Residency (medicine)

Residency is a stage of graduate medical training. A resident physician or resident (also called a house officer / senior house officer in the United Kingdom and several Commonwealth countries) is a person who has received a medical degree (MD, DO, MBBS, MBChB, BMed and who practices medicine under the supervision of fully licensed physicians, usually in a hospital or clinic. Residencies are also available, and may be required for, students graduating from pharmacy, dental or podiatric schools. Residencies are optional for students graduating from optometry school.

A residency may follow the internship year or include the internship year as the first year of residency. The residency can also be followed by a fellowship, during which the physician is trained in a sub-specialty. Successful completion of residency training is a requirement to practice medicine in many jurisdictions.

Whereas medical school teaches physicians 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. A physician may choose a residency in anesthesiology, dermatology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pathology, pediatrics, plastic and reconstructive surgery, psychiatry, physical medicine and rehabilitation, radiology, radiation oncology, surgery, or other specialties.

In Australia and New Zealand it leads to eligibility for fellowship of the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, or a number of similar bodies.

In Canada it leads to eligibility for certification by and fellowship of the Royal College of Physicians and Surgeons of Canada, or the College of Family Physicians of Canada.

In South Africa it leads to board certification as a specialist with the Health Professions Council and eligibility for fellowship of the Colleges of Medicine of South Africa.

In the United States it leads to eligibility for board certification and membership/fellowship of several specialty colleges and academies.

Terminology

A resident physician is more commonly referred to as a resident, senior house officer/registrar (in the UK and Commonwealth countries), or alternatively as a house officer. Residents have graduated from an accredited medical school and hold a medical degree (MD, DO, MBBS, MBChB). The residents collectively are the house staff of a hospital. This term comes from the fact that resident physicians traditionally lived the majority of their lives "in house," i.e. the hospital. Duration of most residencies can range from three years to seven years for a specialized field such as neurosurgery. A year in residency begins between late June to early July depending on the individual program, and ends one calendar year later. A first-year resident is often termed an intern, although this term is quickly being changed to "first year resident". Depending on the number of years a specialty requires, the term junior resident refers to residents that have not completed half their residency. Senior residents are residents in their final year of residency. Some residency programs refer to residents in their final year as chief residents or "Senior Registrar" (often in surgical fields). Alternatively, a chief resident may describe a resident who has been selected to extend his or her residency by one year and supervise the activities and training of the other residents (typically in internal medicine and pediatrics). If a physician finishes a residency and decides to further his education in a fellowship, he or she is referred to as a "fellow". Post-residency physicians are referred to as attending physicians or attendings or "consultants".

History

Residencies as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th century from 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 went directly from medical school into independent, unsupervised medical practice, and more state and provincial governments began 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 internship, often served at different hospitals, and only a minority of physicians served them.

Argentina

In Argentina, the residency (Spanish, residencia) consists of a three to four years of practical and research activities in the field selected by both the candidate and already graduated medical practitioners. Specialized fields such as neurosurgery or cardio-thoracic surgery require longer training. Through these years, consisting of internships, social services, and occasional research, the resident is classified according to their residency year as an R1, R2, R3 or R4. After the last year, the "R3 or R4 Resident" obtains the specialty (especialidad) in the selected field of medicine.

France

In France, students attending clinical practice are known as "externes" and newly-qualified practitioners training in hospitals are known as "internes". The Residency, called "Internat", lasts from three to five years and follows a competitive national examination. It is customary to delay submission of a thesis. As in most other European countries, many years of practice at a junior level may follow. French Residents cannot be called "Doctor" during their residency. They are still considered as students and become M.D. only at the end of their residency and after submitting a thesis.

United Kingdom

In the United Kingdom, house officer posts used to be optional for those going into general practice, but almost essential for progress in hospital medicine. The Medical Act of 1956 made satisfactory completion of one year as house officer necessary to progress from provisional to full registration as a medical practitioner. These pre-registration house officer posts lasted six months, and it was necessary to complete one surgical and one medical post. Obstetrics could be substituted for either. In principle, general practice in a "Health Centre" was also allowed, but this was almost unheard of. The posts did not have to be in general medicine: some teaching hospitals had very specialised posts at this level, so it was possible for a new graduate to do neurology or orthopaedics, for a year before having to go onto more broadly based work. The pre-registration posts were nominally supervised by the General Medical Council, which in practice delegated the task to the medical schools, who left it to the consultant medical staff. The educational value of these posts varied enormously.

