The Road to Becoming a Doctor
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The Road to Becoming a Doctor
PROJECT MEDICAL EDUCATION
America’s medical schools and teaching hospitals
working together to inform Congress, policymakers,
and opinion leaders about medical education for
the benefit of all Americans.
Association of
American Medical Colleges
This publication was adapted from the Road to Becoming a Physician brochure produced by the office of marketing and communications at University of Iowa Health Care in Iowa City, Iowa.
opular images of physicians have While most people realize that it takes a physicians-in-training with whom
P changed over time—from the small-
town doctor of Norman Rockwell paint-
long time to become a doctor, relatively
few fully understand the process of
patients may come into contact at
teaching hospitals or other clinical
ings to the medical team of television’s medical education and training. This education sites and explains the
“Grey’s Anatomy.” But common to these brochure outlines this process and ways in which patients can help educate
very different images is a view of the explains how physicians prepare for tomorrow’s doctors.
physician as a professional whose knowl- different types of careers. It describes
edge and skills take years to acquire. the various types of physicians and
Association of American Medical Colleges 1
Types of Physicians
Medicine offers a vast variety of career and specialists. The term primary care Doctors may hold many other degrees in
choices. Most physicians treat patients refers to medical fields—usually family addition to medical degrees. Some have
full time, while others also teach, con- medicine, general internal medicine, and Ph.D. or master’s degrees in the sciences
duct research, manage hospitals and general pediatrics—that cover the most or in fields such as public health, hospi-
clinics, and develop health care policy. common health problems. tal administration, or education.
There is no single road to becoming a
doctor, but most medical career paths Specialists (or subspecialists) concen- Of course, many other health care
share key characteristics. trate on particular types of illnesses or professionals in addition to physicians
problems that affect specific tissues or deliver patient care. Professionals in
Doctors are often considered in two organ systems in the body. These nursing, pharmacy, dentistry, physical
main groups: primary care physicians doctors may treat patients with compli- therapy, and clinical psychology also
(sometimes referred to as generalists) cated illnesses who are referred to them provide patient services. Individuals
by primary care physicians or by other with degrees in the laboratory sciences
specialists. Whatever their focus may be, and medical technology are also
all physicians must hold one of two essential to the health care system.
degrees. Most have an M.D. (doctor of Some of these health professionals—
medicine) degree, while others hold a particularly physician assistants or nurse
D.O. (doctor of osteopathy) degree. practitioners—may provide many basic
While the two types of degrees reflect medical services as part of teams with
different theories and practices of physicians. Working together with physi-
medicine, medical licensing authorities cians, these members of the health pro-
recognize both training paths. fessions community create a seamless
continuum of care.
Association of American Medical Colleges 2
The Academic Medical Center
The term academic medical center usually well as conduct research. Clinical faculty are
describes a medical school—either publicly usually staff physicians at the school’s affili-
or privately owned—and its affiliated teach- ated teaching hospitals and clinics. They
ing hospitals, clinics, and other university- treat patients, teach future physicians, and in
sponsored programs. These institutions are many cases, conduct research.
the foundation of our nation’s health care
system. They not only prepare tomorrow’s In their hospital roles, these doctors are
doctors, but also care for patients and referred to as attending physicians. They
generate new scientific knowledge. oversee the work of residents and fellows—
medical school graduates pursuing
Different aspects of the medical education advanced education in a medical or
process occur in various parts of the surgical specialty. They also instruct
academic medical center. While medical medical students on their way to earning
students learn basic principles in the M.D. degrees.
classroom, their education would not be
complete without experience in teaching
hospitals, clinics, and doctors’ offices.
