So confused!!

Discuss about the Residency Match process - applications, interviews, visas, medical school transcripts, residency programs, ECFMG certificate, match strategies and post-match scramble. Meet current Residents & Fellows here and network for Residency placement. Post your opinion on specific residency programs.

Postby nadiranaqvi » 31 Jul 2005, 06:25

Oh okay - that's makes things a bit clearer.

But I'm not even sure about the more basic stuff than that!

For instance, over here the first year after Med School is your pre registration house officer year (PRHO), which essentially is when you're the lowest of the low and you have to do a minimum of 4 months in Medicine and 4 months Surgery (usually 6 months of each though) in hospital, plus something else maybe so that you have a year in total of experience, and provided you're not dangerous, you get signed off by each of your Consultants (the equivalent of an Attending I believe), you are able to become a registered doctor and progress further.

At that point most people specialize into which ever branch they wish to (eg Surgery in my case) and become a Senior House Officer (SHO) and do various specialities within that branch to gain further experience, also allowing you to then take exams which providing you pass allow you to progress further to become a Registrar (Reg).
Most people spend about 3yrs at SHO level and then may do research for another 2 or 3 years before actually getting a specialist training number to get onto a Reg rotation.

You then spend about 5-7 years at Reg level and take exit exams so that you can then become a Consultant of a particular speciality in Surgery (eg Upper GI/General etc). Although, even having passed the final exit exam this doesn't guarantee a post at Consultant level - this very much depends on the demand and openings available at the time that you are applying, and therefore there maybe a short period of essentially waiting around where you continue at Registrar level and just improve your skill set in order to bag the next Consultant job that you go for by being the most desirable candidate there!

Other thing here - contacts count for a lot and most people tend to stick to one area of the country (usually the same area that you quallified form University) where you get known by the people who count and often that may be the reason why you get the job as opposed to the guy next to you - ie. better the devil you know than the one you don't and all that, plus people prefer home grown stock, that have been nurtured almost to fit the job!

So how does it compare over there though in that respect?
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Postby DrJeff » 31 Jul 2005, 08:05

This is very interesting to me. I see why UK docs would fare better over here.

So if I am following you then PRHO is what we call intern and is technically Post Grad Year 1 (PGY-1). Usually this is tied to a full program (gen surgery, IM, FP) so you dont get a whole experience that first year unless you are in an FP program. For the truely undecided there is a TRANSITIONAL year which means 12 months of trying various things. A way of not commiting. Usually a bad plan. After that you are a Resident but actually people now call interns residents interchangably but no one would ever call a second year resident an intern. As an intern there is always someone ahead of you watching the patient also. (We all have stories about how the intern tried to kill someone in the night.) Depending on the program they may have 2 interns and 1 resident in 2,3,4,5th year. Gen surg is 5 years total. US guys dont usually do extra years of research or have to repeat. They may do extra years to sub specialize in thoracic but that is completely different. You finish your 5 years you are board eligible and can go anywhere you want to get a job with a big group or just start your own practice anywhere you think you can survive on your own. You take your board certification exam offered by the board of surgery and if you pass you are BC Gen Surgery. Your program director signs off on you to take your test (after 5 years).

So you get a residency in Gen Surgery it is for 5 years the first you are an intern and then you move yearly up the food chain. Often a program will be something like this. There will be 2 interns, then 1 resident at 2,3,4,5. The Pgy 5, 3, and an intern will run one team and watch over 20 pts that they have operated on. The 5 is the chief resident and will do the surgery with the attending (aka Staff Physician...fully trained out in practice). The 3 or the 1 may help on the case. But mostly the 1 is on the ward, taking out stitches, answering pages from the nurse, etc. The Pgy 4,2, and 1 will make another team. The 4 is acting chief and will watch another 20pts on his team. The PGY5, just like the attending will really be looking over that team too but not as much because the 4 is pretty sharp. SO the 1 is called to the ER to see an abd pain. He will then get some lab or xray and call the 2 or 3 to tell him what he is doing. Then they will call the 4 or 5 and he will come see the pt. The 4or5 will call the attending and say we have a choly ready to go to the OR. etc.

To make it more complicated a program may have 3 hospitals and 10 residents at each level, changing services every month mixing up the team.

As For getting a residency.
The best deal is to get a 5 year catagorical spot. That is the only thing a US grad would ever consider (unless they just need 1 year before they stat anesthesia or radiology or something like that). There are tons of PGY-1 only years for General Surgery (PRELIM spots), but there are no guarantees associated with this and usually only FMGs take these spots. So when you hear about fmgs or there schools bragging that their grads are doing surgery at Johns Hopkins they are usually only doing a prelim year and next year they are out on their bum as you say. SOunds good but aint much.

