Many people think that becoming a doctor is difficult. Others have some sense that becoming a physician takes many years and is expensive. Most people realize that being a physician is difficult yet rewarding. All these people are correct. Becoming a physician is a long, arduous, expensive process that can only be accomplished with great dedication.
The details of this process can be fascinating. For example, have you ever heard of the Scramble? How about the Match? Are you up on the AMCAS, AMCAS-E, or the NRMP? Can you tell me the difference between the SAT, MCAT, and the USMLE-1, USMLE-2, or USMLE-3? OK try this one - What's the difference between an M.D. and a D.O.? Strap yourself in because in this article I will explain the process of becoming a doctor. You are about to take a ride through the unbelievable world of medicine, previously known but to a few!
To Be or Not To Be a Doctor
Before starting the process of becoming a physician (or any profession) you must do some honest soul searching. First of all you must be aware of the time commitment involved in becoming a physician. Medicine is a career that requires many years of preparation. Generally most people graduate college at age 22 and medical school at 26. Then after 3 years of internship and residency, many physicians begin their career at age 29. However, the training for some specialties can last until the physician's early to mid 30's. Obviously this can delay plans for marriage and starting a family. Some people begin their medical education after pursuing other careers, which can further delay the completion of their medical training. You must decide early on if you are willing to dedicate the time it takes to become a physician. As you can see, this is not a decision to be made lightly.
More importantly, you must decide if medicine is a field that is right for the kind of person you are. I believe that there are three cornerstones of a successful career in medicine:
- A love for learning in general
- A true intellectual curiosity about medicine in particular
- A strong desire to help others.
Being smart and doing well in the sciences are obviously important components of being a successful physician. However, do not fall into a medical career because you have done well in the sciences. Although this is a necessary requirement, you must also be able to relate well with people.
As a physician you have an opportunity to help others. Wanting to help others and enjoying helping others are necessary attributes of a good physician. This is something that cannot be taught. However, there are many other professions that can help others. Politicians, religious leaders and social workers all have the opportunity to help others, perhaps in larger numbers.
Medicine is a career filled with choices. In what other career can you choose between delivering babies, taking care of children, handling emergencies, removing someone's cancer, or talking to someone who needs psychiatric help? Better yet, you can teach others any of these specialties, and while teaching have the opportunity to both practice your profession and teach it. Alternately, you can do research in whatever specialty you choose, with the potential to make a real breakthrough in preventing or treating illness. In addition medicine is a career that is honorable and is held in high esteem, allows you the ability to live just about anywhere, and provides job security (unfortunately, illness is something that will be around for the foreseeable future).
However, all of this comes at a price. The many years of preparation, the discipline, the awesome responsibility, the worry about malpractice and the long hours can take their toll. Medicine is a unique field and it demands a unique person.
One word about money. Please don't let this be a driving factor in your decision, for the sake of your patients and yourself, because it will not sustain you. There are other careers in which you can make more money without the responsibility and the effort it takes to be a physician.
A famous Chinese proverb says that a journey of a thousand miles begins with a single step. Well the same is true with the road to becoming a physician. While in high school it is important to get a good general education. This is good by itself, but also prepares you for doing well on the S.A.T. Taking a complete science curriculum in high school is key to having a good science foundation for future science courses in college and medical school. Take 4 years of science in high school, including biology, physics and chemistry, plus 4 years of math (including calculus). It is so important to have a good foundation in these sciences so that you can learn the subject matter in college well enough to earn A's. It seems inconceivable that someone can do well in the killer science courses in college without having been introduced to these in high school. Getting high grades is the most important component in being accepted into a prestigious college. However, do not be tempted to take easy courses that allow you to get high grades. This will not prepare you for taking courses in college that are much more difficult than those in high school.
More importantly, high school is the time to learn about the real world of medicine (not the one you see on TV). Do something that gets you in touch with the medical field to see if it is right for you now, before putting in all that effort. Learn about other fields that may interest you so that you may compare them to medicine. Also, for the same reason, take elective courses other than sciences to see if these interest you more.
When I was in high school, I volunteered at my local hospital. I enjoyed my experiences there, especially in the Emergency Room. This was part of the impetus in my decision to become a physician. Many years later while in medical school I selected Emergency Medicine as my specialty. I then completed an internship and residency in Emergency Medicine and have been practicing Emergency Medicine ever since. It is surprising how small decisions at an early age can influence the rest of your life.