Physicians who work in academic medicine
fulfill several roles. Full-time faculty mem-
bers are part of a medical school’s basic
science or clinical departments. Basic
science faculty teach medical students as
Association of American Medical Colleges 3
Patients Are Essential in Medical Education
A central mission of any academic they play in medical education and Medical schools and teaching hospitals
medical center is patient care. But, training extremely rewarding. They cannot train physicians alone. They
patients also make valuable contribu- can make a young medical student feel must also train nurses, physician
tions to a center’s education and re- comfortable while performing his or assistants, and other health practitioners.
search roles. They put a human face on her first physical examination, or they Moreover, they depend on the individu-
illnesses and issues that students learn can help an experienced doctor see an als and communities who bring their
about in their studies. They also assist old problem in a new light. Patients experiences, beliefs, and wisdom to
with new discoveries by volunteering to should understand that, in many cases, students, residents, and even established
participate in research studies and trials. the people who care for them are at dif- doctors. A spirit of cooperation between
ferent points on the road to becoming a doctor and patient assures that future
Patients are often the most effective doctor and that they play a vital role in generations will have access to the best
teachers of even the most seasoned helping them reach their destinations. possible physicians.
physicians. Many patients find the role
Association of American Medical Colleges 4
The Medical Education Process
A physician’s education officially begins medical school immediately after
with medical school, which is typically completing their bachelor’s degrees,
four years in length. In the United States, others choose to begin their studies
the Liaison Committee on Medical after spending time in other careers.
Education (LCME), sponsored by the
Association of American Medical Medical schools strive to recruit
Colleges (AAMC) and the American students who reflect the varied
Medical Association (AMA), accredits communities they will serve. A more
all M.D.-granting medical schools. The diverse physician workforce will help
American Osteopathic Association challenge assumptions, broaden
(AOA) accredits D.O.—granting medical perspectives, and shape more culturally
schools. Annually, these schools gradu- competent health care providers for the
ate approximately 19,000 students. future. Schools also seek students who
demonstrate a sincere interest in medi-
Medical students come from a wide cine and public service and who possess
range of backgrounds, although most certain key characteristics. The ability to
begin medical school after completing analyze information and solve problems,
at least a four-year bachelor’s degree establish relationships and communicate
program at a college or university. Some with patients and colleagues, display
students have studied the sciences, while good judgment, and make sound
others majored in liberal arts or human- decisions under pressure are characteris-
ities. While many individuals enter tics sought in future medical students.
Association of American Medical Colleges 5
The Oath of Hippocrates
Physicians traditionally take the Oath of
Hippocrates as they enter the medical
profession. Some medical students take
the oath before beginning their studies, Individuals seeking admission to
committing themselves to medicine’s code medical school should also demonstrate
of conduct from the first day of their their commitment to complete a rigor-
education. The oath reads: ous educational program. To affirm their adherence to the highest
I do solemnly swear by that which I hold most ethical principles embedded in the
sacred: that I will be loyal to the profession of Students admitted to medical school practice of medicine (altruism, honesty,
medicine and just and generous to its mem- tend to have records of high academic integrity, and the intention to help,
bers; that I will lead my life and practice my achievement, including high scores on comfort, and heal others), new medical
art in uprightness and honor; that into what- the Medical College Admission Test students usually participate in a sym-
soever house I shall enter, it shall be for the (MCAT), a national examination ad- bolic “white coat ceremony” during
good of the sick to the utmost of my power; ministered by the AAMC and taken by which they are “cloaked” in the white
I, holding myself aloof from wrong, from cor- medical school applicants. Prospective
ruption, and from the temptation of others to jacket typically worn by doctors and
students also visit campuses for personal recite the Hippocratic Oath (or a mod-
vice; that I will exercise my art solely for the
interviews—an integral part of the ern version of the oath) before they
cure of my patients, and will give no drug,
perform no operation for a criminal purpose, admissions process. begin their classes.
even if solicited, and far less suggest such a
thing; that whatsoever I shall see or hear of Medical students learn both the science In general, the medical school curricu-
the lives of others which is not fitting to be and the art of medicine. They study sub- lum in the first two years stresses both
spoken, I will keep inviolably secret. jects such as biochemistry, anatomy, and factual knowledge and key skills such as
genetics, while also acquiring problem critical thinking, establishing rapport
These things I do promise, and in proportion solving, teamwork, and communication
as I am faithful to this, my oath, may happi- with patients and colleagues, and con-
skills. Medical school curricula empha- ducting medical histories and physical
ness and good repute be ever mine—the
size professionalism and a commitment examinations. In the final two years of
opposite if I shall be forsworn.