As for test, as I said Im not a surgeon but IM pretty sure they just take the Inservice exams each year, which is like an imitation board certification exam. If you do poorly as most pgy-1 and 2 do, they tell you to study more, make you take more call, but seldom if ever not promote you to the next year. Making connections is good during residency but many folks get up and move cross country and take a job with an established group. For example we recently had a guy who trained in NY, came to a little hospital in Texas which needed more doctors, went into practice by himself. Covered a couple of little towns. Here for 4 years, couldnt make enough money( didnt get enough referals from the local docs...got to learn to get along) so he took a job in Missouri, 5 states away. So it is not so much who you know but learning to get along with people in general. (most docs problem in the US)

There are little subtleties along the way too, but that is the big picture.
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Postby nadiranaqvi » 31 Jul 2005, 14:05

Wow! Now I get it! Thank you so much for that - but as for how you can now see why UK Docs would fare better in the US ... I'm not so sure - it sounds like a pretty dog eat dog world out there!

So basically (in summary!):
A Consultant = An Attending
Senior Registrar = PGY 5
Junior Registrar = PGY 4
Senior SHO = PGY 3
Junior SHO = PGY 2
PRHO = Intern

And given that I have figured the above out right, over here I'm a PGY 3 going on to be 4 shortly, but am I right in thinking that when I come across there I start at intern level?

The other thing is, although the system here may seem a bit long and no set time in which you reach an end point, that can actually work out, especially in my case - for instance, that period of time where people do research, its also a great time to pop out a few kids! I mean how do females in Surgery in partcular manage to have a family as well as a career over there?
The other thing - over here they are improving the number of hours we work in an average week to a maximum of 45. Being from the old school where when I first qualified we were meant to do 72 hours a week but more often than not did more like 100, I do think that training has suffered as a result (there is nothing like good old experience!) but equally a pro is that it does allow for a life outside medicine.
The other thing is that as you go up the hierachy, the on calls aren't so gruelling - you can be on call from home for instance - but I'm not sure if that's the case there.
Also, although yeah it may make a take a long time to reach a Consultant, when you do get there, there's no possibility of not making enough money and being unsuccessful - that's it, you've made it!
And also, from what I understand, although you guys work like dogs from the outset pretty much, am I right in thinking that its not really until you become an Attending that you earn a decent wage - although yes, we're not just talking decent we're talking hitting the big time - but up until that point, you can be barely making ends meet? You see over here, you pretty much earn a decent amount from the start and every year that goes up!

One other thing that you might be able to clear up for me - I've heard that you guys can do fellowships I think at Attending level - have I got that right? In which case I think that again changes how that equates to the levels here, in that a Consultant here = an Attending with a fellowship where as an Attending without a fellowship = a Senior Registrar.

As for changing services every month! Surely you've barely got use to the set up after only a month let alone actually learnt that much in that time!
It all sounds horribly scary I have to say - has made me very apprehensive about coming over!!
I'm sure its not that bad - I mean as part of our Medical Degree we got to spend time abroad as part of our elective in 4th year and I spent a month in a hospital in San Francisco doing General Surgery. I had a great time and although the hours you guys do there are longer, the intensity didn't seem as heavy as it is over here. Also you guys have a very good ongoing teaching program as well as ensuring that doctors are doing what they should be rather than mundane jobs (eg taking blood, ECGs, paperwork etc etc!).
But stilll - I'm worried now!! :(
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Postby DrJeff » 31 Jul 2005, 14:14

what can I say to take reassure you?

PGY -1 start around $40,000/yr. Yes we are trying to implement the rules of no more than 6days a week and no more than 80 hrs a week.
The interns life is hard because he doesnt know any better. You will be well seasoned and it may be a bit boring. But you can spend time teaching medical students. As for salary it goes up about $1000/yr.

As an attending you will make $150,000 bare minimum. The surgeon who went on to Missouri was offer $300,000 or so.

Call is about every 3rd or 4th night at most times.
Rotations are often more than a month if you spend 3 months on the trauma service. It may noy be all the same residents but the new guy will learn from the old guys for a month then the old guys will be done and the new guy will be starting his 2nd month.

I have heard of fully qualified surgeons (whatever that means) coming to the US and going right into a fellowship, esp. things that may not currently be in vogue. The programs need residents and fellows are a real treat for the attendings.
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Postby nadiranaqvi » 31 Jul 2005, 14:24

Now that is what I call "instant messaging"!! That was one speedy reply! Heh heh heh.

But just so I have got it right - I do go in at intern level?

And the other thing - where do females out there who are keen and want to do well in Surgery, fit in having a family?!!
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Postby DrJeff » 31 Jul 2005, 17:10

I had two friends married in med school. Both wanted to be surgeons. He is a cardiothoracic surgeon trained in inner city NJ. She finished school and had 4 kids. Dont know if she will ever go back. I can give examples of females who do it but ouch!

I would never want my wife or daughter to try to do surgery residency and have a family. Of course I also dont like day care, or credit card debt or alot of things that people use in America to get what they want and get it now.

There are plenty of females in Pediatrics and FP and it is much more family friendly.
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Postby nadiranaqvi » 01 Aug 2005, 01:03

No way! So you're telling me that in a modern developed western society such as the States, that women aren't able to be Surgeons and have a family, or that if they do, her kids will more likely be under the impression that the nanny is their mother for not having seeing their real mum ever?!!

