How to become a doctor

Most laypeople don't understand the medical education process.  When I was a med student, lots of folks asked me what my specialty was; now that I'm a resident, people sometimes ask when I graduate and become a doctor.  I've spent a lot of time clearing up confusion, often with varying degrees of success.

The pathway into medicine starts in high school or earlier.  Anyone who thinks he or she might like to be a doctor needs to perform well enough in high school to secure college admission, preferrably at a reputable school with a good track record for sending graduates to professional (MD/DO, DMD/DDS, PhD, etc.) programs.  Smart high school students will take a tough courseload with multiple AP and math or science classes.  Over my final two years of high school, for example, I took seven AP courses in subjects ranging from US history to calculus and from English literature to physics.

Then comes college.  Some universities have a dedicated premed major, others don't; but prospective doctors may major in any field they desire, so long as they remember that medical schools have specific requirements for applicants.  Med schools typically require several science and math courses, as well as other courses like literature and philosophy to ensure a well-rounded application.  Premed students also need to consider the content of the Medical College Admissions Test (MCAT), the standardized exam required of all med school applicants.  The MCAT tests physics, biology, and organic and inorganic chemistry, as well as verbal reasoning and writing abilities.  So premed students can major in French or journalism if they'd like, but they'll need to fill up their elective slots with coursework that will both prepare them for the MCAT and satisfy med schools' admission requirements.

As strenuous as these requirements may seem, there are still far more outstanding prospective physicians than there are med school spots, so schools also consider non-academic pursuits as a way for applicants to set themselves apart.  Schools are interested in applicants who are involved in the community, who are engaged in service opportunities, and who participate in extracurricular activities like music and sports in addition to maintaining a full courseload with excellent grades.  They also want applicants who have shown some dedication to the medical field, whether it's going on an overseas humanitarian mission or simply shadowing a local physician after school.  Healthcare-related employment is helpful.  And having published research on your CV is a big plus.

The next step to becoming a doctor is to apply to med school.  Some universities (like the one where I did my undergrad work) have a premed committee that helps guide premed students through this process, advising them about application requirements, counseling them about their chances at different schools, and organizing their letters of recommendation and other supporting documents.  A year before the applicant wants to start med school, the student fills out an online application through the American Medical College Application Service (AMCAS), a service operated by the Association of American Medical Colleges (AAMC).  Nearly all med schools in the nation accept the AMCAS application (the University of Texas system has its own application service), and the applicant simply checks boxes for the schools to which he or she is applying.  There's a fee for the first school checked, then a flat fee for every school afterward.  The AAMC notifies the university premed office of the schools to which the application has been submitted, and the committee forwards the applicant's packet to those schools.

Shortly after submitting the primary application, a prospective med student will begin receiving letters from the schools to which he/she applied.  These letters contain instructions for completing each school's secondary application, which contains individualized questions not covered by the primary AMCAS application.  And each secondary application must be submitted together with an additional application fee; when I applied to med school in 2004, the fees were anywhere between $50 and $100 for each school.

And then comes the waiting.  Each med school reviews the primary and secondary application, together with the supporting documents.  They weed out the applicants in whom they have no further interest; these students receive a letter thanking them for applying and wishing them better luck elsewhere.  The remaining students also receive letters inviting them to visit the med school for an interview.  It is up to the applicants to schedule their interview date, get themselves to the school, make it to the appropriate location on their interview day, and effectively sell themselves to the school.  This can get quite expensive, and applicants often apply to several schools in a given area so they can (hopefully) knock out multiple interviews in a single trip.  The interviews themselves vary in terms of their content and focus; but they all share the similarity of being a final chance for each applicant to set him or herself apart from the thousands of hopefuls who will not be accepted.

After the interviews come more waiting.  Starting in October, med schools start sending out letters telling each interviewee their status: in, out, or wait-listed.  Some applicants receive one admission out of all the schools they applied to; some receive multiple admissions; and most receive none.  Applicants are allowed to accept multiple admissions, but there is a date in the spring by which they must relinquish all but one admission so schools can determine the fates of the applicants who were placed on the wait list.

Med school starts a few months later, generally in the mid- or late summer.  A traditional med school curriculum is four years long and is divided between two years of classroom learning and two years of clinical work.  During the classroom years, students spend several hours each day in lectures and small workgroups, then spend a large portion of their out-of-school time studying.  There are frequent exams, which are uniformly rigorous.  Med students also frequently find themselves in the hospital during the evenings, learning the basics of hands-on patient care (how to take a pulse, how to check blood pressure, how to take a medical history, how to perform a physical exam, etc.).

At the end of the second year of their training, med students are required to take Step 1 of the United States Medical Licensing Examination (USMLE, aka "the boards").  It's a day-long standardized exam involving about 350 questions, and it must be passed before the student is permitted to assume clinical duties as a third year med student.  The exam has long-term implications, too: just as universities consider SAT/ACT scores and med schools look at MCAT scores, residency programs use board scores to determine which prospective residents interest them.  Since it is such an important exam, many schools provide their students several weeks without coursework so they can focus solely on studying for Step 1.

