Prerequisites for applying to a specialist training program

A physician practicing in Sweden may apply to a specialist training program (Swedish: Specialisttjänstgöring) after being licensed as a physician by The National Board of Health and Welfare.^[14] To obtain a license through the Swedish education system a candidate must go through several steps. First the candidate must successfully finish a five-and-a-half-year undergraduate program, made up of two years of pre-clinical studies and three and a half years of clinical postings, at one of Sweden's seven medical schools—Uppsala University, Lund University, The Karolinska Institute, The University of Gothenburg, Linköping University, Umeå University, or Örebro University—after which a degree of Master of Science in Medicine (Swedish: Läkarexamen) is awarded.^[15] The degree makes the physician eligible for an internship (Swedish: Allmäntjänstgöring) ranging between 18 and 24 months, depending on the place of employment.

The internship is regulated by the National Board of Health and Welfare and regardless of place of employment it is made up of four main postings with a minimum of nine months divided between internal medicine and surgery—with no less than three months in each posting—three months in psychiatry, and six months in general practice.^[16] It is customary for many hospitals to post interns for an equal amount of time in surgery and internal medicine (e.g. six months in each of the two). An intern is expected to care for patients with a certain degree of independence but is under the supervision of more senior physicians who may or may not be on location.

During each clinical posting the intern is evaluated by senior colleagues and is, if deemed having skills corresponding to the goals set forth by The National Board of Health and Welfare, passed individually on all four postings and may go on to take a written exam on common case presentations in surgery, internal medicine, psychiatry, and general practice.^[16]

After passing all four main postings of the internship and the written exam, the physician may apply to The National Board of Health and Welfare to be licensed as a Doctor of Medicine. Upon application the physician has to pay a licensing fee of SEK 2,300^[17]—approximately equivalent to EUR 220 or USD 270, as per exchange rates on 24 April 2018—out of pocket, as it is not considered to be an expense directly related to medical school and thus is not covered by the state.

Physicians who have a foreign medical degree may apply for a license through different paths, depending on whether they are licensed in another EU or EEA country or not.^[18]

Specialty Selection

The Swedish medical specialty system is, as of 2015, made up of three different types of specialties; base specialties, subspecialties, and add-on specialties. Every physician wishing to specialize starts by training in a base specialty and can thereafter go on to train in a subspecialty specific to their base specialty. Add-on specialties also require previous training in a base specialty or subspecialty but are less specific in that they, unlike subspecialties, can be entered into through several different previous specialties.^[19]

Furthermore, the base specialties are grouped into eight classes—pediatric specialties, imaging and functional medicine specialties, independent base specialties, internal medicine specialties, surgical specialties, laboratory specialties, neurological specialties, and psychiatric specialties.^[19]

It is a requirement that all base specialty training programs are at least five years in length.^[19] Common reasons for base specialty training taking longer than five years is paternity or maternity leave or simultaneous Ph.D. studies.

Application process

There is no centralized selection process for internship or residency positions. The application process is more similar to that of other jobs on the market—i.e. application via cover letter and curriculum vitae. Both types of positions are however usually publicly advertised and many hospitals have nearly synchronous recruitment processes once or twice per year—the frequency of recruitment depending mainly on hospital size—for their internship positions.

Base specialties

History

In the United Kingdom, house officer posts used to be optional for those going into general practice, but almost essential for progress in hospital medicine. The Medical Act 1956 made satisfactory completion of one year as house officer necessary to progress from provisional to full registration as a medical practitioner. The term "intern" was not used by the medical profession, but the general public were introduced to it by the US television series Dr. Kildare. They were usually called "housemen", but the term "resident" was also used unofficially. In some hospitals the "resident medical officer" (RMO) (or "resident surgical officer" etc.) was the most senior of the live-in medical staff of that specialty.

