Are you a doctor in the United States

Specialist training in the USA: At the beginning there is contact with the patient

The medical profession has hardly lost its attractiveness for high school graduates and students. With around 10,000 unemployed doctors, however, the recession does not stop at medical professionals. The competition for a job is getting tougher. As an alternative to German specialist training, Dr. med. Christian Koch completed his training as an internist at the American Ohio State University.

The first year of residency is the internship. With an average of 26 years, American interns are about the same age as German interns. The internship requires a lot of physical and psychological substance: the weekly working time is around 80 hours with only two days off a month. In the first "year of training" interns should gain clinical experience through as much patient contact as possible and learn to master most emergency situations. You will be supported by an assistant doctor (resident) and a senior doctor (attending). In addition to these three doctors, the typical team also includes two to three medical students who actively participate in patient care and ask many questions that are answered with references to current publications on the respective problem.
For an assistant (internal and resident) in internal medicine, a normal working day begins at 7.30 a.m. with a round. At 9 o'clock the "morning report" takes place, in which interesting cases from the previous night are presented and discussed. Every day between 10 a.m. and 12 noon, the assistants visit with the senior physician, who gives short presentations on individual patient-related problems and includes the students in diagnosis and therapy decisions. In the afternoon, the interns take care of new admissions. They end their duty on non-standby days around 6 p.m. Every Thursday from 12 noon to 1 pm, professors from other universities give guest lectures ("grand rounds") on general medical or subject-specific problems. On the weekends the interns have to show up for rounds, even if they are not on call. On "off duty" Saturdays and Sundays, work is carried out from 8 a.m. to around 12 p.m. In the first year of training, two weekend days per month are free. There are far fewer service commitments in the second and third years.

If the assessment is poor, there is a risk of termination
In internship, the assistant changes departments every month, in internal medicine, for example, from cardiology to gastroenterology, etc. This keeps the motivation going. At the end of each month, internal, assistant and senior physicians as well as medical students are assessed. On a scale from 1 to 5, medical knowledge, clinical judgment, humanistic qualities, dealing with patients, professional demeanor and "manual" skills are rated as well as punctuality and didactic skills. If the internal, resident or medical student's assessment is below average, a committee decides whether the relevant month of rotation must be repeated. If there are more than two bad assessments per year, there is a risk of termination. This system also includes the senior physicians and seems to favor teamwork and a good working atmosphere without intrigue. For example, the friendly treatment of American chief and senior physicians with assistants and students is in no way comparable to that of many German chief and senior physicians, who often come across as arrogant.
The interns are on duty every fourth to fifth night on average. However, the workload decreases in the course of the training. This is already noticeable in the second year of the residency. The training plan then only provides for seven months in the clinic. The remaining five months are so-called consultation months. During this time, the resident visits outpatients and inpatients, together with the senior physician and students, whose therapy requires specialist medical advice. But there is also the option of completing two months of research instead of two months of consultation. Case reports with a literature review or retrospective studies come into question as research topics. Larger research projects are possible, but very time-consuming.
During the consultation months, only two night shifts per month have to be performed. In the third year of training, residents spend six months on the ward, the remaining six months are consultation months, of which two months can alternatively be devoted to research. Income is not affected because night shifts are not paid extra. The annual income is different in the individual states. In Ohio, an intern earns around $ 30,000. The maximum rate in states like California or New York is 40,000 US dollars, which is comparatively little given the higher cost of living. Income increases by around $ 1,500 a year. Anyone who has acquired a permanent license after the first or second year of training can earn an enormous amount through "moonlighting" (roughly equivalent to serving at a district hospital), especially in the consultation months with few night shifts. A "moonlight shift" of 12 hours is remunerated at around 900 US dollars. This should not be compared with DM, as the value of a US dollar in America is much higher than in Germany and the maximum tax rate in the USA is much lower at around 33 percent.

