Q: What is an internship?
the old days, all physician completed a one year "rotating internship"
after graduating from medical school. Such an internship consisted of
all the major subdivisions of medical practice: Internal medicine,
obstetrics and gynecology, etc. The idea was to provide a broad
spectrum of training to allow the new physician to work in the community
as a "general practitioner."
Q: What is a "preliminary" year? A "categorical"
Today, the closest thing we have to the rotating
internships of old is the "transitional year," also completed after
graduating from medical school. For a few specialties, a year of
post-gradute training is required before beginning a residency in that
field. Many who want to go into these fields fill that requirement with
a transitional year. Fields that require a year before beginning
residency include radiology,
In the current lingo, the first year of post-graduate
training is called "internship," and any medical school graduate in the
first year of post-graduate training is called an "intern" regardless of
what that first year of training consists. Most specialties do not
require a transitional year, but instead accept medical school graduates
straight out of medical school.
A: An alternative to the transitional year for
some is the "preliminary year." Preliminary years come in two flavors,
internal medicine and surgery. Each of these preliminary years somewhat
resembles the rotating internships of old, but with a focus on either
internal medicine or surgery. Those programs that require a year of
post-graduate education before beginning residency may accept either a
transitional year or a preliminary year. Obviously, surgical residencies
will require that you do a preliminary surgery year while some other
specialties will prefer a preliminary medicine year.
Q: What is the Match?
The other reason that a new M.D. would go into a
preliminary year or transitional year would be because he didn't match
into the specialty of his choice. The hopeful applicant then takes a
preliminary or transitional year in the hopes of improving his chances
and qualifications for the next year's residency match.
The term "categorical" is used largely to distinguish
between the interns who are doing a preiminary year and those who are
already accepted into the residency program. For instance, a general
surgery program may have 6 interns every year, but two of them may doing
surgery as a preliminary year. Those positions that are already accepted
into the whole surgical residency program are called "categorical."
A: The Match
is a way to bring together residency applicants and residency programs
in an organized fashion. After applying to and interviewing at various
residency programs in their specialty of choice, students submit a "rank
order list" which specifies their preferences for programs in numerical
order. Residency programs submit similar lists. After all of the lists
have been received, a computer matches applicants and programs. At noon
Eastern time, on a fateful day in March of each year, all applicants
across the country receive an envelope telling them where they will
spend the next several years.
Q: How many hours do interns/residents work?
Controversy has surrounded the Match algorithm in recent
years, due to a slight preference for residency programs in a very small
percentage of cases. The algorithm has since been changed to favor
A: Intern and resident hours vary very
widely depending on specialty, hospital, and within
hospitals between different departments. Some
specialties are well-known for their less demanding
hours during residency (and often afterwards as well).
These "lifestyle" fields include
anesthesiology, and physical medicine and rehabilitation
(physiatry). Specialties whose residencies are reputed
for difficulty and lack of sleep are general
obstetrics and gynecology. Most of the other specialties
fall somewhere in between.
Q: What does "board certified" mean?
Surgical interns and often internal medicine interns
routinely work 100+ hours a week, with some months
requiring a brutal every other night call schedule. This
means, for instance, that you go to work on Monday
morning (around 5-6 am) work all day, stay in the
hospital all night (with varying amounts of sleep but
usually 2-3 hours), work the following day as well
(hoping that you may get out early), then go home for
around 6 pm only to repeat the whole cycle again the
next day. On months such as these, if you have a spouse,
children, or pets, you won't see them. You can do the
math to figure out how many hours per week that amounts
to. Most call schedules for intern years run either
every third or every fourth night on call
Generally, to become certified by one of the boards
recognized by the American Board of Medical Specialties
<http://www.abms.org>, a physician must meet several requirements:
1) Possess an MD or DO degree from a recognized school
2) Complete 3 to 7 years of specialty training in an
3) Some boards require assessments of competence from
the training director
4) Most boards require the physician to have an
5) Some boards require experience in full-time practice,
usually 2 years
6) Pass a written examination, and sometimes an oral
After certification, a physician is given the status of
"diplomate" in that specialty. Many boards require recertification at
Q: How do a choose a residency program? I need to
declare a medical specialty before long, but I have so
many conflicting feelings and thoughts about various
clinical areas. How can I make the right choice?