to lifelong learning. medical school, students rotate through
Association of American Medical Colleges 6
Curriculum Highlights
The following curriculum is a representative of
many medical schools, but there is a wide variety
of course format and approaches:
clerkships in both primary care and spe- Participants take the first two years of
Year 1 – Normal structure and function of cialty medicine, applying what they have the M.D. curriculum alongside other
body tissues learned in the classroom to supervised medical students. After completing one
• First semester – biochemistry, cell biology, experiences with real patients. or two of the third-year clinical clerk-
medical genetics, gross anatomy
ships, they enter the graduate phase of
• Second semester – structure and function of
human organ systems, neuroscience,
During their education, students must the program—usually in a basic science
immunology take the United States Medical or an interdisciplinary research field.
Licensing Examination (USMLE), a Once they complete their Ph.D. degrees,
Year 2 – Abnormal structure and function three-step test all potential physicians they return to clinical studies. The entire
• First semester – infectious diseases, must pass in order to practice medicine process takes seven to eight years.
pharmacology, pathology in the United States and Canada. The
• Second semester – clinical diagnoses and first step—which covers basic medical After earning their joint degrees, most
therapeutics, health law principles—comes near the end of the graduates begin a clinical residency pro-
second year of medical school, followed gram. They often go on to apply this
Years 3 and 4 – The clinical years
• Generalist core – experience in family and com-
by the next step—on clinical diagnosis combined clinical and research
munity medicine, general and ambulatory care and disease development—in the fourth experience to careers as faculty members
internal medicine, obstetrics and gynecology, year. A final step on clinical manage- at academic medical centers.
pediatrics, surgery, research, and other interests ment is usually taken during the first or
• Other requirements – neurology, second year of residency. Preparing for Residency
psychiatry, subspecialty segment (anesthesia, Students make important career
dermatology, orthopaedics, urology, M.D./Ph.D. Option decisions as they approach their final
radiology, ophthalmology, otolaryngology), For students interested in biomedical medical school year. They choose the
continuity of care segment (sub internships, specialties in which they want to
research, some institutions offer joint
emergency room and intensive care
M.D./Ph.D. programs. practice and begin applying to graduate
experiences), and electives.
Association of American Medical Colleges 7
Medical Student Debt
Medical student debt has increased in
recent years. Factors that may account for
the rising indebtedness of medical school
medical education programs usually ensures that applicants have a uniform graduates include declining institutional
referred to as residencies—specialized date of residency program appointment. grant support, increases in tuition and cost
training programs that follow gradua- This day in March, known as “Match of living, and the ease with which money
tion from medical schools. Most Day,” is an occasion of great anticipation can be borrowed.
students secure residency positions for students. On Match Day they learn
Many medical schools are educating
through the National Resident Match- where they will spend the next several
students on expense management
ing Program (NRMP), which pairs stu- years of their medical training. Pro- techniques as well as implementing new
dents’ preferences for specific residency grams are both competitive and limited payment mechanisms such as frozen tuition
programs with the preferences of resi- in the number of residency slots they fees while the student is in school. Yet, the
dency program directors for specific may offer. financial reality exists that indebtedness has
applicants. Through the systematic com- continued to rise more rapidly than physi-
parison of rank-order lists, the NRMP Medical school financial aid and student cian income. As the debt burden becomes
services’ administrators and programs more unmanageable, fewer people may be
such as the AAMC’s Careers in Medi- attracted to a career in medicine.
cine program can help ensure that the
Most medical students borrow at least
professional decisions medical students a portion of the money they need to
and residents make are compatible with finance their education. In 2008, the
their interests and skills. The Careers in median amount of that debt was $140,000,
Medicine program provides crucial in- more than $10,000 higher than 2007. High
formation and guidance about specialty levels of debt may impact individual deci-
options, residency program selection, sions to pursue a fellowship program, to
and the physician workforce. subspecialize, or to practice in an under-
served area.
