About the Residency and Fellowship that Physicians Complete
Residency training has been part of physician education after medical school for about 125 years. Initially, though, residency wasn’t a requirement following medical school. Today, physicians must complete at least one year of residency to obtain a license to practice medicine–in some states, even that isn’t enough.
To become board-certified, physicians must complete 3 to 7 years of residency, depending on their chosen specialty. Physicians in their first year of residency are often known as interns.
Fellowships are physician education beyond residency. A fellowship is meant to provide more specialized training within a specific field of medicine. For instance, after finishing a residency in Internal Medicine (3 years after medical school), a physician might choose to then specialize in cardiology by doing a Cardiology Fellowship (another 3 years).
Physician residencies and fellowships are accredited by the Accreditation Council of Graduate Medical Education (ACGME),which ensures that uniform standards are met for all programs. These standards include educational guidelines, milestones, and assessments, along with graduated patient care responsibility. The ACGME annually reviews all programs to ensure compliance with the standards, and they regularly update their standards to ensure excellent trainee education.
Residencies and fellowships are rigorous undertakings. Traditionally, these trainees are referred to as “housestaff” or “house officers,” terms which originated from the time when trainees literally lived in “house” at the hospital.
Appropriations of the Terms “Residency” and “Fellowship”
It has recently been brought to light that nurse practitioners (NPs) and physician assistants (PAs) have developed programs that institutions are calling “residencies” and “fellowships.” While this was spurred on by recent news of a possible NP/PA Emergency Medicine “Residency” at the University of North Carolina (UNC), UNC is hardly alone in this. To their credit, once they learned of the opposition to the use of the term residency, they have agreed that any future program that is developed will not utilize that term.
However, many programs still exist at other institutions, including, but not limited to, the Johns Hopkins, the Mayo Clinic, Massachusetts General (Harvard), Penn State, and Vanderbilt University. With few exceptions, these programs are just 12 months in length, often with multiple “administrative half days.” Further, these programs are not necessarily standardized or accredited. In many of these fellowships, the NP or PA is paid more than a first-year physician resident who has completed far more training while in medical school.
Lastly, and perhaps most disheartening, many of these programs claim equivalence with physician training, although they are 1/3 or less of the residency training time for physicians. Some of the programs claim “comparable training experiences” to physicians with “residents functioning as house-staff members.” By simple definition, PAs and NPs, while valued members of the team, cannot function at the same level as a physician resident or fellow. They simply do not have the same rigorous basic science and clinical education that physicians receive during medical school.
Even beyond NP and PA training using the terms “residency” and “fellowship” are the nursing (RN) programs doing the same. Some hospitals have renamed their RN orientation process, calling it “residency”. Using these words, which have long been part of physician training lexicon, for new nurse orientation and onboarding, devalues them and can confuse patients.
Why This is Wrong
When patients are admitted to the hospital, they often see interns, residents and fellows as part of their treatment team. Physicians introduce themselves and their role on the team. When PAs and NPs introduce themselves as a resident or fellow, it is very confusing to patients. Patients do not understand that they are not seeing a physician. In fact, even without this confusing terminology, patients are confused about who is taking care of them. The AMA did a survey that found that 35% of the general public believed that NPs with their doctorate of nursing practice were physicians.
Completing a residency or fellowship is a significant milestone in physician education, and it’s something physicians aspire to and celebrate. When other fields appropriate physician-specific terminology for a portion of their training, it is demoralizing.
Physicians consider their time in residency and fellowship as an initiation into the profession. It is a time of great emotional, personal, and financial sacrifice, all in the name of honing skills to become the best physician possible for their patients.
Taking a Stand
At least two professional organizations, the American Academy of Dermatology (AAD) and the American Academy of Emergency Medicine (AAEM) have taken a stand against this. In the AAD position statement, they state that the “education of physicians and non-physician clinicians is entirely different…this labeling [of advanced practice residencies or fellowships] is misleading to the general public as it portrays a level of training that has not been established.”
The AAEM position statement takes it a step further and recommends that NP/PA education programs should only be used to “prepare its participants to practice only as members of a physician-led team” and “should be initiated with the consultation of residents and faculty.” We hope that other organizations and institutions take a stance and re-name these programs. One example is Brown University’s “Physician Extender Development Program.”
A Call for Change
When you are in the hospital or at a clinic, you may be taken care of by interns, residents, fellows, attendings, and non-physician clinicians. Traditionally, interns, residents, fellows and attendings are all physicians who have completed medical school. Non-physician clinicians include physician assistants (PAs) and nurse practitioners (NPs).
PAs and NPs are now calling their additional training “fellowships” or “residencies” and may refer to themselves as a resident or fellow. However, they are not physicians and their programs are not rigorously standardized or accredited. We hope these programs will change their terminology and find their own language for NP and PA training.
I could not agree more. I dedicated 4 years completing my residency. They were tough years but they made me an expert in my field. Completing that residency and passing my board exam was a badge of honor. In my opinion, abbreviated training programs for midlevels should be called something else so as not to confuse the public about a healthcare provider’s background and qualifications.