The pre-registration house officer posts lasted six months, and it was necessary to complete one surgical and one medical post. Obstetrics could be substituted for either. In principle, general practice in a "Health Centre" was also allowed, but this was almost unheard of. The posts did not have to be in general medicine: some teaching hospitals had very specialised posts at this level, so it was possible for a new graduate to do neurology plus neurosurgery or orthopaedics plus rheumatology, for one year before having to go onto more broadly based work. The pre-registration posts were nominally supervised by the General Medical Council, which in practice delegated the task to the medical schools, who left it to the consultant medical staff. The educational value of these posts varied enormously.

On-call work in the early days was full time, with frequent night shifts and weekends on call. One night in two was common, and later one night in three. This meant weekends on call started at 9 am on Friday and ended at 5 pm on Monday (80 hours). Less acute specialties such as dermatology could have juniors permanently on call. The European Union's Working Time Directive^[26] conflicted with this: at first the UK negotiated an opt-out for some years, but working hours needed reform. On call time was unpaid until 1975 (the year of the house officers' one-day strike), and for a year or two depended on certification by the consultant in charge – a number of them refused to sign. On call time was at first paid at 30% of the standard rate. Before paid on call was introduced, there would be several house officers "in the house" at any one time and the "second on call" house officer could go out, provided they kept the hospital informed of their telephone number at all times.

A "pre-registration house officer" would go on to work as a "senior house officer" for at least one year before seeking a registrar post. SHO posts could last six months to a year, and junior doctors often had to travel around the country to attend interviews and move house every six months while constructing their own training scheme for general practice or hospital specialisation. Locum posts could be much shorter. Organised schemes were a later development, and do-it-yourself training rotations became rare in the 1990s. Outpatients were not usually a junior house officer's responsibility, but such clinics formed a large part of the workload of more senior trainees, often with little real supervision.

Registrar posts lasted one or two years, and sometimes much longer outside an academic setting. It was common to move from one registrar post to another. Fields such as psychiatry and radiology used to be entered at the registrar stage, but the other registrars would usually have passed part one of a higher qualification, such as a Royal College membership or fellowship before entering that grade. Part two (the complete qualification) was necessary before obtaining a senior registrar post, usually linked to a medical school, but many left hospital practice at this stage rather than wait years to progress to a consultant post.

Most British clinical diplomas (requiring one or two years' experience) and membership or fellowship exams were not tied to particular training grades, though the length of training and nature of experience might be specified. Participation in an approved training scheme was required by some of the royal colleges. The sub-specialty exams in surgery, now for Fellowship of the Royal College of Surgeons, were originally limited to senior registrars. These rules prevented many of those in non-training grades from qualifying to progress.

Once a Senior Registrar, depending on specialty, it could take anything from one to six years to go onto a permanent consultant or senior lecturer appointment. It might be necessary to obtain an M.D. or Ch. M. degree and to have substantial published research. Transfer to general practice or a less favoured specialty could be made at any stage along this pathway: Lord Moran famously referred to general practitioners as those who had "fallen off the ladder".

There were also permanent non-training posts at sub-consultant level: previously senior hospital medical officer and medical assistant (both obsolete) and now staff grade, specialty doctor and associate specialist. The regulations did not call for much experience or any higher qualifications, but in practice both were common, and these grades had high proportions of overseas graduates, ethnic minorities and women.

Research fellows and PhD candidates were often clinical assistants, but a few were senior or specialist registrars. A large number of "Trust Grade" posts had been created by the new NHS trusts for the sake of the routine work, and many juniors had to spend time in these posts before moving between the new training grades, although no educational or training credit was given for them. Holders of these posts might work at various levels, sharing duties with a junior or middle grade practitioner or with a consultant.

Post 2005

The structure of medical training was reformed in 2005 when the Modernising Medical Careers (MMC) reform programme was instituted. House officers and the first year of senior house officer jobs were replaced by a compulsory two-year foundation training programme, followed by competitive entry into a formal specialty-based training programme. Registrar and Senior Registrar grades had been merged in 1995/6 as the specialist registrar (SpR) grade (entered after a longer period as a senior house officer, after obtaining a higher qualification, and lasting up to six years), with regular local assessments panels playing a major role. Following MMC these posts were replaced by StRs, who may be in post up to eight years, depending on the field.