Hmmm ... tell me, are the on calls always so frequent throughout the training period? And what about as an Attending?

As for paediatrics and family practice - all very good and nice, but that is not what I trained to do nor what I want to do!!

But another thing - I DO have to start at intern level then? And you mentioned that you are Chief Resident - what does that mean and entail?

On a separate issue - may be a bit of a random question but still, do hospitals provide any type of accommodation at all for Doctors (+/- family) working at the hospital? I'm just thinking intially when you do get a post, do you have to run around sorting out somewhere to live or would you at least have somewhere to reside initially whilst sorting out something (I'm ones of these people who like to plan well in advance if haven't gathered yet!!).
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Postby DrJeff » 01 Aug 2005, 13:31

No. They can be surgeons. They just have to sacrifice for a few years during residency.

On call is usuall every 3rd to 5th night. Come in at 6am one day and usually leave by 1p the next day. Some months you have no call, some months have call from home.

As for attendings it depends on the job you take. I know guys who take trauma call once a week in house, some twice a week. Most take call from home and it depends how many docs are in the group and whether you have a resident or fellow in house to solve problems for you.

For most FMGs coming to this country, what you want to do and what you can do are not the same. I know many surgeons who are FP or IM.

I was a chief resident. It means different things. The PGY-5 on the surgery team is a CHief, because he is in charge. Of all the senior residents in a program there is usually one who is the CHief resident and he makes the schedule and helps problem solve, recruit, interview, etc.

Many programs have a CHief resident who is in his first year as an attending. So you do 3 years of peds. Most get out and go take a job for $120,000/yr. Some guy stays behind and does a year as chief and they pay him $50-80k. He can be an attending for the residents (making the other attendings take less call) he can teach, etc.
No one in their right mind would do this unless they were trying hard to get a specific job or fellowship and they are putting in extra time.

This is pretty common for FMGs in IM programs. They do a chief year or a research year and then they are promised a cardiology fellowship spot, etc.

Most places dont provide housing. SOme of the inner city hospitals do have apt bldgs next door that you can rent from. Helps you stay closer. Otherwise everyone goes out to a nice neighborhood and its hard to get back for home call. WHen you are on call in house there is always a room. Some are nice with tv, ac, private bath, desk, books, lockers, couch, frig. SOme are a closet with a bed.
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Postby nadiranaqvi » 07 Aug 2005, 03:18

Okay - thanks for that. I think that's all the questions answered ... for now at least!
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Thanks

Postby Thanks » 17 Nov 2005, 19:25

Thanks for the info..I am participating in this years match and god willing will match
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Postby nadiranaqvi » 13 Feb 2006, 05:16

Have been away for a long time but yet again I come back with another question that I'm hoping someone out there will be able to give me the heads up on!

I'm wondering whether its possible to work in the States without having to do all the exams first. Its just that I'm pretty sure I've heard of people here (at Registrar level) going out there, and because they are considered pretty experienced and also because I think because they're really in demand and really wanted there, people have gone across (albeit temporarily - like for a couple of years or so) for like a "fellowship" or something, and somehow they are able to work out there but not have to do the exams - they are somehow made exempt.

Do any of you know if this is the case and what are the rules about such situations (eg. like you have to pretty much have finished your training in the UK and just be waiting for a consultant job here to fit the criteria or something along those lines)?
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NO

Postby NO » 13 Feb 2006, 17:45

You cannot touch any patient(for the purpose of diagosing/treating) in the US without ECFMG certification. Period.
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Postby nadiranaqvi » 14 Feb 2006, 09:58

Are you sure that's really the case - just because I'm sure I've come across people where that's not been the case (unfortunately, I didn't ask them the finer details of how come at that point!), but also I was just browsing above and Dr Jeff mentioned something along these lines also;

"I have heard of fully qualified surgeons (whatever that means) coming to the US and going right into a fellowship, esp. things that may not currently be in vogue. The programs need residents and fellows are a real treat for the attendings."

So I'm just trying to find out how that situation is possible - any answers, much appreciated![/quote]
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regarding USMLE

Postby imranali » 14 Feb 2006, 13:59

I have completed my graduation(MBBS) from Pakistan recently.I have heard that it is not necessray to do the internship for USMLE because in interviews they hardly look at the work one has done overseas, Is that right? Does Internship play any role in attaining a residency? Is a doctor who has not done internship overseas at disadvantage in comparison with the doctors who have completed their internship in their homeland?
and lastly what role academics play in attaining a residency for an overseas doctors,as I have heard that Interview panel only looks for USMLE Scores,USCE,RESEARCH vice versa and sometime they dont even look at academics of an overseas doctor! Pls do reply these questions in detail so that I can proceed further.....
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fellowship

Postby Dr.No » 14 Feb 2006, 15:28

What Dr.Jeff mentioned is going into fellowship first even before doing residency, which is possibvle if you are already a specialist. You will need to complete your residency at a later date, otherwise, you will not be eligible to sit for the felllowship or residency board exams(ABIM).

But, you cannot do either of the above(cannot touch patients) until u get ecfmg certified.

GL
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