Becoming a US medical doctor

Richard Hwang explains how the system works for US citizens

College (undergraduate)

Students apply for college during their senior year of high school. Traditionally, college takes four years (ages 18-22), although this time range varies. Medical schools do not require a particular undergraduate major but instead have premedical course prerequisites spanning the humanities and the sciences, for example English and biology.¹

Applying to medical school

Many college graduates take 1-2 years off for activities such as research or travel before applying for medical school. The average age of matriculating US medical students in 2004 was 24.²

Common requirements

• Medical College Admissions Test: A standardised national exam³
• College grades and courses
• Extracurricular activities and postundergraduate activities.

Most medical schools require students to submit an initial application to the American Medical College Application Service, a centralised application service⁴; secondary supplementary applications; and letters of recommendation before deciding whom to invite for interviews. Combined programs such as MD/PhD, MD/JD (law), or MD/MBA (business) have additional requirements.

The application process is involved, expensive, time consuming, and competitive. Duke University's 2004 acceptance rate was 3.9% because applicants vie for a limited number of positions across the country.⁵ In 2004, 16 648 matriculants but 411 151 applicants.⁶ People often aim for highly ranked medical schools to improve their chances for a more competitive residency. US News & World report rankings are a popular way to determine top ranked schools.⁷

Medical school

Medical school lasts for four years. The first two years usually consist of basic science courses. Once completed, students take the United States Medical Licensing Exam (USMLE) Step 1 which tests knowledge of the basic sciences.⁸ This score is important because it is used in the residency application. The next two years consist of clinical rotations, in which medical students get clinical knowledge in hospitals and outpatient clinics. Application for residency programmes occurs in the fourth year. Students usually take the USMLE Step 2 late in the fourth year. This involves a written exam that tests clinical knowledge and a clinical skills exam, given via standardised patients. Although the Step 2 score is not required for the application process, most medical schools require students to pass Step 2 to graduate.

Competitiveness for residency positions varies by specialty. The recent trend among applicants has been towards specialties and away from primary care.⁹ Specialties with higher anticipated income and fewer work hours tend to be more desirable and competitive.¹⁰ Students who plan to pursue fellowships often aim for highly ranked residency programmes.

Residency application

Common requirements:

• USMLE Step 1 (and 2)
• Basic science and clinical grades
• Research and publications
• Extracurricular activities.

PHOTOS.COM

Most residency programmes use the Electronic Residency Application Service (ERAS),¹¹ a centralised application service; letters of recommendation; and interviews to evaluate their applicants. After their interviews, students rank programmes in order of preference, and programme directors rank applicants in their order of preference. All ranked lists must be submitted to a matching programme. The largest matching programme is the National Residency Matching Program (NRMP),¹²

a private not-for-profit corporation that uses an unbiased algorithm to pair applicants and programmes based on their preferences. Most specialty programs that do not participate in the NRMP - for example, neurosurgery and ophthalmology - participate in the San Francisco Match Program (dubbed "early match"),¹³ which has an earlier deadline. All students across the country discover where they will go for residency at the same time on Match Day in mid-March. Students are required to go to the programme to which they have matched.

Residency

Residency training varies according to specialty and institution. For example, internal medicine is three years and general surgery is 5-7 years. Residents must pass USMLE Step 3 before completing their training. Once finished, they can choose either to practise or to pursue a fellowship.

Richard Hwang, third year medical student, Duke University, Durham, NC, USA
Email: ryh@duke.edu


studentBMJ 2005;13:221-264 June ISSN 0966-6494

1. Association of American Medical Colleges. Admission to US medical schools. www.aamc.org/students/applying/about/start.htm (accessed 19 May 2005).
2. Association of American Medical Colleges. Facts: applicants, matriculants, and graduates. www.aamc.org/data/facts/2004/2004age.htm (accessed 19 May 2005).
3. Association of American Medical Colleges. Medical college admissions test. www.aamc.org/students/mcat/start.htm (accessed 19 May 2005).
4. Association of American Medical Colleges. American college application service. www.aamc.org/students/amcas/start.htm (accessed 19 May 2005).
5. US News & World Report. America’s best graduate schools: Duke University. www.usnews.com/usnews/edu/grad/directory/dir-med/brief/glanc_04081_brief.php (accessed 19 May 2005).
6. Association of American Medical Colleges: Facts: applicants, matriculants, and graduates. www.aamc.org/data/facts/2004/2004school-2.htm (accessed 19 May 2005).
7. US News & World Report Ranking Guides. Top medical schools: research. www.usnews.com/usnews/edu/grad/rankings/med/brief/mdrrank_brief.php (accessed 19 May 2005).
8. United States Medical Licensing Exam. www.usmle.org (accessed 19 May 2005).
9. Andriole DA, Whelan AJ, Schechtman KB. Recent trends in match process for US senior medical students. Acad Med 2003;78(suppl):S6-9.
10. Levinsky NG. Recruiting for primary care. New Engl J Med 1993;328:656-60.
11. Association of American Medical Colleges. The electronic residency application service. www.aamc.org/students/eras/start.htm (accessed 19 May 2005).
12. National Residency Matching Program. www.nrmp.org/index.html (accessed 19 May 2005).
13. San Francisco Matching Program. www.sfmatch.org (accessed 19 May 2005).