On call work in the early days was full-time, with frequent night shifts and weekends on call. One night in two was common, and later one night in three. This meant weekends on call started at 9 am on Friday and ended at 5 pm on Monday (80 hours). The European Union's Working Time Directive conflicted with this: at first the UK negotiated an opt-out for some years, but working hours needed reform. On call time was unpaid until 1975 (the year of the interns' one-day strike), and for a year or two depended on certification by the consultant in charge - a number of them refused to sign. On call time was at first paid at 30% of the standard rate. Before paid on call was introduced, there would be several house officers "in the house" at any one time and the "second on call" house officer could go out, provided they kept the hospital informed of their telephone number at all times.

A "pre-registration house officer" would go on to work as a "senior house officer" for at least one year before seeking a registrar post. SHO posts could last six months to a year, and junior doctors often had to travel around the country to attend interviews and move house every six months while constructing their own training scheme for general practice or hospital specialisation. Organised schemes were a later development, and do-it-yourself rotations became rare in the 1990s. Outpatients were not usually a junior house officer's responsibility, but such clinics formed a large part of the workload of more senior trainees, often with little real supervision.

Registrar posts lasted one or six years, and sometimes much longer outside an academic setting. It was common to move from one registrar post to another. Fields such as psychiatry and radiology used to be entered at the registrar stage, but the other registrars would usually have passed part one of a higher qualification, such as a Royal College membership or fellowship. Part two was necessary to obtain a senior registrar post, usually linked to a medical school, but many left hospital practice at this stage rather than wait years for promotion.

Most British clinical diplomas (requiring one or two years' experience) and membership or fellowship exams are not tied to particular training grades, though the length of training and nature of experience may be specified. Participation in an approved training scheme is required by some of the Royal Colleges. The sub-specialty exams in surgery, for Fellowship of the Royal College of Surgeons, were originally limited to senior registrars. These rules prevent many of those in non-training grades from qualifying to progress.

Once a Senior Registrar, depending on specialty, it could take anything from one to six years to go onto a permanent consultant and/or senior lecturer appointment. It might be necessary to obtain an MD or ChM degree and to have substantial published research. Transfer to general practice or a less favoured specialty could be made at any stage along this pathway: Lord Moran famously referred to general practitioners as those who had "fallen off the ladder."

There are also permanent non-training posts at sub-consultant level: previously Senior Hospital Medical Officer and Medical Assistant (both obsolete)and now Staff Grade and Associate Specialist. The regulations do not call for much experience or any higher qualifications, but in practice both are common, and these grades have high proportions of overseas graduates, ethnic minorities and women.

Research fellows and PhD candidates are often clinical assistants, but a few were senior or specialist registrars. A large number of "Trust Grade" posts have been created by the new NHS Trusts for the sake of the routine work, and many juniors have to spend time in these posts before moving between the new training grades, although no educational or training credit is given for them. Holders of these posts may work at various levels, sharing duties with a junior or middle grade practitioner or with a consultant.

British medical training is constantly being reorganised. House officers and senior house officers have been replaced by two years of Foundation Year training (FY1 and FY2). Registrar and Senior Registrar grades were merged in 1995/6 as the Specialist Registrar (SpR) grade (entered after a longer period as a senior house officer, after obtaining a higher qualification, and lasting up to six years), with regular local assessments panels playing a major role, and these posts have in turn been replaced in 2007 by Specialty Registrars, who may be in post up to eight years, depending on the field.

Recent changes in postgraduate medical training, collectively organised under the Modernising Medical Careers (MMC), have created new labels for equivalent training grades. Foundation Year 1 and Foundation Year 2 are equivalent to house officer and first year as senior house officer. Specialty Trainee year 1 and year 2 are equivlant to the old second and third year of SHO grades. It is customary for trainees to sit their Membership examinations (either for the Royal College of Physicians (MRCP) or Royal College of Surgeons) in order to progress and compete for designated sub-specialty training programmes that attract a national training number as Specialty Training year 3 (ST3) and beyond -- up to ST 9 depending on the particular training specialty. Given that UK specialist training takes 3 to 4 years longer than in other developed countries, it is evident that UK registrars continue to perform general medical duties in addition to their sub-specialty training.

As such, the FY1, FY2, ST1 grades are equivalent to the American 3-year residency period; at ST2 when UK doctors sit the Membership examinations, this would be equivalent to American trainees sitting their ABIM (American Board of Internal Medicine) exams to progress to sub-specialty fellowship training. The UK equivalent is the specialty trainee (ST2 - ST9) grade of sub-specialty training, but note that while US fellowship programmes are generally 3 years in duration after completing the residency, UK trainees spend 3 to 7 years in additional specialist training equivalent to US fellowships with an additional general medicine component; this discrepancy lies in the competing demands of NHS service provision and UK postgraduate training stipulating that even specialist consultant (attending) physicians must be able to accommodate the general acute medical take -- equivalent to what dedicated attending internists perform in the United States.