Association of American Medical Colleges 8The ACGME requires residency programs to
provide educational experiences and evalua-
tions ensuring that resident physicians are
competent in the following domains:
Graduate Medical Education Programs • Patient Care that is compassionate, appro-
priate, and effective for the treatment of
Upon graduating from medical school, award of the M.D. degree. The Accredi-
health problems and the promotion of health
students earn their M.D. (or D.O.) tation Council for Graduate Medical • Medical Knowledge about established and
degrees as well as the title “doctor.” But Education (ACGME) approves about evolving biomedical, clinical, and cognate
their education is far from complete. For eight thousand residency programs and (e.g., epidemiological and social-behavioral)
most new doctors, the years after med- their institutional sponsors nationwide. sciences and the application of this knowl-
ical school are spent in residencies— The ACGME sets the standards for U.S. edge to patient care
usually at hospitals—where they pursue residency programs including residents’ • Practice-based Learning that involves inves-
advanced training in their chosen educational experiences, duty hours, and tigation and evaluation of their own patient
specialties. During residency they master safety. care, appraisal and assimilation of scientific
evidence, and improvements in patient care
the comprehensive responsibilities of a
• Interpersonal and Communication Skills
physician and the special skills and Like medical school, residency programs that result in effective information exchange
knowledge required to practice in a are selective and often competitive, and teaming with patients, their families, and
specialty of medicine. requiring a formal application, letters of other health professionals
recommendation, and personal inter- • Professionalism, as manifested through a
Physicians must complete an accredited views. But unlike medical school, they commitment to carrying out professional re-
residency program to become certified offer stipends and benefits. sponsibilities, adherence to ethical principles,
to practice in a specialty. Residency pro- and sensitivity to a diverse patient population
grams vary in length depending on the Many physicians reflect on their residen- • Systems-based Practice, as manifested by
actions that demonstrate an awareness of
specialty, but generally last three to five cies as years filled with hard work and
and responsiveness to the larger context and
years for initial board certification. Sub- invaluable lessons. A resident physician’s system of health care and the ability to effec-
specialty training may extend the period time is spent treating patients, teaching tively call on system resources to provide care
to as long as 11 years following the less-experienced colleagues, attending that is of optimal value.
Association of American Medical Colleges 9conferences, and pursuing ongoing and is now charged with overseeing its Once their education is complete,
educational activities. This training can daily operations. physicians obtain certification in their
be very demanding, but it is a period chosen specialties. In the United States,
that reveals medicine’s challenges and Rather than immediately enter a spe- 24 specialty boards establish criteria that
rewards. cialty residency program, some medical physicians must meet to be certified in a
graduates take a transitional year of given field. The certification process
Resident physicians assume greater training designed to give them addi- requires doctors to demonstrate that
responsibilities as they proceed through tional experience in general medicine or they have completed training and passed
their training programs. The first year surgery. These programs are usually pre- a written examination. Some boards re-
of postgraduate medical education is cursors to residencies in specialties like quire an oral examination as well. Physi-
sometimes called an internship, dermatology, ophthalmology, neurology, cians who complete the process become
although this term is no longer used as and others. diplomates of their specialty boards.
widely as in the past. An intern (not to
be confused with internist, the term for Physicians who seek more specialized Medical licensure is a separate process
a physician who practices internal medi- training may pursue fellowships after governed by boards established by each
cine) or a first-year resident is a recent their residencies. For example, a doctor state, and procedures vary depending on
medical school graduate who is just who intends to specialize in cancer the state. After completing their training,
starting specialty training. A senior treatment may complete an internal doctors must apply for a permanent
resident is in the third, fourth, or fifth medicine residency followed by an on- license to practice medicine.
year, depending on the specialty. Finally, cology fellowship. Physicians in these
the chief resident is a doctor who has programs are referred to as fellows.