Choosing a College
When choosing a college, remember that there is no perfect college. There is only what is right for you. Some of the factors to consider are:
- Academic reputation
- Distance from home
- Location - rural, suburban, urban
- Academic programs - quality of faculty, facilities, advisors; choice of majors; number of pre-meds, percent of pre-meds accepted to medical school.
You may want to select a college that has a medical school as part of the University. In the end you will know what is right by what your gut tells you.
College life is not just grades and studying. Your college experience should be one of the most exciting and enjoyable times of your life. The good friends and good times from college are some of the fondest memories I have. After all this is where I met my wife. Having fun is very important. However, you must have the discipline to know when to stop. Remember, chances are you have moved away from home and are living in a dorm and have more freedom now than ever before. However, with this freedom must come the wisdom to act responsibly for your own sake.
In college you must learn how to manage your time. This is a skill which will be invaluable as a medical student and for the rest of your medical career. Some things that are just deadly time killers such as video games and TV should be curtailed significantly or banished altogether.
The courses you take in college (especially science courses in this case) are infinitely more difficult than you can imagine. If you do not take the time to study you will not do well enough to get into medical school. It's that simple. It is possible to do well and have fun- I did. However, it is a balancing act that must be mastered. Going to the library to study is not synonymous with studying. Many people go there and waste time.
A major decision you must make early on in college is choosing a major. There are no required majors for acceptance into medical school. The most common major is biology. However, medical schools accept students from many backgrounds. Sometimes it is better to have a major outside of the usual so that your application is more unique. Some medical schools are looking for more diversity and want some students with liberal arts degrees. However this places more emphasis on how well you do on the courses required for medical school admission. Whatever major you choose should be something you enjoy. However, you should also take a wide breadth of courses to experience other fields because it may be your last opportunity.
Requirements for Medical School
Here are the required courses for most medical schools:
- 1 year of Biology with lab
- 1 year of Inorganic Chemistry with lab
- 1 year of Organic Chemistry with lab
- 1 year of English
- Many schools require 1 year of calculus or college level math
- Some medical schools request a course in Biochemistry
Most pre-med students try to spread out the science courses required for medical school so that they are not overwhelmed all at once. It is also helpful if some of the material is fresh when taking the MCAT.
Needless to say, getting good grades in college is absolutely necessary. Your GPA (grade point average) is probably the most important factor in being accepted into medical school. Most medical students have GPA's of 3.5 to 4.0 (on the standard 4.0 scale used in the U.S.). When you apply to medical school, the standard application requests your GPA for your science courses, your GPA for non-science courses and your overall GPA. For those students who entered medical school in 1998, the average science GPA was 3.52, the average non-science GPA was 3.64, and the average overall GPA was 3.57. If you do poorly on one of the required courses it is probably a good idea to take another course in that field to improve your grades and show that you can handle that subject. It is also important to do well in college from the beginning. After all, if you only get a 2.0 in your first year and then get a 4.0 the next 2 years your GPA will still be under 3.5. However, medical schools do consider the fact that you are improving. Doing well at a college with an outstanding reputation goes a long way. Try not to fall behind in your class work. This leads to cramming, poor grades and, more importantly, poor learning.
The sciences courses, in particular Organic Chemistry, are traditionally the "weed out" courses that eliminate students who will not make it into medical school. I remember my first major exam in Chemistry. Many students failed. As a result, a large percentage of students dropped the course, stopped their pursuit of a medical career and changed majors. All this occurred in the first few weeks of college.
Besides your college transcript, most medical schools require you to take the M.C.A.T. and supply your score with your application. The M.C.A.T. (Medical College Admission Test) is an all-day, standardized, multiple-choice test administered by the American Association of Medical Colleges (A.A.M.C.) (www.aamc.org/stuapps/admiss/mcat/). The M.C.A.T. is given twice per year (April and August) and in 1999 cost $165. It is intended to assist admissions committees in predicting who will do well in medical school. Almost all medical schools require it. This is a way for medical schools to compare candidates from different schools and different backgrounds. After all, one could argue that the same GPA from a more prestigious school means more. However, the MCAT provides a common denominator to compare candidates from different schools. This is a one of the most important tests you will take and you should study for it. I studied for almost 2 months for it.