       

           

	CAREERS Becoming a US medical doctor       Richard Hwang (June 2005)
	RR Gollapenne & S Gella (June 06, 2005)       SHO Orthopaedics, Pinderfields General Hospital mrgella@hotmail.co.uk
	Is it the high time for UK to change selection process? We have gone through the article called "Becoming a US medical doctor" by Richard Hwang. It is very interesting and we think that there are some interesting points that we in UK need glancing. Traditionally all UK exams are qualifying exams and some times it is very difficult for the people in the selection panel to choose the right person among the bundles of applications they receive. Keeping in mind clinical workload the consultants have, it is very difficult for any one in their shoes to allocate sufficient time to go through all the applications to make a correct choice. It might not be an exaggeration, some time or the other every medical graduate in training feels a necessity for some sort of grading system so that the selection process will be much more straightforward and away from personal bias. Through out the world, countries are taking different measures to choose best candidates for their best posts. Many of the developed and developing countries are adapting to the grading methods of their doctors. Most common method of grading is by multiple choice questions followed by clinical examinations or interviews (US, India). Unfortunately we do not have any such standardised method of choosing and we are relying most of the times on traditional methods where there is always a scope for personal bias. Clinical governance emphasises the importance of creating an environment in which excellence in clinical care will flourish (1), but to achieve this there must be systems to avoid bias in selecting the best candidates for the post. To achieve this we feel that it is high time we follow some of the US selection methods like grading exams and centralized selection process, through which best candidates deserving the posts can be selected. References G Scally and L J Donaldson, 'Clinical governance and the drive for quality improvement in the new NHS in England' BMJ (4 July 1998): 61-65

	CAREERS Becoming a US medical doctor       Richard Hwang (June 2005)
	Taiyyab Mehmood (August 23rd, 2005)       Medical Student/Medicine/3rd year, England/Latvia mrt1066@yahoo.com
	I concur. The UK system needs a total revamp. Too late too late has been done. This "tomorrow doctors” document that came at in the mid 902 is all fine and well on paper, but if you read (it is rather cumbersome to also), it waffles on the new direction in a administration be accuracy way about the way doctors should in effect be anyhow in the first place and how to train them. But the reality is totally different. WE have to admit the yanks have hit the hole in one for the time being. A-levels are no way a good factor to rep-dtermin if you will be a good doctor at all, or coming from a private school and/or from a privileged society. USA system is based on merit and non-biases. MCAT scores are statically very good benchmark to see if a student is good or not. I am aware personally of uk A-level students who failed to get in due to coming from low social backgrounds or non fee paying schools and went to student medicine and are now in good medical jobs. Their crime was that that the UK selection is very biases, prejudice, stale, archaic and against human rights. Another thing is that how do I know a new doctors from one medical school is as good or knows the same as the average doctor from another medical school? WE have no gauge to know let alone with overseas doctors coming here in UK (and consequently are 3-5 times worse off to be liable to be struck off or sued!). We need a fair, unbiased, unprejudiced system which can only work hand in hand with the support from all spheres of the government, GMC, BMA, the royal "elist" colleges and more so from the private sector. There is no doubt that the private sector is slowly coming in during the so called "socialist "labour government" (pink conservatives) and the sooner we all open and eyes and accept privatisation is the key to running the health care system, the sooner and better we can radicalise the whole medical system undergraduate and postgraduate training. Get rid of SHO and make doctors go straight into residency. Any reason not to then means the young doctors have not been trained good enough as they should be in line with USA or eastern European doctors, both of whom are able to go straight into residency after graduating. Less talk and more constructive action is the key. Time is of the essence!!! Peace to all :))