The structure of the training programmes varies with specialty but there are five broad categories:

• Themed core specialties (A&E, Intensive Therapy Unit [ITU] and anaesthetics)
• Surgical specialties
• Medical specialties
• Psychiatry
• Run-through specialties (e.g., general practice, clinical radiology, pathology, paediatrics)

The first four categories all run on a similar structure: the Trainee first completes a two-year structured and broad-based core training programme in that field (e.g., core medical training), which makes them eligible for competitive entry into an associated specialty training scheme (e.g., gastroenterology if core medical training has been completed). The Core training years are referred to as CT1 and CT2, and the specialist years are ST3 onwards until completing training. Core training and the first year or two of speciality training are equivalent to the old Senior House Officer jobs.

It is customary for trainees in these areas to sit their Membership examinations (e.g., Royal College of Physicians (MRCP), Royal College of Surgeons (MRCS)) in order to progress and compete for designated sub-specialty training programmes that attract a national training number as specialty training year 3 (ST3) and beyond – up to ST 9 depending on the particular training specialty.

In the 5th category, the trainee immediately starts specialty training (ST1 instead of CT1) progressing up to Consultant level without break or further competitive application process (run-through training). Most of the run-through schemes are in stand-alone specialties (e.g., radiology, public health, histopathology), but there are also a few traditionally surgical specialities which can be entered directly without completing core surgical training (e.g., neurosurgery, obstetrics & gynaecology, ophthalmology). The length of this training varies; for example, general practice is 3 years while radiology is 5 years.

The UK grade equivalent of a US fellow in medical/surgical sub-specialties is the specialty registrar (ST3–ST9) grade of sub-specialty training. However, while US fellowship programmes are generally 2–3 years in duration after completing the residency, UK trainees spend 4–7 years. This generally includes service provision in the main specialty; this discrepancy lies in the competing demands of NHS service provision, and UK postgraduate training stipulating that even specialist registrars must be able to accommodate the general acute medical take—almost equivalent to what dedicated attending internists perform in the United States (they still remain minimally supervised for these duties).

Specialty selection

Specialties differ in length of training, availability of residencies, and options. Specialist residency programs require participation for completion ranging from 3 years for family medicine to 7 years for neurosurgery.^[29] This time does not include any fellowship that may be required to be completed after residency to further sub-specialize.

In regard to options, specialty residency programs can range nationally from over 700 (family medicine) and over 580 (internal medicine) to 33 programs for integrated thoracic surgery and 28 programs for Osteopathic neuromusculoskeletal medicine.^[30][31] U.S. graduates commonly have no difficulties with entering residency program after graduation.

Residents choose the teaching hospital where they want to perform their residency based upon many factors, including the medical specialties offered by the hospital and reputation and credentials of the hospital. The following table shows medical specialties and the residency training times for medical specialties, as reported by the American Medical Association in 2021.^[32]

Application process

History of long hours

Medical residencies traditionally require lengthy hours of their trainees. Early residents literally resided at the hospitals, often working in unpaid positions during their education. During this time, a resident might always be "on call" or share that duty with just one other practitioner. More recently, 36-hour shifts were separated by 12 hours of rest, during 100+ hour weeks. The American public, and the medical education establishment, recognized that such long hours were counter-productive, since sleep deprivation increases rates of medical errors. This was noted in a landmark study on the effects of sleep deprivation and error rate in an intensive-care unit.^[50][51] The Accreditation Council for Graduate Medical Education (ACGME) has limited the number of work-hours to 80 hours weekly (averaged over 4 weeks), overnight call frequency to no more than one overnight every third day, and 10 hours off between shifts. Still, a review committee may grant exceptions for up to 10%, or a maximum of 88 hours, to individual programs. Until early 2017, duty periods for postgraduate year 1 could not exceed 16 hours per day, while postgraduate year 2 residents and those in subsequent years can have up to a maximum of 24 hours of continuous duty. After early 2017, all years of residents may work up to 24-hour shifts.^[52] While these limits are voluntary, adherence has been mandated for the purposes of accreditation, though lack of adherence to hour restrictions is not uncommon.