Before you apply to medical school you should know that there are two types of medical training: Allopathic and Osteopathic. Allopathic medical schools are the traditional medical schools that confer an M.D. degree to graduates. Osteopathic schools confer a D.O. degree. They are very similar except that Osteopathic schools have additional courses in Osteopathic Manipulative Treatment (OMT). OMTs are manipulative techniques to help heal, relieve pain, and restore range of motion. There are approximately 38,000 D.O.'s in the U.S., 57% are in primary care and 43% are in a range of other specialties. To find out more about Osteopathic Medicine go to www.aacom.org.
Applying to Medical School
There are 125 Medical Schools and 19 Osteopathic schools in the U.S. In 1998 there were 41,000 applicants for 16,170 spots in traditional medical schools (see www.aamc.org/stuapps/facts/famg3.htm). There were 9,500 applicants for 2,500 spots in Osteopathic schools. Application is usually made towards the end of junior year of college. There is a centralized application service run by A.M.C.A.S. (American Medical College Application Service) for M.D. schools (cost - $55 for 1st school and decreasing amount for additional schools) and A.A.C.O.M.A.S. (American Association of Colleges of Osteopathic Medicine) for D.O. schools. 113 of the 125 medical schools participate in the AMCAS program. There is also the AMCAS-E which allows you to send the application over the Internet. Basically you fill out the application, which includes your grades, personal information and a personal essay and send it to them. They verify the information and send it to the schools that you designate. This saves you from filling out multiple applications and gives the medical school verified information in a standard form. The essay on this application is very important and should be personal, interesting and fun to read. It needs to set you apart from the other applicants.
Some medical schools require secondary applications and letters of recommendation. Many colleges have a premedical committee that writes a unified recommendation letter about each student. It is vitally important that your college send a good letter of recommendation about you.
Pre-Med students apply to average of 13 medical schools. You should generally apply to all the schools in your state, some that you feel are your safe schools, and some that you can only dream of getting into. State supported medical schools take an overwhelming majority of students from their own state. It is close to impossible to get into a state supported medical school if you are not a resident of that state. Occasionally they will take some students from neighboring states or states without medical schools (Alaska, Idaho, Montana, and Wyoming).
Medical School Interview
Being granted an interview is a big hurdle. Now your chances of being accepted increase tremendously because only a minority of applicants are granted an interview to a particular school. You have met their academic criteria for admission -- otherwise they would not invite you for an interview. This is their chance to get to know you personally. Some rules:
- dress nicely
- be on time
- be polite and pleasant
- make eye contact
- don't interrupt
- be yourself
- and above all be honest.
Most interviewers have been doing this a long time and can tell when you are telling them something you think they want to hear. Know as much about the school and its curriculum as possible. They will probably ask you why you have chosen this medical school. Also, be prepared for the usual questions about things such as why you want to be a doctor, how you feel about managed care and health care reform, what you think about different ethical questions, etc. While at the school talk to as many students and faculty as you can. Learn as much as you can about the place as possible. There is a good section about people's experiences at medical school interviews at Student Doctor Network. Finally, always write a thank-you note to the people who have interviewed you.
Now you're in medical school. In 1998 there were 69,340 medical students in U.S. medical schools (57% males, 43% female). Medical school is very difficult -- I'm sure you don't have to be warned about that. In order to get through medical school you must be dedicated to learning and have excellent study skills. If you can retain the information presented to you, not just memorize and forget, you will be highly successful. You will need unparalleled time management skills. Time is a luxury not to be wasted. Just as in college, TV is an enemy. Learn to do several things at once. Also learn when to take a break from it all.
Most of the day is filled with lectures, labs and small group activities. Some medical students end up missing lectures because they fall behind in their studies. However, many medical schools have a note taking service that transcribes lectures. These are then distributed to everyone so that they can be reviewed at any time. Try not to fall behind. Once you fall behind it leads to cramming for tests, and crammed material is forgotten quickly. The problem is not the difficulty of the subject material -- it is the volume. And it just keeps coming. Evenings are filled with many hours of studying.
What drives a medical student to study so much? This is a complex question. Medical students, by nature, are competitive people and always want to do well. Many realize that they will someday have the awesome responsibility of saving peoples' lives, and they take this responsibility to heart. Some fear that they will someday have a patient and have no idea what is wrong with him. These thoughts can give you cold sweats.