completed his or her residency program
Association of American Medical Colleges 10Sample Residency Lengths Selected Medical Specialties
Following are residency lengths for Some of the most common intestines, liver, gallbladder, and diagnosis of organs,
selected specialties: medical specialties and their and related organs) tissues, and body fluids
areas of emphasis are: • Hematology – the blood and • Pediatrics – the health care
Family medicine – 3 years • Allergy and immunology – blood-forming parts (such as of children from birth to
allergies and other disorders bone marrow) of the body adolescence
Emergency medicine – 3 years
involving the immune • Internal medicine – diagno- • Psychiatry – mental, emo-
General Internal Medicine – 3 years system sis and nonsurgical treat- tional, and/or behavioral
• Anesthesiology – adminis- ment of diseases in adults disorders
Pediatrics – 3 years tration of medications • Nephrology – the kidneys • Pulmonary diseases – the
Pediatric subspecialties – 5 years (anesthetics) to prevent pain lungs and other chest
• Neurology – the brain,
or induce unconsciousness tissues
spinal cord, and nerves
Obstetrics and gynecology – 4 years during surgical or diagnostic
• Obstetrics and gynecology – • Radiology – study and use
procedures
Pathology – 4 years women’s health, pregnancy, of various types of radiation,
• Cardiology – the heart and including X-rays, and imag-
and childbirth
Anesthesiology – 4 years blood vessels ing systems in the diagnosis
• Oncology – all types of can-
• Dermatology – the skin, hair and treatment of disease
Dermatology – 4 years cer as well as other benign
and nails • Rheumatology – the joints,
and malignant tumors
Neurology – 4 years • Endocrinology – the internal muscles, and tendons,
• Ophthalmology – vision
(or endocrine) glands such including arthritis
Ophthalmology – 4 years problems and other disor-
as the thyroid and • Surgery – treatment of
ders affecting the eye
Psychiatry – 4 years adrenal glands, and disor- diseases, injuries and other
ders such as diabetes • Orthopaedic surgery
conditions using operative
Radiology – 4 years (orthopaedics) – the
• Family medicine/family or manual procedures
muscles, bones, and joints
Orthopaedic surgery – 5 years practice – broad-based • Urology – the urinary
health care of individuals • Otolaryngology – the ears,
system and the male
Otolaryngology – 5 years and families respiratory and upper
reproductive organs
alimentary systems, and
• Gastroenterology – the
Urology – 5 years related structures
digestive tract (stomach,
Surgical subspecialties – 6 to 7 years • Pathology – examination
Association of American Medical Colleges 11Financing Graduate Medical Education Revenues from many sources finance the costs of graduate medical education (GME). Historically, the Medicare program has been the largest single explicit financing source for GME. Medicare makes the following types of payments to teaching hospitals—direct graduate medical education payments (DGME) and indirect graduate medical education payments (IME). The DGME payment compensates teaching hospitals for “Medicare’s share” of the costs directly related to the training of residents. Medicare does not make payments related to the clinical education of medical students. The added direct costs of GME incurred by teaching hospitals include: stipends and fringe benefits of residents; salaries and fringe benefits of faculty who supervise the residents; other direct costs; and allocated institutional overhead costs, such as maintenance and electricity. Other direct costs include, for example, the cost of clerical personnel who work exclusively in the GME administrative office. Teaching hospitals also maintain an environment in which clinical research can flourish, and assure all patients have access to highly specialized care, regardless of their ability to pay. Because of their education and research missions, teaching hospitals offer the newest and most advanced services and equipment. Additionally, the residents and supervising physicians at teaching hospitals are available around-the-clock, prepared to care for the nation’s most critically ill or injured patients. These unique teaching hospital missions increase the cost of patient care at these institutions. Recognizing the differences in the patient care costs between teaching and non-teaching hospitals, the Medicare program includes a special IME payment adjustment in its prospective payment system (PPS). Over 1,100 teaching hospitals receive IME payments, which are determined by inserting the hospital’s individual intern/resident-to-bed ratio (IRB) into a formula established under Medicare statute. As a hospital’s involvement in GME increases, its percentage add-on to the basic PPS payment also increases. Association of American Medical Colleges 12
Continuing Medical
Education
Even after they complete postgraduate selected topics such as risk reduction, tion, community service, policymaking,
training and begin to practice medicine, pain control, or human sexuality. Many or, in many cases, a combination of the
