It's a Mad, Mad Medical Training World

Or, "What is a resident anyway?"

Medical training in the US is an odd mish-mash of formal education, tradition and state and federal regulation. Moreover, the US model of training is very different than the European model. And while there are a few countries that follow the US model, most other places in the world follow Europe.

In the USA, the progression of training is generally undergraduate, medical school, internship, and residency, followed by either practice or fellowship then practice. The undergraduate part is pretty straightforward - before being admitted to medical school you need to have completed some flavor of bachelor degree. The odd part is that it can be any flavor of bachelor degree. Certainly things like biology, biochemistry or pre-medicine are the most degrees, but any B will do. I have one classmate whose BS is geology. Another has a BFA (bachelor of fine arts). As long as you have all of the required classes (lots of biology, physics and chemistry), your piece of paper can say anything you want.

OK, so you get into medical school (congratulations!), and eventually you graduate. Congratulations (again), you're a doctor. That is, you have completed a doctorate level degree. And while you have more medical training than, say a PhD in philosophy, you have no more legal right to practice medicine than one. To do that you need to complete your internship. Indeed the first bit of confusion stems from this quirk of terminology. To wit: a physician is not synonymous with a doctor. "Doctor" is a degree, "Physician" is a profession. Technically being a doctor only connotes that one has completed a doctor level degree.

And this where history and modernity collide. Prior to the about the mid 60s all doctors (as in medical school graduates) had to complete an internship. The internship was one year of (usually) moth long rotations in a myriad of core medical fields like pediatrics and surgery. After completing internship a doctor was eligible for licensure in nearly every state, and could hang out their shingle as a "general practitioner" or GP. All those jovial, rumpled, small town docs in Norman Rockwell paintings took this route. My dad who is currently an ER doc took this route. If a doctor wanted to be a surgeon or a obstetrician he then needed to do a residency.

Residencies varied in length from two years for Internal Medicine to four for Surgery. It was also not at all unusual for a doctor to work for several years after his internship before beginning his residency. Not surprisingly, the locations for internships and residencies were very rarely the same.

Things gradually began to change in the years after WWII. Specialty medicine became much more common and the number of doctors completing residencies grew dramatically. It became common for doctors to go directly from internship to residency with no time for practice in between. Eventually specialty programs began offering "package" residencies - internship and residency in one location. At this point the distinction between internship and residency was essentially obliterated, although it still remains tradition to call first year residents "interns."

Today there are really no more GPs, in the sense that no one goes out to practice medicine after only one year of training. (Even the GP's modern replacements, primary care physicians, have specialty training, usually Family Medicine or Internal Medicine.) The intern year is still significant though. Even under the current "internshipless" system a doctor can not be licensed to practice until they've completed their first year of residency. An intern can only practice medicine under the direct supervision of a licensed doctor (kind of like driving with a learner's permit). At the end of their intern year residents must pass a board exam, after which they are eligible for licensure and able to practice without supervision.

There are a few residencies that do not automatically include the intern year. Many anesthesia programs do not, for example, requiring residents to complete a "transition" year (i.e. an internship) at another institution before beginning their residency.

Interestingly, the law regulating licensing has not changed. It would still be entirely legal for a doctor to complete her internship and then go out and start practicing medicine. No one does it, though. I suspect this has largely to do with getting malpractice insurance - I am sure it is prohibitively expensive (if it is available at all) for docs who have not completed a residency. I also strongly doubt there would be any health insurance companies willing to reimburse a GP. Savvy patients would be understandably reluctant to been seen by such a GP when more thoroughly trained physicians are everywhere. One would also not be eligible for board certification without completing a residency. In short, no more GPs.

And none of this address fellowship, board certification or restrictions on what a license does or does not allow you to do. But that's an essay for another time.