Medical schools are not in the business of trying to get you to flunk out. They selected you because you because they felt that you could handle the work, and they will help you succeed. As a result, you'll be happy to know that over 95% of the students entering medical schools do end up earning their M.D. degree.
Medical School Curriculum
Most medical schools have similar configurations. Generally the first two years are classroom-based, with patient contact beginning in the second year. The third and fourth years consist of rotations through the different major specialties of medicine.
The 1st year of medical school consists of basic sciences which educate you about normal body functions. Courses include:
- Anatomy - the science of the structure of the body and the relations of its parts (especially those that can be seen with the naked eye). This course is taught by lecture and dissection of a human cadaver
- Physiology - the science of the function of the body and its parts (and the chemical and physical steps involved)
- Histology - the science of the cells and tissue on the microscopic level (microscopic anatomy)
- Biochemistry - the science of the chemistry of the cells, tissue, and organs of the body
- Embryology - the science of the development of a human from its most immature form
- Neuroanatomy - the anatomy of the nervous system
In the 2nd year of medical more emphasis is placed on disease and its treatment. Courses in the 2nd year include:
During the 2nd year medical students also take courses that introduce them to taking a medical history and performing a physical exam.
The structure of the first two years of medical school has been undergoing a transition recently. Some medical schools use an organ-based approach. In this system, all of the Anatomy, Physiology (normal function), Pathology, Pharmacology, etc. about one organ system (i.e. the heart) is taught at one time before going to the next organ system. Some medical schools teach only one subject at a time. For instance, Anatomy is taught all day, every day for 8 weeks, then the next subject is taught. Some students find it easier to concentrate on only one subject at a time. Many schools are doing more teaching in small groups and less in large lectures and are using case studies to teach medicine. Of course, there are numerous medical schools that use a hybrid of the systems mentioned above.
At the end of 2nd year all medical students take the first part of the United States Medical Licensing Examination (USMLE-1), administered by the National Board of Medical Examiners (NBME). The purpose of the NBME is to prepare and administer a test that states feel confident in using to determine medical competency when deciding to issue a license to practice medicine. There is no national license to practice medicine. Each state has its own rules and issues its own license.
The USMLE is a three-part exam:
- Part 1 is taken in the 2nd year of medical school and tests your knowledge in the basic medical sciences.
- Part 2 is taken in the 4th year of medical school and tests whether you can apply your medical knowledge in providing patient care under supervision.
- Part 3 is taken in the first year of residency (internship) and tests your ability to apply your medical knowledge in providing unsupervised medical care.
These are very difficult exams. However, over 90% of students from U.S. M.D. schools pass these exams (see www.usmle.org).
In the 3rd year, medical students begin rotating through each of the specialties of medicine, such as Internal Medicine, Surgery, Pediatrics, Obstetrics and Gynecology, Psychiatry, Neurology, Radiology, Emergency Medicine, Family Medicine, etc. In the 4th year more clinical rotations with a higher level of responsibility are completed, in addition to electives.
Cost of Medical School
I thought medical school was expensive when I attended it. Now it is extremely expensive. The average first year tuition at a private medical school in the 1998-1999 school year was $24,917. The average first year tuition at a public (state-supported) medical school for in-state residents in 1998-1999 was $9,263 and for out of state residents it was $22,391. In addition, there are fees, housing costs, meals, books, equipment, car expenses, etc.
The high cost of medical school has implications that are not obvious at first. Most medical school graduates have large financial debts when they graduate. In 1996 the mean educational debt of medical graduates who had to borrow money was $75,103. Some medical students don't borrow money because they enter the military, which pays for medical school in exchange for a time commitment. One third of graduates of private medical school have financial debt greater than $100,000. As a result, many graduates tend to enter high-paying sub-specialties. This trend has left a need for primary care physicians.
In your 4th year of medical school you must decide which field of medicine (specialty) to practice. Each medical field requires a residency (a training period -- sort of an apprenticeship) of 3 or more years.
Information about residency programs can be obtained from the book Directory of Graduate Medical Education Programs published by the AMA (www.ama-assn.org) or online through FREIDA online (Fellowship and Residency Electronic Interactive Database) at www.ama-assn.org/go/freida. After deciding which specialty to enter, you must decide which residency program you like, then go visit and interview there. This is where the "Match" comes in.