United States

In some states of the United States, physicians may usually obtain a general medical license to practice medicine without supervision after completing one year of internship in the state of their license. 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 most residency-related settings, residents are supervised by attending physicians who must approve of their decision-making.

Interviews

The interview process involves separate interviews at hospitals around the country. Frequently, the individual applicant pays for travel and lodging expenses, but some programs may subsidize applicants' expenses. Generally, an interview begins with a dinner the night before in a relaxed, "meet-and-greet" setting with current residents and/or staff. Formal interviews with attendings and senior residents are then held the next day, and the applicant tours the program's facilities.

Interview questions are primarily related to the applicant's interest in the program and specialty. Some specialties hold interviews in a more competitive format. The purpose of these tasks is to force an applicant into a pressured setting and less to test his or her specific skills.

To defray the cost of residency interviews, social networking sites have been devised to allow applicants with common interview dates to share travel expenses. Nonetheless, additional loans are often required for "residency and relocation".

International medical students may participate in a residency program within the United States as well but only after completing a program set forth by the Educational Commission for Foreign Medical Graduates (ECFMG). Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG) assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).

Matching

See also: National Resident Matching Program

Access to graduate medical training programs such as residencies is a competitive process known as "the Match." Senior medical students usually begin the application process at the beginning of their (usually) fourth and final year in medical school. After they apply to programs, programs review applications and invite selected candidates for interviews held between October and February. After the interview period is over, students submit a "rank-order list" to a centralized matching service (currently the National Residency Matching Program, abbreviated NRMP) by February. Similarly, residency programs submit a list of their preferred applicants in rank order to this same service. The process is blinded, so neither applicant nor program will see each other's list. Aggregate program rankings can be found here, and are tabulated in real time based on applicants' anonymously submitted rank lists.

The two parties' lists are combined by an NRMP computer, which creates stable (a proxy for optimal) matches of residents to programs using an algorithm. On the third Thursday of March each year ("Match Day") these results are announced in Match Day ceremonies at the nation's 155 U.S. medical schools. By entering the Match system, applicants are contractually obligated to go to the residency program at the institution to which they were matched. The same applies to the programs; they are obligated to take the applicants who matched into them.

On the Monday prior to Match Day, candidates find out from the NRMP if (but not where) they matched. If they have matched, they must wait until the Match Day (Thursday) to find out where. If they have not secured a position through the Match, the locations of remaining unfilled residency positions are released to unmatched applicants the following day. These applicants are given the opportunity to contact the programs about the open positions. This is what is known as "The scramble." This frantic, loosely structured system forces soon-to-be medical school graduates to choose programs not on their original Match list. Occasionally and unfortunately, this sometimes requires students to choose entirely new specialties. The scramble is widely considered to be an unfavorable and highly stressful way of obtaining a residency position.

Inevitably, there will be discrepancies between the preferences of the student and programs. Students may be matched to programs very low on their rank list, especially when the highest priorities consist of competitive specialties like radiology, plastic surgery, dermatology, ophthalmology, orthopedics, otolaryngology, radiation oncology, and urology.

A similar but separate osteopathic match exists which announces its results in February, before the NRMP. Osteopathic physicians (DOs) may participate in either match, filling either traditionally Medical Doctor (MBBS,MD,MBChB,etc) positions accredited by the Accreditation Council for Graduate Medical Education (A.C.G.M.E.), or Doctor of Osteopathic Medicine positions accredited by the American Osteopathic Association (A.O.A.).

Further information: [[:Comparison of MD and DO in the US (residency training)]]

Military residencies are filled in a similar manner as the NRMP however at a much earlier date (usually mid-December) to allow for students who did not match to proceed to the civilian system.

In 2000–2004 the matching process was attacked as anti-competitive by resident physicians represented by class-action lawyers. See, e.g., Jung v. Association of American Medical Colleges et al., 300 F.Supp.2d 119 (D.D.C. 2004). Congress reacted by carving out a specific exception in antitrust law for medical residency. See Pension Funding Equity Act of 2004 § 207, Pub. L. No. 108-218, 118 Stat. 596 (2004) (codified at 15 U.S.C. § 37b). The lawsuit was later dismissed under the authority of the new act.

The USMLE score is just one of many factors considered by residency programs in selecting applicants. The median USMLE Step 1 scores for graduates of U.S. Medical Schools for various residencies are charted in Table 2 on page 5 of "Charting Outcomes in the Match" available at http://www.nrmp.org/data/chartingoutcomes2009v3.pdf. Third year core clerkship grades are also considered prominently.

