fellowship"
after recommendation by their colleagues. Example: American College
of Surgeons.

After a physician has received board certification in his/her field,
and has gained a set amount of experience in that field (usually a
specified number of years of practice), that physician can be
recommended for fellowship status in their specialty college. After
approval, the physician can then use their fellowship status on
stationery and business cards, i.e. Susan M. Avery, M.D.,
F.A.C.S. signifies that Dr. Avery has received fellowship status in
the American College of Surgeons.

7.10) What is an IMG/FMG?

Those who have graduated from medical schools outside of the United
States and Canada are called International Medical Graduates (IMGs)
or Foreign Medical Graduates (FMGs). Sometimes, US citizens who
have attended foreign schools are called USFMGs to distinguish them
from non-citizens.

There has been a move of late among some members of Congress, the
Accreditation Council for Graduate Medical Education (ACGME), and
the AAMC, in light of a perceived surplus of physicians in the US,
to reduce the number of Medicare-funded residency positions to 110%
of the number of graduating US medical school seniors. As of yet,
this has not been implemented.

7.11) What is the ECFMG? The CSA?

The Educational Commission for Foreign Medical Graduates (ECFMG)
<http://www.ecfmg.org> is an organization sponsored by the
Federation of State Medical Boards, the AAMC, the AMA, the American
Board of Medical Specialties, and others, that coordinates
certification of graduation, passing grades on the United States
Medical Licensing Examination (USMLE), and other information about
FMGs. Prior to applying to residency or fellowship programs in the
United States that are accredited by the Accreditation Council for
Graduate Medical Education (ACGME), an FMG must hold a certificate
from the ECFMG.

CSA stands for "Clinical Skills Assessment," a new requirement for
foreign-trained physicians seeking to obtain ECFMG certification.
Applicants face 10 simulated patients and be evaluated on their
ability to take a history, perform a physical exam and record a
written note. More information can be found on the ECFMG web site
at <http://www.ecfmg.org/csahome.htm>.

7.12) What is CME?

A physician's education does not end with medical school and
residency. Continuing Medical Education, or CME, allows physicians
to keep up with new developments in all medical fields. Physicians
earn "credits" for hours spent in various learning activities.

The American Medical Association (AMA) offers the Physician
Recognition Award (PRA) for doctors who complete 50 hours of CME
credit per year. The AMA's classification of CME is as follows:

Category 1: Formally organized and planned educational meetings,
e.g., conferences, symposia. Also includes residency.
Category 2: Less structured learning experiences, e.g.,
consultations, discussions with colleagues, and
teaching.
Other: Reading "authoritative" medical literature, e.g.,
peer-reviewed journals, textbooks.

Organizations that receive the nod from the Accreditation Council
for Continuing Medical Education (ACCME) <http://www.accme.org>, as
well as state medical societies and other groups recognized by the
AMA can provide "category 1" CME courses.

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