The third year of med school is often the hardest.  Med students spend their time in the hospital, passing several weeks at a time on each rotation before moving on.  My med school required third-year rotations in internal medicine, general surgery, pediatrics, family medicine, obstetrics/gynecology, psychiatry, and neurology.  Students receive grades for their performance on rotations; these are generally subjective grades, but some services also have a written or oral examination that factors into the grade.  The grades are important, as residency programs see them and use them to decide between applicants.

After they've finished their required base rotations, med students are allowed more flexibility in their schedule so they can complete elective rotations.  It's during this time that many med students determine which specialty they would like to pursue.  In my case, I didn't even begin considering anesthesiology until more than halfway through my third year of med school, and I didn't firmly decide on it until I was beginning my fourth year.

During the fourth year, med students also have to take USMLE Step 2.  There are two components: Step 2 CK (for Clinical Knowledge), a computer-based multiple-choice exam; and Step 2 CS (for Clinical Skills), an in-person practical exam with "standardized patients" (aka actors being paid to act as patients).  Step 2 CK can be scheduled at a testing center near the med student, but Step 2 CS is only offered in five cities nationwide: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia.  Students must apply, pay the testing fee, get themselves to the city they've chosen, find overnight lodging, and get themselves home.  For the exam, students see 12 standardized patients and must take a history, do a physical exam, discuss "next steps" with the patient (i.e. labs, studies, etc.), and write an encounter note.  And some of the standardized patients are instructed to simulate the "angry patient."  And the whole thing is timed.

Fall and winter of the fourth year of medical school are spent doing clinical rotations and applying to residency programs.  The residency application process is similar to the med school one: applications, application fees, supporting documents, and in-person interviews.  Some specialties and some hospitals are more competitive than others.  Unlike applying to med school, doctors-to-be are actually applying into their desired specialty at this stage.  Also unlike the med school application process, interviewees are not informed of their status on an ongoing basis.  Rather, applicants rank the programs that interviewed them and programs rank the applicants whom they interviewed.  These rank lists are submitted to the National Residency Matching Program (NRMP), where they are entered into a computer that compares all rank lists nationwide and determines a "best fit" for each applicant.  Each med school receives a sealed envelope for each fourth-year student containing their "best fit."

On a specific day in mid-March is Match Day.  Each fourth-year med student in the nation goes to his or her med school, where they receive their individual envelope.  Inside the envelope is their match, telling them the hospital and the specialty in which they will complete their residency training.  There are no multiple acceptances on Match Day.  Students are free to reject their match, of course, but getting picked up by a reputable program in a desirable specialty is nigh impossible if not done through the match system.  And with hundreds of thousands of dollars of debt, very few med students have the luxury of not working right out of school.

In late spring, the med students graduate.  They are doctors at that point, having received their doctorate in medicine (or osteopathy); but they are not licensed to practice medicine and are not considered competent to operate without supervision.  The next few weeks are spent wrapping up any remaining obligations and usually preparing to move again for residency.

Residency is the period during which new doctors are trained in their specialty.  Residency programs range from three (internal medicine and a few others) to seven (neurosurgery) years in duration.  Anesthesiology is a four-year residency consisting of a non-anesthesia first year followed by three years of clinical anesthesiology training.  The first year of residency is called "internship" and is a year-long exercise in pain.  Long hours, plenty of sleep deprivation, and lots of time spent out of your comfort zone make internship an experience that no physician wishes to repeat.  During internship, doctors are required to complete USMLE Step 3, a two-day standardized exam that must be passed in order to secure a medical license.  (During residency, residents without their own medical licenses practice on the licenses of their supervisors.)  Some residents also choose to subspecialize, which involves a fellowship of one or more years after residency.

After residency (and fellowship, if applicable), the physician has finally completed the training necessary to practice medicine independently.  At that point, he or she is free to take the exams necessary for certification in his/her specialty.  The learning process never really ends, though, because new research is always being done and most specialty certification bodies require recertification at specific intervals.  Anesthesiologists are required to take board exams to recertify every ten years.

Where am I in all this?  I'm in my last year of anesthesiology residency, or my twelfth year of training after completing high school.  A pertinent question, given how long it's taken to get where I am, is whether I would do this all over again.  My answer is...probably.  At the outset, I was warned that this was a difficult career path but there's no way I could fully appreciate how difficult without experiencing it firsthand.  The first two years after med school were without question the toughest ones for me, and I was already too far in to back out at that point.  I love my job, though, and I would likely choose it again, even knowing how tough this path really is.  But I'm also very glad to have so much of it behind me, and I can say without reservation that I wouldn't want to go through it again.  At this point, I'm just enjoying the fact that I can finally see light at the end of the tunnel.