How did your doctor become a doctor?

Sometimes I say "I can explain it to you, but it'll take about 12 years." Yes, I'm a smart-ass, but consider the education required to become a physician:

Before Med School:
Most people finish high school. About 28% of people finish college. So, completing the requirements for a 4 year degree is something a lot of people have done, and a lot more people understand. Not all med schools require an undergrad degree, but getting into medical school requires some specific coursework that often leads to a little bit more than a 4 year degree. It’s not that much, honestly, particularly when compared to what comes later.

“Pre-requisites” for medical school are generally specific college courses. The Medical College Admission Test, or MCAT, tests achievement in these pre-requisite courses, among other things. The typical courses are:
2 biology courses - typically including cell biology; 2 general chemistry courses; 2 organic chemistry courses; 2 physics courses; Lab courses for each of the science classes; Calculus (usually); English - from one to three courses;

Then, you have to score well on the MCAT. You need to have a pretty good GPA (mostly "A"s), and you have to interview in person at the school. This can be intense, or it can be pretty laid back.

In medical school, you take classes that are essentially graduate-school-level study in several specific subjects, called “Pre-clinical” subjects. This takes about 2 years in most medical schools. You have to pass each class, and you typically have to pass the National Board of Medical Examiners’ tests at the end of those classes. They are usually:
Gross Anatomy
Microanatomy / Cellular Biology
Microbiology
Embryology
Immunology
Physiology
Biochemistry
Pharmacology
Neuroscience
Behavioral Sciences
Genetics
Ethics
Pathophysiology

After completing these courses, you have to take and pass the U.S. medical licensing exam, (USMLE) part 1. If you fail, you get two more tries. If you fail 3 times, you’re out. This is the most difficult exam I have ever taken.

The typical third year of medical school consists of “Clinical” rotations. You actually have substantial patient contact in addition to didactic lectures, periodic exams, educational rounds, etc. The areas of medicine required in the 3rd year are:
--Family Medicine: This includes public health modules, sports medicine, occupational medicine, as well as the typical general practice components of internal/adult medicine, obstetrics, pediatrics, mental health, geriatrics, etc.
--Internal Medicine: This includes exposure to the subspecialty areas, such as cardiology, gastroenterology, allergy/immunology, rheumatology, endocrinology, nephrology, pulmonary medicine / intensive medicine, infectious disease, oncology/hematology, etc.
--Neurology
--Neurosurgery
--Obstetrics/Gynecology: including Maternal/Fetal Medicine, Gynecologic Oncology, Urogynecology, and Reproductive Endocrinology.
--Pediatrics: Including the pediatric subspecialties similar to the Internal Medicine subspecialties, along with Developmental Pediatrics, Behavioral Pediatrics, and Genetics.
--Psychiatry
--Surgery: General, Trauma, Surgical Intensive Care, Cardiovascular/Thoracic, Colorectal, Head/Neck (ENT), Orthopedics, etc.

After the third year, you take Step 2 of the USMLE. Same rules as before: Three strikes and you’re out. It’s easier, though, if you’ve been paying attention.

The fourth year consists largely of “electives” to allow exploration of potential specialty selections and other interests, but some requirements may be included. This also allows for flexibility in scheduling travel to visit other training sites and potential residency programs.

Then you GRADUATE MEDICAL SCHOOL. Congratulations! You are now a medical doctor--except that you know nothing; you aren’t licensed, certified or even certifiable, and you’re more dangerous than helpful. That’s okay, at least you are ready for:

Internship:
Internships are hard to explain. You work hard. You get paid a little bit, but it’s a “stipend” more than a salary. You don’t even pay SS taxes on it. You are lower than the lowest staffer or student in the hospital. You practice under the supervision of at least one resident, and usually under a “Junior” and “Senior” resident. A “Chief” resident may also be involved, but mostly as a liaison. An “Attending Physician” is the doctor of record. S/he has finished residency, often a fellowship, has passed all three licensing exams, and has usually passed one or more board certification exams. Even the medical students are more important than you because they are being recruited by the residency program for future employment.

But, you’re a doctor, so get to work! Specifically, work 80 hours per week for 49 weeks of the year. It used to be more (when I was in school), but we’ve gotten soft. Now the rules prevent such dangerous things as working more than 30 consecutive hours. At this point, you have help, but they are at least as busy as you. You have had 4 years to learn how to look stuff up, and you have observed enough to be aware of your own limitations. By the way, you need to get rid of those limitations, buddy, and the best chance you have for that is to be ready when called in the middle of the night. You can’t wait on someone else when your patient needs a needle thoracotomy, or you won’t have a patient any more.

Typically, during internship, you will rotate through some of the areas of sub-specialization. You may go to the ER for a month, then the ICU, then nephrology consults, then you may be the “mole”-the designated overnight doctor, then general medicine inpatient, maybe an outpatient rotation. If you are doing a “transitional” internship, you may be abused a little. You’ll fill in the rotations that nobody else wants to do prior to your departure for your regular residency.

