Residency (medicine)

Residency is a stage of postgraduate medical training in North America and 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 hospitalized or clinic patients, mostly with direct supervision by more senior physicians. A residency may follow the internship year or include the internship year as the first year of residency.

Whereas medical school gives 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. This term comes from the fact that traditionally resident physicians lived the majority of their lives "in house," i.e. the 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. 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. 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 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 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 internship, often served at different hospitals, and only a minority of physicians served them.

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 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 interview typically in the fall. 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.

The two parties' lists are combined by an NRMP computer, which (theoretically) creates optimal matches of residents to programs using an algorithm. On the third Thursday of March each year ("Match Day") these results are announced. By entering the Match system, applicants are contractually obligated to go to the residency program at the institution to which they were matched.

On the Monday prior to Match Day, candidates find out from the NRMP if (not where) they matched. If they have matched, they must wait until the Match Day (Thursday) to find out where. If they have not, they typically "scramble" into a program the next day. This means contacting unfilled residency programs to secure a position. This frantic, loosely structured system often forces soon-to-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.

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 in the competitive specialties like dermatology, orthopedics, and radiation oncology.

A similar but separate osteopathic match exists which announces its results in February, before the NRMP. Osteopathic physicians (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.).

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.

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 doctor. 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.^[1] The Accreditation Council for Graduate Medical Education (ACGME) has 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. While these limits are voluntary, adherence has been mandated for the purposes of accreditation.

Critics of long residency hours trace the problem to the fact that resident physicians have 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.[2] This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours.

Graduates of the old system postulate that shorter work hours may lead to residents gaining less clinical experience. Whether this will be reflected in numbers of procedures performed, patients seen, competitiveness in job placement and/or other tangible outcomes measures is yet to be seen.

Some of the clinical work traditionally performed by residents has been shifted to non-physician personnel. This may include some of the non-patient care facets of medicine typically referred to as "scut work."

Adoption of an 80 hour work week

Regulatory and legislative attempts at limiting medical resident work hours have materialized, but have yet to attain passage. 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."[3]

The U.S. Occupational Safety and Health Administration (OSHA) rejected a petition seeking to restrict medical resident work hours, opting to rely on standards adopted by ACGME, a private trade association that represents and accredits residency programs.[4] On July 1, 2003, the ACGME instituted standards for all accredited residency programs, limiting the work week to 80 hours/wk averaged over a period of four weeks. These standards have been voluntarily adopted by residency programs.

On November 1, 2002, the 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.

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 report their hours using self-reporting mechanisms such as 80hours.com and it is not unheard of for a resident to be dismissed to home in the middle of ongoing patient care.

Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care.^[5]

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, orthopaedics, neurosurgery, otonasolaryngology, urology, physical medicine and rehabilitation, and psychiatry. Family practice and emergency medicine 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.

References

1. ^ 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. PMID 15509817.{{cite journal}}: CS1 maint: multiple names: authors list (link)
2. ^ Drazen JM (2004). "Awake and informed". N Engl J Med. 351 (18): 1884. PMID 15509822.

See also

• Physician training
• Junior doctor
• Post graduate year annotation (PGY)

External links and sources

• Match anti-trust suit dismissal
• The Accreditation Council for Graduate Medical Education in the United States
• The American Osteopathic Association Accreditation for osteopathic residency
• FindArticles.com - 'Medical education's dirtiest secret - use of medical residents', Humanist, M.H. Klaiman (November-December, 2003)
• Residency Match Application Information