Basically the Match is run by the National Resident Matching Program (a non-profit corporation). They conduct a sort of computer matching game. It works in the following way. After everyone has completed their interviews, the graduating medical student submits their list of residency programs in order of preference. At the same time, the residency programs rank the students that they prefer. The NRMP enters the info into a computer to match students and residency programs with their highest possible preference. Every graduating medical student finds out the results on the same day in mid-March on "Match day".
You are committed to accept the position you have matched into. If you did not match into a residency you are informed a few days prior to match day. A list of unfilled positions is provided to the unmatched medical students so that they can participate in the Scramble (getting unmatched medical students into unfilled positions).
In 1998, 16,000 graduating medical students and another 19,000 candidates (former graduates of U.S. medical schools, graduates of foreign medical schools, students in U.S. Osteopathic schools, and students in Canadian medical schools) competed for 23,000 positions through the Match. Approximately 80,000 physicians are in residency or fellowship programs at any particular time in 701 teaching hospitals offering residency programs in the U.S.
In the U.S., physicians complete a residency in one of numerous specialties. A residency takes a minimum of 3 years. Sub-specialty training (called fellowships) take additional years to complete.
Here is a synopsis of different medical specialties and subspecialties and the length of their training programs (internship, residency, fellowship) after medical school:
- Anesthesiology - 4 years
- Dermatology - 4 years
- Emergency Medicine - 3-4 years
- General Surgery - 5 years; Subspecialties of Surgery require an additional 1 to 4 years after the 5 year residency, they include: Vascular Surgery, Cardio-Thoracic Surgery, Pediatric Surgery, Colon and Rectal Surgery. Some surgical specialties require 1-2 years of General Surgery, then an additional 3-5 years of specialty training, they include: Neurosurgery, Orthopedic Surgery, Ophthalmology, Otolaryngology, Plastic Surgery, and Urology
- Internal Medicine - 3 years; subspecialties of Internal medicine require an additional 2-3 years after the 3 year residency, they include: Cardiology, Endocrinology, Gastroenterology, Geriatrics, Hematology, Oncology, Infectious Diseases, Nephrology, Pulmonary, Rheumatology
- Neurology - 4 years
- Obstetrics and Gynecology - 4 years
- Pathology - 4 years
- Pediatrics - 3 years; subspecialties of Pediatrics require and additional 2-3 years after the 3 year residency, they include: Pediatric Cardiology, Pediatric Endocrinology, Pediatric Gastroenterology, Pediatric Infectious Diseases, Pediatric Critical Care, Neonatology, Pediatric Nephrology, Pediatric Pulmonology, Pediatric Rheumatology
- Psychiatry - 4 years
- Radiology - 4-5 years; subspecialties of Radiology require and additional 1-2 years after residency, they include: Neuroradiology, Vascular and Interventional Radiology, Pediatric Radiology
For more info see this page.
Internship, Residency and Fellowship
As I discussed above, Residency is a 3+ year training program in a medical specialty. The first year of training after medical school is called internship, or more commonly it is called first year of residency or PGY-1 (PostGraduate Year-1). The following years are called PGY-2, PGY-3, etc. The training that is done after a residency (in a subspecialty) is usually called a fellowship. Much of what you will learn in your chosen specialty will be learned in your residency.
It's hard to believe that, after 12 years of school, 4 years of college and 4 years of medical school, there is still so much to learn. The first 20 years of school are the foundation and the tools you will need to learn your specialty. During your residency you will learn medicine by caring for patients with a variety of diseases. The more patients you care for, and the more disease and variations of disease that you see and treat, the more proficient you will become. The knowledge obtained from patient care is supplemented with lectures and conferences.
There are so many different residencies, but generally the first year of residency (internship or PGY-1) is spent either rotating through different specialties or rotating to different areas within one specialty. In my case I spent the year rotating, in 1 month intervals, to the ER, General Surgery, Internal Medicine, Intensive Care Unit, Orthopedics, Pediatrics and OB/GYN. After the first year much more emphasis is placed on your own specialty.