Agree! Calling NP training “residency” is fraudulent and a great disservice to patients and the public at large. We need truth in advertising! Patients beware.
I also think we should mention the terms “boarded” as well. I hear it all the time in hospitals and staff lounges. It confuses me, even as house staff. Once I was training a class and someone introduced themselves as a resident and fellow. I responded, oh that’s great, what medical school did you go to? She told me she was a psychologist. Another time, it was a Neurosurgery NP. The look of confusion on my face was apparent. I felt a knife in my chest. When you quote “cheapen the physician experience” it’s true. It also cheapens the patient experience as well. Physicians care about the health and well being of their patients, truly sick patients which is why training and specialty training is so lengthy and expansive. There is no comparison in education or shortcuts, nor should these terms be congruent or interchangeable. They mean two completely different things by two different organizations (BON) and (BOM). The patients suffer ultimately. Education matters and we are still learning everyday.
I couldn’t agree with this more! Can one of the PPP goals be working on trademarking the terms “residency” and “fellowship”? Long shot, but might be worth trying.
Also, what about focusing on getting truth in advertising laws passed in all the states that require everyone to state their license (MD, DO, NP, PA, etc) after their name and on their ID badge at work? It would at least help patients see who they are being treated by and theoretically wouldn’t be a political thing pitting “us” against “them”. As in, we can frame it as a way of transparency and being good for the patient.
And any chance we can also work on passing state laws that limit the use of the term “doctor” in the medical setting to those who have a MD/DO/MBBS? This one may be harder to get through legislature, though.
We need to start going on the offensive with legislation in addition to reacting to the FPA attempts all over the country.
I find this line of thought to be extremely diminutive. Nursing orientation programs have chosen to call their programs residencies for the very same reason physicians chose to refer to their post-graduate training as a residency, for the fact that these nurses in training spend the majority of their time in the hospital. Many orienting nurses are required to be present at the hospital several days a week whether they are in a classroom setting or actually caring for patients.
Many nurses have spent years caring for patients before a physician resident sees their first patient. Many physician residents have been saved from making fatal errors by an experienced nurse looking out for the health and well-being of their patients because as you have said, patients first. Nurses always put their patients first because it is the patients that have driven them to pursue their chosen career, not because they want glory or recognition but because they want to care for those in need. They want to care for those that cannot care for themselves.
As for the terminology confusing patients, most patients are not even aware of what a resident is. The patients are only aware of doctors and nurses. Most patients are not confused about nurse practitioners being doctors because nurse practitioners identify themselves as “nurse practitioners” when entering the room and often correct patients that mistakenly refer to them as doctors.
For one to focus on a word like “residency” takes the focus away from the things that matter. If you truly wanted to make a difference in the lives of patients, it seems your focus would be more on working as an interprofessional team to assure that the patients are receiving the best care possible and that patients experience the best outcomes possible. Healthcare should be a team effort where everyone has an important part to play yet no part is more important than another. The healthcare team is comprised of many different disciplines from pharmacists, physician, physical therapists, nurses, and patient care technicians all playing an equal part. Surely, no physician could provide complete care for a patient alone.
@Team Patient:. Residencies aren’t called residency because much *of the training time* is in the hospital. It’s called that because more of *life* is spent inside the hospital than out. Interns spend 16 hours/ day, 6 days per week, in the hospital. Upper levels spend even more time there. For three years. They essentially live there.
Having orientation there, a few days a week, 8 hours or less a day, for a few weeks, isn’t anywhere near residing there, and using that explanation goes to show the lack of understanding of physician training.
By your logic re: “RNs have been caring for patients before a physician touches one”, an MA or LPN are better at patient care than an RN. LPNs are working directly with patients a year before RNs, and MAs even before that. By this logic, “candy stripers” are the highest level of medical expertise.
Also, a physician resident has spent two years caring for patients, at 1.5-2x FTE (so, 3-4 years worth of “full time” experience) before seeing a patient as a resident.
I don’t think ‘diminutive’ means what you think it means?
The average intern has over 5000 clinical hours of training on their first day of postdoctoral training. The average NP needs as little as 250 hours of clinical experience in some states. That clinical experience doesn’t have to be in a clinic or a hospital inpatient ward. It is also not medical training.
While the assertion may be true that many nurses have been performing patient care for years, that’s not the same thing as supervised medical training focused on teaching good diagnostic skills, treatment plan development, and medical decision making. Nursing clinical experience focuses on risk management, patient safety, accuracy in following medical orders, and facilitating good communication. All of these are important skills, but they are a totally different skill set than the one used by physicians to arrive at their decisions.
I agree that every member of the team has a valuable role to play in the delivery of good patient care, from the janitor to the surgeon. However, I do not agree that every person has an “equal part” or that “no part is more important than another.” Yes, everyone has a unique role, but it’s hardly accurate to say that medical care cannot happen if the janitor or the phlebotomist doesn’t show up to work. The only person who must absolutely show up to work for medical care to happen is a physician. The only absolutely essential person in the surgical suite is the surgeon. Everyone else may have a relatively uncommon set of skills that are needed to do the job, but by and large, most people can be replaced by someone else, or other people who are there can step up and do the job of the missing person. That’s simply not true for the physician. Nobody else can do the surgery or make the medical decisions because nobody else has the training.