History of long hours

Medical residencies traditionally require lengthy hours of their trainees. Early residents literally resided at the hospitals, often working in unpaid positions during their education. During this time, a resident might always be "on call" or share that duty with just one other practitioner. More recently, 36-hour shifts were separated by 12 hours of rest, during 100+ hour weeks. The American public, and the medical education establishment, recognized that such long hours were counter-productive, since sleep deprivation increases rates of medical errors. This was noted in a landmark study on the effects of sleep deprivation and error rate in an Intensive-care unit.^[2] The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly (averaged over 4 weeks), overnight call frequency to no more than one overnight every third day, and 10 hours off between shifts. Still, a review committee may grant exceptions for up to 10%, or a maximum of 88 hours, to individual programs. Duty periods for postgraduate year 1 must not exceed 16 hours per day, while postgraduate year 2 residents and in those in subsequent years can have duty periods up to a maximum of 24 hours of continuous duty. While these limits are voluntary, adherence has been mandated for the purposes of accreditation, though lack of adherence to hour restrictions is not uncommon.

Most recently, the Institute of Medicine (IOM) built upon the recommendations of the ACGME in the December 2008 report Resident Duty Hours: Enhancing Sleep, Supervision and Safety. While keeping the ACGME's recommendations of an 80-hour work week averaged over 4 weeks, the IOM report recommends that duty hours should not exceed 16 hours per shift, unless an uninterrupted five-hour break for sleep is provided within shifts that last up to 30 hours. The report also suggests residents be given variable off-duty periods between shifts, based on the timing and duration of the shift, to allow residents to catch up on sleep each day and make up for chronic sleep deprivation on days off.

Critics of long residency hours trace the problem to the fact that a resident has no alternatives to positions that are offered, meaning residents must accept all conditions of employment, including very long work hours, and that they must also, in many cases, contend with poor supervision. [3] This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours.

Supporters of traditional work hours contend that much may be learned in the hospital during the extended time. Furthermore, it remains unclear whether patient safety is enhanced or harmed by a reduction in work hours which necessarily lead to more transitions in care.

Some of the clinical work traditionally performed by residents has been shifted to healthcare workers: ward clerks, nurses, laboratory personnel, phlebotomists. This may include the non-patient care facets of medicine typically referred to as scut work. It has also resulted in a shift of some resident work towards home work, where residents will complete paperwork and other duties at home as to not have to log the hours.

Adoption of an 80 hour work week

United States federal law places no limit on resident work hours. Regulatory and legislative attempts at limiting resident work hours have been proposed, but have yet to be passed. Class action litigation on behalf of the 200,000 medical residents in the US has been another route taken to resolve the matter.

Dr. Richard Corlin, president of the American Medical Association, has called for re-evaluation of the training process, declaring "We need to take a look again at the issue of why the resident is there."[4]

On November 1, 2002, an 80-hour work limit went into effect in residencies accredited by the American Osteopathic Association (AOA). The decision also mandates that interns and residents in AOA-approved programs may not work in excess of 24 consecutive hours exclusive of morning and noon educational programs. It does allow up to six hours for inpatient and outpatient continuity and transfer of care. However, interns and residents may not assume responsibility for a new patient after 24 hours.

The U.S. Occupational Safety and Health Administration (OSHA) rejected a petition filed by the Committee of Interns & Residents/SEIU, a national union of medical residents, the American Medical Student Association, and Public Citizen that sought to restrict medical resident work hours. OSHA instead opted to rely on standards adopted by ACGME, a private trade association that represents and accredits residency programs.[5] On July 1, 2003, the ACGME instituted standards for all accredited residency programs, limiting the work week to 80 hours a week averaged over a period of four weeks. These standards have been voluntarily adopted by residency programs.

Though re-accreditation may be negatively impacted and accreditation suspended or withdrawn for program non-compliance, the amount of hours worked by residents still varies widely between specialties and individual programs. Some programs have no self-policing mechanisms in place to prevent 100+ hour work-weeks while others require residents to self-report hours. Fear of their program losing accreditation commonly leads residents to underreport hours worked.

Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care.

Recently, there has been talk of reducing the work week further, to 57 hours. In the specialty of neurosurgery, some authors have suggested that surgical subspecialties may need to leave the ACGME and create their own accreditation process, because a decrease of this magnitude in resident work hours, if implemented, would compromise resident education and ultimately the quality of physicians in practice "AANS News".. It should be noted, however, that in other areas of medical practice, like internal medicine, pediatrics and radiology, reduced resident duty hours may be not only feasible but advantageous to trainees because this more closely resembles the practice patterns of these specialties, though it has never been determined that trainees should work fewer hours than graduates. In addition, there are no "outcomes studies" or other substantive data to support either conclusion.