A typical day in residency starts around 7AM. First you see your patients prior to "rounds" to check on the results of diagnostic tests, to see how they are responding to therapy. Next are "rounds" with your team. A team usually consists of several interns, a upper level supervising resident, and an attending or teaching physician. They take care of a specific group of patients. "Rounds" mean you walk around to each patient to discuss his or her care. Suggestions on further diagnostic tests and treatments are the usual topics of discussion. After rounds you may return to see some patients in more depth, do whatever procedures need to be done, talk to the patient's private physician, etc.
Usually there is a lecture or conference at some point in the day. After lunch new patients are often admitted to your team. You will need to do a history and physical exam. Then write their admitting orders. These are written instructions about which tests, medications, etc. are to be given for this patient. At the end of the day you "sign out" to the team that is "on call" that night. This is done to tell them about either all your patients or the ones that may run into trouble that night. At home it is important to continue to read about medicine, especially at this point in your career. However, fatigue plays a big role and you often need recovery sleep from your night on call.
Being on call while in residency means that you stay in the hospital over night and care for the patients on your team and the other teams, and care for the new admissions. This means you will be working up to 30-36 hours with little or no sleep. This is done every 2nd, 3rd, or 4th night depending on the institution and specialty you are in. This is a long-standing tradition in medicine. Many people outside the medical field see this as an unnecessary, perhaps dangerous tradition. The argument on the other side goes that the more experience you have treating patients and their diseases the better you will be as a physician. In order to see the same number of patients from 9AM-5PM, the length of training programs would need to be considerably longer. Also, someone needs to care for patients after hours. An old saying in medicine goes - the only thing wrong with being on call every other night is that you only get to see half the patients.
An intern is at the bottom of the food chain at a teaching hospital. Any unpleasant, menial task (called "scut" work) is the intern's job.
Another medical tradition during internship is the phenomenon of "see one, do one, teach one". In other words when a procedure needs to be performed you see someone do it. Next time it needs to be done you do it. The following time, now that you are an expert, you teach someone else to do it. This is how some medical knowledge gets passed on.
At this point you are finally being paid for your services. The mean salary for a first year resident in 1998-99 was $34,104. For each additional year of residency the mean salary increase was $1,451 see this page for details).
After completing a residency or fellowship, you must obtain a medical license so that you can practice medicine. Each state has its own individual rules. For graduates of U.S. medical schools this is a relatively straightforward procedure. Generally you have to have graduated from an approved medical school in the U.S. Medical schools are approved or accredited by the Liaison Committee on Medical Education (LCME), which is a joint committee of the Association of American Medical Colleges (AAMC) and The American Medical Association (AMA). Many states require only 1 year of training after medical school (internship) in an approved residency program as the bare minimum for obtaining a license. Residency programs are accredited by the Accreditation Council of Graduate Medical Education (ACGME) through the Residency Review Committees (RRC). You need to have passed one of several exams to prove that you are competent (such as the USMLE). Letters of reference are usually required. A check of your malpractice history will also be obtained. The rules for graduates of foreign medical schools are more complex and can be obtained from each state medical licensing board.
Becoming a board certified physician in a specialty involves the completion of a residency in a given specialty, then completing a comprehensive exam (often a written and oral exam). When you have satisfied the requirements of that particular board you are now Board certified and are called a Diplomate of that board (e.g. Diplomate of the American Board of Emergency Medicine). There are 24 approved medical specialty boards in the U.S. (see www.abms.org, the American Board of Medical Specialties). Many boards require recertification every 7-10 years.
Now it is time to find a real job. You can join a group practice, start your own private practice, join a clinic or join an H.M.O. Some physicians are hospital based (emergency physicians, radiologists, pathologists, anesthesiologists) but can be part of a private practice or an employee.
I hope you have enjoyed our long journey on the road to Becoming a Doctor. It has been a long and fruitful one for myself and many others.
About the Author:
Dr. Carl Bianco, M.D. is an Emergency Physician practicing at Dorchester General Hospital in Cambridge, MD, located on the Eastern Shore of Maryland. Dr. Bianco attended Medical school at Georgetown University School of Medicine and he received his undergraduate degree from Georgetown University majoring in nursing and pre-med. He Completed an internship and residency in Emergency Medicine at Akron City Hospital in Akron, Ohio.
Dr. Bianco lives near Baltimore with his wonderful wife and two wonderful children.