Specialist examination is very practice-oriented
The residents make most diagnoses and therapy decisions on their own responsibility, but can always ask the senior physician for advice. The start of training in the USA is very tough, which in extreme cases can endanger patient care (1). The training goal is achieved by 99 percent of interns. The specialist examination in internal medicine, which consists of a written and an oral part, can be taken after a 3-year residency. However, only 54 percent of the participants pass the very practice-oriented exam on their first attempt. A series of questions published by the American College of Physicians serves as preparation. After passing the exam, the "boardcertification" follows, the license to become a specialist, which allows you to practice as an internist. The annual income of an internist is around 100,000 US dollars for a 40-hour week and two on-call night shifts per month in the first year of the branch. The work is similar to that of a general practitioner. Anyone who would like to deal more with minor surgery, paediatrics or obstetrics can complete a three-year residency in family practice with appropriate board certification as an alternative to internal medicine. The income in this field is slightly higher at 130,000 US dollars annually, but there are also more hours worked, for example due to births.
Anyone striving for a specialization, be it for an academic career or because of their own medical practice, will also encounter difficulties in the USA in the future (2, 3). In principle, a fellowship must be completed, which lasts two to three years and brings in a slightly higher salary compared to the residency. In the past, specialists in the USA made astronomical sums of several hundred thousand dollars a year. The annual income of a gastroenterologist in the 1980s was between $ 300,000 and $ 800,000. In the meantime, doctors who settle down have to reckon with significantly lower incomes.

General medicine should be promoted
The American government wants to regulate the number of specialists and general practitioners in favor of general practitioners by 2002. Some clinics (e.g. UCLA) only accept medical students who want to work as general practitioners in a residency program (4). American cities are oversupplied with doctors of all specialties. A neurologist from Los Angeles, for example, has to share his patient clientele with nine other resident colleagues in close proximity. He sees this as the reason for the loss of income. Only 25 kilometers away is a less attractive part of the city with only one neurologist who earns three times as much. For the future, the doctor must go where the patient is. Then he will not be left without work (5).
Nevertheless, fellowships have not lost their attractiveness. In addition to working as a specialist, there is still the option of settling down as a generalist or pursuing an academic career. This begins in the USA after the residency with one year of clinical work in a sub-specialization subject. This is followed by either clinical or laboratory research. After the examination in the chosen specialty, for example in gastroenterology, there is the possibility of settling down as a gastroenterologist or of continuing to work at the university clinic as an "assistant professor". The "assistant professor" initially receives a five-year contract. During this time he has to support his academic position through teaching and research. If he passes this section, he can be promoted to "associate" and finally to "full professor". The income of a university professor is generally lower than that of a general practitioner. The equipment of the American university hospitals is excellent. The patients are only accommodated in single or double rooms. Each ward has a computer on which "cis" (clinical information system) is installed, a program with which all patient data such as laboratory values, radiological findings and echocardiography can be called up. In addition, every ward computer has access to the "medline", which lists the latest publications for every patient problem. Access to examinations such as CT, MR, MRA is ensured even in emergency situations without long waiting times. The entire hospital complex is air-conditioned. In the infection department there are special air-pressure controlled rooms for people with tuberculosis. In the oncology department, the humidity is also reduced.
Training at a university clinic is better than at other clinics, especially for applicants who are striving for a fellowship, as there is an obligation to teach, which is also guaranteed by the aforementioned evaluation procedure. Every year in its July issue, the magazine "US News" publishes a ranking of the best American clinics.

Author's address:
Dr. med. Christian A. Koch
Ohio State University Hospitals
202 Means Hall
1654 Upham Drive
Columbus, OH 43210
United States

1. Green MJ: What (if anything) is wrong with residency overwork? Annals of Internal Medicine, 1995, 123: 512.
2. Iglehart JK: Health Care reform and graduate medical education. New England Journal of Medicine, 330: 1167.
3. Stillman AE: Modern Times. New England Journal of Medicine, 1995, 333: 1086.
4. Church GJ: Teaching hospitals in crisis. Time, 1995, 146.
5. Cooper RA: Unemployed physicians. New England Journal of Medicine, 1996, 334: 541.