This nonsense of “we are all equally important” is part of the problem that medicine has come to face in recent years. I can’t tell you how many times I was denied leave or refused opportunities for CME because I was the only physician in the clinic and couldn’t be spared because nobody else could supervise. If everybody is truly of equal importance in the clinic, then my absence should hardly be that much of a groundbreaking problem. The truth is that there is no one more important in the medical hierarchy than the physician, and there is no one better suited to Leading the team of healthcare providers than a physician. Anybody who says otherwise is selling something.
Ooh, “several days a week”. Wow! JFC…. get over yourselves. I “grew up” in the era of resident duty hours post Libby Zion. Yeah, we would routinely spend 30-40 hours straight in the hospital with “cat naps”. That they think that their NORMAL WORK WEEK even COMPARES to the mental and physical torture a true MD/DO resident goes through is sickening….
In 2013, Larry Bucshon, MD(R-IN) sponsored a bipartisan bill called the “Truth in Advertising” bill. The bill was necessary because patients were becoming confused as to who the actual doctors were on their medical team. He proposed that everyone on a patient’s medical team wear a badge that clearly delineated not their degree, but their field of practice(ie: MD/DO, NP, RT, PA, RN, PT, etc.). The clarity also extended into marketing and advertisement.
The bipartisan bill was re-introduced in 2017. PPP met with the Congressman in Washington, D.C. and gave him our support for the bill because we support truth and transparency in medicine.
In May 2020, the Association of Mature American Citizens(AMAC), 1.2 million strong, offered Congressman Bucshon their support as well.
“H.R. 6663 strives to reduce confusion over professional licensure, education level, training, degrees obtained, and clinical expertise and makes it unlawful for providers to misrepresent these credentials. H.R. 6663 also requires advertisements for specific health care services disclose the appropriate license that authorizes the delivery of these services. This component is very timely as some Americans spend more time at home consuming information, entertainment, and advertising due to the lockdown resulting from the COVID-19 pandemic.”
Teams have members clearly identified. Only in medicine is there a push to blur the lines, titles and roles. God forbid the physician be recognized as the team leader. There is no good reason to do this except to deceive the public. They won’t ask questions if they don’t know. Their ignorance is paramount to perpetuating this unethical behavior. How hard can it be to do what is right? It is indeed possible to have a team with clearly identifiable members, a team leader and cohesiveness since no man is an island. It’s been done. Successfully.
The reality is that words do matter. Identification matters. The misappropriation of titles to confuse the public is unethical. The fact that a layperson may not know the difference between a nurse “resident”, PA “resident” or medical resident is not a reason to take advantage of their ignorance. One has to wonder why the conflation is compulsory when it wasn’t in the past. For those who wish to deceive, the confusion of the public is imperative to achieve their goal. But again, it is unethical. Trusting that individuals will be honorable and delineate the distinction is naive at best and foolish at worst. Not when they are vested in the deception.
Want to be professional? Don’t lie. It’s that simple.
Residencies were termed that because in the old days residents were not allowed to marry and were expected to live at the hospital. This was after spending 2/4 years of medical school taking care of patients . Most residents now spend 3-7 years working 80 hours a week doing direct patient care . To call spending a few days a week at the hospital a residency is a misnomer .
Veterinarians, dentists, physical therapists, podiatrists, and pharmacists are also using the terms “residency” and “fellowship” to refer to their post-graduate training programs (and have been for years). As physicians, are you also opposed to nomenclature appropriation by these professions, and why or why not?
Does use of these terms by the aforementioned professions also confuse patients and cheapen the physician experience?
Some physician fellowships are not accredited by the ACGME (for example, dermatologists in a cosmetic or contact allergy fellowship). Additionally, some practicing physicians completed their fellowship prior to ACGME-accreditation of their program (example: a Mohs surgeon who completed fellowship 30 years ago, when not all Mohs programs were accredited). As physicians, are you opposed to your DO/MD colleagues referring to themselves as “fellowship trained” if their fellowship was not formally accredited by ACGME at the time of graduation?
If a PAs and NPs succeed in standardizing the curricula of their post-graduate training programs (as they are in the process of doing, google “Association of Postgraduate PA Programs”), and the result is future generations of PAs and NPs who are more competent than their current professional standards, will you as physicians be more or less pleased with that outcome, and with their appropriation of the terms “residency” and “fellowship?”
Aside from “physician extender development program” (or “residency,” or “fellowship”), what alternative terms do you recommend as physicians?
In following one link to the Johns Hopkins webpage for their NP “fellowship,” I see the stipend is $50k paid over 12 months. Is this truly higher pay than what physicians receive in residency, as this author claims?
Looking forward to your thoughtful replies.
It is higher pay than residents make. By a LOT. Break it down by hour.