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.