Oh yeah, if you screw up too much, you’re out. No pressure.

After your 4000 closely supervised hours, you will have the chance to take Step 3 of the USMLE. You can wait on that if you wish, though. Generally, you must complete this step within 7 years from the date you took the first step. The "Three strikes" rule still applies, but it isn’t as universal. After you pass this, you are eligible to apply for full licensure in some states. You could hang a shingle! Except--you usually can’t get hospital privileges (i.e., the right to work in a hospital.) Aaaannnndd--you probably won’t be able to accept many insurance policies. For that, you'll need to go ahead and finish your residency.

Residency:
Residency is highly variable in length and specific duties. On the shorter-duration side of the medical residency world are Internal Med, Pediatrics, Family Medicine, and Emergency Medicine. They usually have an integrated internship and three “Post-Graduate Years.” So, a PGY-1 is an intern, a PGY-2 is a junior resident, and a PGY-3 is a senior resident.

For OB/Gyn, Psychiatry, Neurology, Dermatology, Pathology, et al., you have a 4-year to 5-year training requirement. Internships may or may not be integrated. Your PGY-2 year, therefore, feels a lot like another internship. You are the low-man again, but you aren’t so clueless, so it’s not as bad.

For Surgery, count on at least 5 years. Surgical specialists take 6 to 8 years.

When you are a “junior” resident, you have to supervise interns and students while you are supervised by senior residents and attendings. Senior residents get first choice of procedural cases and are usually on “backup” call, meaning that they get to leave the hospital sometimes. As a resident, you will rotate through every sub-specialty possible. You will have a “continuity” clinic where you see patients who you discharged from the hospital or who have come to the clinic for general care within your specialty. You still take “in-service” exams. In most specialties, if you flunk an in-service exam, you’re out. In other specialties, the exams are intended more as assessments of the program itself or as practice for board certifications.

After residency, you are typically eligible to take a board certification exam from your primary specialty board. If you pass (NOT a given--AT ALL), you are usually going to be able to practice independently. You could even be an “Attending” clinical instructor at your school, all in as little as 11 years since your finished high school!

Fellowship:
Additional training is often needed to deal with complex or difficult cases. In a fellowship, a board-certified specialist will focus intensely on training in a division within the specialty. At the end of a fellowship, usually from one to three years in length, you should have increased ability and understanding in an area beyond that which is common to general specialty members. For example, a cardiologist goes to fellowship for 3 years after residency. An electrophysiologist or interventional cardiologist or transplant cardiologist may go another year or two after a fellowship. They are “sub-specialists” or “sub-sub-specialists.” A surgeon may specialize in Urology via a hybrid residency/fellowship, then become a uro-oncologist and take on difficult cancer cases. A neurosurgeon may specialize in cancer or spinal diseases or neurovascular disease. You get the point? All of these people have a HUGE base of primary knowledge on which they build a HUGE base of speciality knowledge.

Board-Certification:
This is a test or series of tests your doctor has to take after having completed a residency. S/he may be able to practice without a certification, but his options will be limited. S/he may not be able to maintain hospital privileges or may not be eligible to participate in come insurance panels.

Continuing Medical Education:
Various requirements exist. They are state-specific and specialty specific, and individual hospitals have their own internal requirements. "Maintenance of Certification" exams and reporting requirements are now commonplace. Your doctor may have to devote more time education each year than some people have to complete to get college degrees. That's not a bad thing, but it is a real thing.

So, please forgive your doctors when they say “don’t mistake your google search for a medical degree.” The doctors are not trying to be trite; in fact, they are trying to be polite. See, it is considered rude to tell people how much training and education you really have. (If your doctor wanted to be trite, s/he would say “don’t mistake your searches for our MDs, or for our scientific backgrounds, our licenses, internships, residencies, fellowships, board certifications, experience, etc.”)

Financial note:
All of these residencies are 80-hours per week and 49 weeks per year. With knowledge comes a few efficiencies, so it isn’t necessarily so horrible as an upper-level resident. However, you are still paid a pittance. The salary works out to MUCH less than minimum wage (Mine worked out to $1.70/hr), and you can’t earn much extra. So while you are training, you are usually deferring your quarter-million dollar student loans and adding interest to the principle exponentially. This nets to a less-than-nothing income over your internship and residency. But, hey, you are getting an education equivalent of TWO YEARS of experience per one year of real-time. (4000 hours per year for 3 to 8 years = 12000 to 32000 hours of training.) You can pack a lot of knowledge in a head in that amount of time, and saving a life may be worth that, particularly if that life is yours.

Consider that your doctor had to wait 11 to 18 years before he got a real job after high school, and s/he had to borrow a ton of money just to live, let alone pay for school, and s/he works 55 to 100 hours per week, depending on specialty, coverage, location, and other factors, before you give him a hard time about his bill, and remember that all of his expenses, fees, nurses' salaries, required insurances, etc., all have to come out of that payment, so overhead is between 40 and 70%.