It's time for fourth year students to get serious about
choosing their specialty area. Some of you are lucky,
and everything lines up: you know which clinical area
interests you most, your board scores and grades/letters
are all in the correct range, and you have helpful
professors on your side. For you, it's just a matter of
doing the paperwork on time. You can stop reading here.
But I know there are many others of you out there who
aren't sure what specialty to choose. Or, you're torn
between 2 or 3 specialties. Or you know what you don't
want but aren't sure what you do want. Or you know what
you want, but aren't sure if your qualifications are
strong enough. Read on!
If you're stuck, here's a decision tree to follow:
Find or make a list of all the specialties available
directly after medical school (ie, skip
Cross off the ones you definitely don't want. You
don't need a string of reasons beyond the fact that
you simply can't see yourself doing it long term.
Perform a Googleâ„¢ search with the phrase "choosing
a medical specialty." When I tried it, I got about
89,800,000 entries. Set a timer for no more than 1
hour and browse through the first several pages.
Take some of the "what specialty are you?" quizzes.
If nothing else, they will give you some ideas and
possibly make you think about specialties you
haven't explored. You can safely avoid making an
exact ranking of specialties at this point. Just see
which specialties you seem to be most suited to and
which you should rule out.
Now, list several specialties you can see yourself
doing long term, no more than 6.
Research those specialties in your institution. Go
to the departments and make friends with the
residency program coordinators. If you haven't
already done so and haven't rotated in the program,
arrange to shadow a faculty member for a day. Talk
with 1 or 2 residents and check out the pros and
cons of the specialty. Finally, ask the program
coordinator if your board scores would be in a
competitive range. Most program coordinators won't
share their board score cut-off, but they likely
would tell you if your scores are within range.
Narrow your list to 2 or 3 specialties. Now, and
only now, talk with family and friends. Tell them
you're thinking of these specialties, and get their
opinions. Listen hard, and get them to articulate
the basis for their opinions.
Delete any reasons related to job shortages or
oversupply of physicians in a specialty. You don't
need 200 jobs, you only need 1, and you should be
prepared to relocate somewhere less attractive if
you choose a specialty that's overcrowded or not in
much demand. Plus, demand can change by the time you
Delete any reasons related to lifestyle or money,
unless those concerns come from your significant
Delete heritage reasons ("Your father is a surgeon;
you should be one, too").
Now, write down your own pros and cons, independent
of all the advice and aptitude testing and board
scores. Be honest here. If your priorities are
lifestyle, having children during residency, income,
opportunities for foreign travel, or avoiding rough
circumstances, then rank them appropriately. What
fascinates you, what could you be passionate about?
Don't be at all logical here.
But do be logical in this next step. And brutally
honest with yourself: Did you barely pass the
boards? Internal medicine might not be for you, even
if you really enjoy outpatient medicine. Do you tend
to avoid or dislike patient contact? Don't consider
family medicine or
pediatrics. Do you have high
board scores, want a benign lifestyle, but aren't
very visual? Don't pick
If you follow all these steps, combining thoughtful
reflection on what makes you happy with an objective
look at your strengths and weaknesses, one option
should start singing out louder than the others. And
that's your specialty.
Note that you should take other people's views of your
strengths and weaknesses into account, but not necessarily follow their
advice. Spouses are a special case because you are making a joint life
together. Still, the final decision should be yours, informed by some
actual data that help you determine "the best fit" between you and your
You can do this in a week; don't procrastinate and don't
make the problem bigger than it is. If you choose a specialty that turns
out to be a bad fit, you can still change after the first year.
Be practical, but don't limit yourself. I know a
physician who started medical school at age 38, one who had to take the
boards several times, one who barely passed one of her steps by 1 point,
and another who doesn't like patient care. The first one is now
in a large private clinic, the second is a fellow
in a high-risk obstetric anesthesia program at a very prestigious
academic medical center after switching from
because of physical
limitations, the third is a fellow in a neonatal intensive care unit
after completing a successful pediatrics
residency, and the last is
working for a large drug company doing information technology, his real
Even if you are "nonstandard," you can find a specialty
you will love and which will value you. Good luck!