Research requirement

The Accreditation Council for Graduate Medical Education clearly states the following three points in the Common Program Requirements for Graduate Medical Education:

1. The curriculum must advance residents’ knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.
2. Residents should participate in scholarly activity.
3. The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities.

Research remains a nonmandatory part of the curriculum and many residency programs do not enforce the research commitment of their faculty leading to a non-Gaussian distribution of the Research Productivity Scale.

Financing residency programs

The Department of Health and Human Services, primarily Medicare, funds the vast majority of residency training in the US. This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education or DME payments. Medicare also uses taxes for Indirect Medical Education or IME payments, a subsidy paid to teaching hospitals that is tied to admissions of Medicare patients in exchange for training resident physicians. Overall funding levels, however, have remained frozen over the last ten years, creating a bottleneck in the training of new physicians in the US, according to the AMA. On the other hand, some argue that Medicare subsidies for training residents simply provide surplus revenue for hospitals which recoup their training costs by paying residents salaries (roughly $35,000 per year) that are far below the residents' market value.. Nicholson's research suggests, in fact, that residency bottlenecks are not caused by a Medicare funding cap, but rather, by Residency Review Committees (which approve new residencies in each specialty) which seek to limit the number of specialists in their field to maintain high incomes. In any case, hospitals trained residents long before Medicare provided additional subsidies for that purpose. A large number of teaching hospitals fund resident training to increase the supply of residency slots, leading to the modest 4% total growth in slots from 1998–2004.

Changes in postgraduate medical training

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

1. Nearly all medical practitioners 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 standard preparation for primary care (what used to be called "general practice").
2. While physicians who graduate from osteopathic medical schools can choose to complete a one-year rotating clinical internship prior to applying for residency, the internship has been subsumed into residency for MD physicians. Many DO physicians do not undertake the rotating internship as it is now uncommon for any 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. Certain specialties, such as ophthalmology, radiology, anesthesiology, and dermatology, still require prospective residents to complete an additional internship year, prior to starting their residency program training.
3. The number of separate residencies has proliferated and there are now dozens. For many years the principal traditional residencies included internal medicine, pediatrics, general surgery, obstetrics and gynecology, neurology, ophthalmology, orthopaedics, neurosurgery, otolaryngology, urology, physical medicine and rehabilitation, and psychiatry. Some training once considered part of internship has also now been moved into the 4th year of medical school (called a subinternship) with significant basic science education being completed before a student even enters medical school (during their undergraduate education before medical school).
4. Pay has increased, but residency compensation continues to be considered an educational stipend and is not sufficient as a "living wage". Additionally, few residents live in hospital-supplied housing anymore, instead having to pay for their housing with their small stipend, 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 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 (averaged over 4 weeks), no more than 24 hours of clinical duties at a stretch with an additional 6 hours for transferring patient care and educational requirement (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. While on paper this has decreased hours, in many programs there has been no decrease in resident work hours, only a decrease in hours recorded. Even though many sources cite that resident work hours have decreased, residents are commonly encouraged or forced to hide their work hours to appear to comply with the 80 hour limits.
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 reduced on these outpatient rotations, this also contributes to the overall decrease in the total number of on-call hours.
7. For all ACGME accredited programs since 2007, there was a call for adherence to ethical principles.

See also

• International medical graduate
• William Osler, a Canadian physician who established the medical residency system in the US.
• Physician training
• Post graduate year annotation (PGY)
• Postdoctoral researcher
• Medical resident work hours
• Validation of foreign studies and degrees

References

US Residency Interview Preparation

• ^ Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW, Czeisler CA (2004). "Effect of reducing interns' work hours on serious medical errors in intensive care units". N Engl J Med. 351 (18): 1838–48. doi:10.1056/NEJMoa041406. PMID 15509817.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• ^ Drazen JM (2004). "Awake and informed". N Engl J Med. 351 (18): 1884. doi:10.1056/NEJMe048276. PMID 15509822.

External links and sources

• The Accreditation Council for Graduate Medical Education in the United States
• The American Osteopathic Association Accreditation for osteopathic residency
• Residency Information - A trusted medical residency resource since 2002 now re-launched
• International Medical Graduates
• FindArticles.com - 'Medical education's dirtiest secret - use of medical residents', Humanist, M.H. Klaiman (November-December, 2003)
• Educational Commission for Foreign Medical Graduates
• Resident Duty Hours: Enhancing Sleep, Supervision and Safety. Institute of Medicine