choosing where you work...

[USFjoe]

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I was wondering how the process works of choosing where you work after your residency is completed. First off, I'm a little confused on the differences between internship and fellowship. When do you do each of them, and do they each last a year? Also, when you're finished do you have to work in the hospital that you did your residency in, or are you free to go and look for groups that you could join? How and when do you choose whether you want to work in private practice or academic medicine?

 

[Winged Scapula]

I was wondering how the process works of choosing where you work after your residency is completed. First off, I'm a little confused on the differences between internship and fellowship. When do you do each of them, and do they each last a year?

Internship is the first year of residency.

A fellowship is a period of advanced specialty training done after the completion of residency. It is not required (unlike an internship which IS required) to be licensed or to work as a physician. For example, a gastroenterologist (someone who specializes in diseases of the gut) has done his internship and residency in internal medicine and after completion of that, did a fellowship in gastroenterology.

Internship lasts a year. Fellowships are anywhere from 1 to 3 years in length generally depending on the specialty.

Also, when you're finished do you have to work in the hospital that you did your residency in, or are you free to go and look for groups that you could join?

You are free to move about and look for jobs anywhere you like. Many people do stay on and work at the hospital where they did their residency...its comforting, you know the people, you don't have to move, etc. but there are drawbacks as well.

For example, I'm originally from California but did all my training back east. When I was done I knew I wanted to come back to someplace nice and warm so started looking for jobs in the Southwest and California.

How and when do you choose whether you want to work in private practice or academic medicine?

Depends on what you're interested in and what's available. If you want to teach, you generally have to work in an academic medical center or least have an affiliation with a medical school or residency program. Want to do lots of research? Hard to do, at least profitably in private practice, so you'd probably want an academic career.

You'll figure these things out as you go along and you may change your mind. I was hardcore research oriented when I started. I wasn't particularly interested in private practice but the location was right and so were lots of other things about the job so here I am.

 

[USFjoe]

1) oh ok...so for example if someone gets accepted into an internal medicine residency is their a specific residency-type for an academic career and another for those going into private practice, or does he/she do the same type of residency either way?

2) Do only academic doctors train residents or does every doctor do this?

3) Do you have to do a residency to teach medicine, or is just an MD sufficient?

4) If you decide to stay at the hospital where you did your residency, do you have to join a group that works for the hospital or are some doctors employed solely by the hospital?

I appreciate you taking the time to answer some of my questions btw =)

 

[Winged Scapula]

1) oh ok...so for example if someone gets accepted into an internal medicine residency is their a specific residency-type for an academic career and another for those going into private practice, or does he/she do the same type of residency either way?

In general it is the same residency training. Now, an IM (since that is the example we are using) program at a community hospital with lots of outpatient rotations, rural medicine, etc. is more likely to appeal to someone who isn't interested in academic medicine but by and large the training is the same. Surgery is probably a better example - someone who is interested in academic surgery should train at a university hospital with time off to spend in a research lab, building skills and a research CV rather than at a community program without research labs, connections or practice of turning out academic physicians. These are gross generalizations and there are some IM residencies with "primary care tracks", etc. but by and large you apply for an IM residency, not an academic IM residency or PP IM residency. The difference is in WHERE you apply.

So in general there are not academic and private practice tracks, just some programs may lean one way or another (ie, you generally don't go to a big name academic hospital and then go into a non-academic PP).

2) Do only academic doctors train residents or does every doctor do this?

Since academic means teaching, physicians who are on faculty or have an academic appointment at a teaching hospital with residencies or medical students do the bulk of teaching. However, even in PP you can teach, but you have to have an academic appointment or some affilitation with a medical school for the students or residents to get credit for it. There are rules about where residents can do rotations and with whom.

3) Do you have to do a residency to teach medicine, or is just an MD sufficient?

It depends on what you want to teach. If you have an MD and an advanced degree say in Biochem, you could probably get a job teaching Biochem at a medical school. But in general, teaching clinical sciences requires completing a residency. Awhile back I was looking at requirements to be on faculty at a prominent academic program and the first requirement to be on clinical faculty was to be Board Certified (not just Board Eligible), which requires finishing residency.