physicians continue their education states are considering moving towards a above. The responsibility to produce
throughout their careers. The rapid pace system of maintenance of licensure, a compassionate, scientifically knowledge-
of change in medicine makes continuing process which requires documentation able, and skillful physicians is not only
education programs essential. Medical of CME activity in addition to other the domain of medical schools and
schools, teaching hospitals, and profes- requirements such as demonstrations residency programs, but also the
sional organizations offer continuing of competence, adequate clinical per- collective responsibility of society as we
medical education (CME) programs to formance, and practice standing. These as individuals actively participate in the
physicians on a regular basis, usually for are parallel to movements in specialty education of future and established
a fee. CME providers are reviewed by boards leading to re-certification on a physicians through our roles as patients
such organizations as the Accreditation regular basis, a process called mainte- and concerned citizens. A complex and
Council for Continuing Medical Educa- nance of certification. collaborative process, medical education
tion (ACCME), which ensures that these in our country has produced some of
programs meet high standards. Medical Education as a the world’s most talented physicians,
The majority of states require Collaborative Process researchers, and scientists, a testament
documented, formal participation in to the rigorous and comprehensive
accredited continuing medical education Though arduous, the road to becoming education and training they receive in
activities. Generally requiring a finite a physician traversed by our nation’s America’s medical schools and teaching
number of hours per year (usually doctors-in-training ultimately ends in a hospitals.
around 50), some states also require that personally and professionally fulfilling
a pre-set number of hours be spent in career in patient care, research, educa-
Association of American Medical Colleges 13Additional AAMC Resources Photo Credits
Association of American Medical Colleges
www.aamc.org
Front Cover, Inside Cover, pages 2, 4, 5
Robert Boston, Washington University School of Medicine in St.
Aspiring Docs Louis © 2007
www.aspiringdocs.org
Careers in Medicine Program Page 1
www.aamc.org/students/medstudents/cim Scott and White University Medical Center
Liaison Committee on Medical Education Page 3
www.lcme.org Kenneth Larsen, Loma Linda University © 2006
Medical College Admission Test
www.aamc.org/students/mcat Pages 4, 8
National Resident Matching Program
Andrew Campbell, Northwestern University © 2008
www.nrmp.org
Page 6
Project Medical Education Jim Ziv, Northwestern University © 2007
www.aamc.org/pme
Page 12
Other Resources Office of Patricia Wolff, M.D., Washington University School of Med-
Accreditation Council for Continuing Medical Education icine in St. Louis © 2004
www.accme.org
Accreditation Council for Graduate Medical Education Page 12
www.acgme.org Loma Linda University © 2005
American Board of Medical Specialties
www.abms.org
American Medical Association
www.ama-assn.org
American Osteopathic Association
www.osteopathic.org
United States Medical Licensing Examination
www.usmle.org
Association of American Medical Colleges 14This document was produced by the AAMC’s Project Medical Education, a focused educational program for members of
Congress, congressional staff, state legislators and staff, as well as other policymakers, influential stakeholders,
community leaders, and board members. Its goal is to provide an increased understanding of the U.S. medical education
process and the role that our medical schools and teaching hospitals play in producing the world’s greatest doctors.
Project Medical Education attendees visit a medical campus and assume the roles of a medical student, resident physician,
and faculty physician. By doing so, attendees are immersed in a hands-on learning experience showing them what it takes to
become a doctor and the challenges that face our nation’s medical schools and teaching hospitals.
The model is flexible, offering institutions the ability to tailor the program to fit their particular goals and issues. A
successful program will touch upon the major areas of medical education financing, tuition and debt, research funding and
how research is conducted, community service and caring for the uninsured, among others.
Project Medical Education is extremely interactive and has grown increasingly popular. Since the project was initiated in 1998,
nearly 900 individuals have attended a program at leading medical institutions across the country.
If you are interested in learning more about attending or hosting a Project Medical Education program, please contact:
Sallyann C. Bergh, M.P.A.
Senior Communications Specialist
Project Medical Education
2450 N Street, N.W.
Washington, D.C. 20037
Phone: 202-862-6289
Fax: 202-828-1123
E-mail: sbergh@aamc.org
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