Therefore, I would venture that most medical schools and residency programs have the same requirements...that to be on clinical faculty, you must have completed a residency. Not only does it assure some sort of standards, but you have to understand that as a resident, are you really going to respect some guy teaching you IM who's never done a day of residency in his life? I think not.

4) If you decide to stay at the hospital where you did your residency, do you have to join a group that works for the hospital or are some doctors employed solely by the hospital?

It depends on how the hospital is set up. Many academic hospitals employ physicians and you are a contracted employee just as you would be anywhere else. Some hospitals do not employ non-hospital based specialties (ie they may employ radiologists, pathologists, etc.) and others do not employ physicians at all, everyone is an independent contractor. You can be employed by the federal government and work at a VA hospital or by an HMO like Kaiser and work in their clinics or hospitals for a salary.

Often in community or private hospitals,you are given privileges to admit and treat patients, but are not paid by the hospital; everything is billed through insurance. This is the setup I have which is the most common arrangement for private practice.

Then you can have something quasi-academic. A gastroenterologist from my former residency program did this - he left medical staff, opened up a private practice in town, retained admitting privileges to the hospital and an academic appointment. I'm sure he raked in much more dough in PP and still got to teach and have the "prestige" of an academic appointment.

There are a variety of practice situations as you can see.

I appreciate you taking the time to answer some of my questions btw =)

Sure. Its confusing and something most of us weren't taught during medical school or residency.

 

[USFjoe]

Thanks, that was very helpful. You made things more clear for me on processes that I had no idea how they worked. One more question to clarify something I'm still a little hazy on...you say academic docs do most of the teaching...by teaching does that mean like in a classroom setting (do residents still go to any lectures or take any tests?), or does it mean teaching (aka training) residents at the hospital? In other words, are the PP docs training residents, or the academic docs, or both? Also, I didn't know there was such a thing as a teaching hospital...I thought every hospital trained residents...is this not true?

 

[Winged Scapula]

Thanks, that was very helpful. You made things more clear for me on processes that I had no idea how they worked. One more question to clarify something I'm still a little hazy on...you say academic docs do most of the teaching...by teaching does that mean like in a classroom setting (do residents still go to any lectures or take any tests?), or does it mean teaching (aka training) residents at the hospital?

Both. Residencies are required to have education sessions, usually in the form of lectures, 5 hours a week (I think). The requirements do not specify that it has to be an attending doing the sessions, so sometimes they are run by the residents themselves (which is variably helpful as you can imagine).

Most, if not all, residencies have some form of examination or testing, usually in the form of a national standardized test taken once a year; the intraining exam (called the ABSITE for surgery for example). Its not like college or med school where you take an exam after each rotation, though.

Teaching also takes the form of classic bedside teaching rounds when you go and see patients, in the operating room, while doing procedures, in clinic or the office, etc. Teaching takes many forms.

In other words, are the PP docs training residents, or the academic docs, or both?

Both, but it depends on the program. Most private practice physicians probably do not have residents or students rotating with them and therefore are not teaching in the sense you are thinking about it. Academic physicians are generally required to spend so much time on clinical duties and teaching to keep their appointment. Some residency programs will have rotations with physicians in private practice, some will not.

Also, I didn't know there was such a thing as a teaching hospital...I thought every hospital trained residents...is this not true?

Absolutely not true. There are simply not enough residents in this country to be based at every single hospital in the US. Hospitals affilitated with medical schools are generally considered teaching hospitals as are hospitals with residency programs. The vast majority of hospitals in the US are NOT academic or teaching hospitals. Or they may be for one specialty but not another (ie, they may have an IM residency but not a Surgery residency).

Does that make sense?

 

[Blade28]

Don't worry too much about the specifics of practicing medicine for now. Do well in undergrad, get into med school, keep an open mind and see what interests you. If you're still interested in a few years and know what type of residency you'll be training in, THEN you can start to think about how you'd like to set up your practice.

But all of this is years away.

 

[USFjoe]

Yes, thank you Winged Scapula for all of your helpful responses =)

And I know what you mean, Blade28...I've been told similar things before...that's just the way I am, for better or for worse...I plan way ahead...I already know where I'm going to be buried...j/k lol