Most recently, the Institute of Medicine (IOM) built upon the recommendations of the ACGME in the December 2008 report Resident Duty Hours: Enhancing Sleep, Supervision and Safety. While keeping the ACGME's recommendations of an 80-hour work week averaged over 4 weeks, the IOM report recommends that duty hours should not exceed 16 hours per shift, unless an uninterrupted five-hour break for sleep is provided within shifts that last up to 30 hours. The report also suggests residents be given variable off-duty periods between shifts, based on the timing and duration of the shift, to allow residents to catch up on sleep each day and make up for chronic sleep deprivation on days off.

Critics of long residency hours trace the problem to the fact that a resident has no alternatives to positions that are offered, meaning residents must accept all conditions of employment, including very long work hours, and that they must also, in many cases, contend with poor supervision. This process, they contend, reduces the competitive pressures on hospitals, resulting in low salaries and long, unsafe work hours.^[48]

Supporters of traditional work hours contend that much may be learned in the hospital during the extended time. Some argue that it remains unclear whether patient safety is enhanced or harmed by a reduction in work hours which necessarily lead to more transitions in care. Some of the clinical work traditionally performed by residents has been shifted to other health care workers such as ward clerks, nurses, laboratory personnel, and phlebotomists. It has also resulted in a shift of some resident work toward home work, where residents will complete paperwork and other duties at home so as to not have to log the hours.

Adoption of working time restrictions

United States federal law places no limit on resident work hours. Regulatory and legislative attempts at limiting resident work hours have been proposed but have yet to be passed. Class action litigation on behalf of the 200,000 medical residents in the US has been another route taken to resolve the matter.

Dr. Richard Corlin, president of the American Medical Association, has called for re-evaluation of the training process, declaring "We need to take a look again at the issue of why the resident is there."^[53]

On 1 November 2002, an 80-hour work limit went into effect in residencies accredited by the American Osteopathic Association (AOA). The decision also mandates that interns and residents in AOA-approved programs may not work in excess of 24 consecutive hours exclusive of morning and noon educational programs. It does allow up to six hours for inpatient and outpatient continuity and transfer of care. However, interns and residents may not assume responsibility for a new patient after 24 hours.

The US Occupational Safety and Health Administration (OSHA) rejected a petition filed by the Committee of Interns & Residents/SEIU, a national union of medical residents, the American Medical Student Association, and Public Citizen that sought to restrict medical resident work hours. OSHA instead opted to rely on standards adopted by ACGME, a private trade association that represents and accredits residency programs.^[54] On 1 July 2003, the ACGME instituted standards for all accredited residency programs, limiting the workweek to 80 hours a week averaged over a period of four weeks. These standards have been voluntarily adopted by residency programs.

Though re-accreditation may be negatively impacted and accreditation suspended or withdrawn for program non-compliance, the number of hours worked by residents still varies widely between specialties and individual programs. Some programs have no self-policing mechanisms in place to prevent 100+ hour workweeks while others require residents to self-report hours. In order to effectuate complete, full, and proper compliance with maximum hour work hour standards, there are proposals to extend US federal whistle-blower protection to medical residents.^[55]

Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care.^[56] Similar concerns have arisen in Europe, where the Working Time Directive limits doctors to 48 hours per week averaged out over a 6-month reference period.^[26]

Recently, there has been talk of reducing the work week further, to 57 hours. In the specialty of neurosurgery, some authors have suggested that surgical subspecialties may need to leave the ACGME and create their own accreditation process, because a decrease of this magnitude in resident work hours, if implemented, would compromise resident education and ultimately the quality of physicians in practice.^[57] In other areas of medical practice, like internal medicine, pediatrics, and radiology, reduced resident duty hours may be not only feasible but also advantageous to trainees because this more closely resembles the practice patterns of these specialties, though it has never been determined that trainees should work fewer hours than graduates.

In 2007, the Institute of Medicine was commissioned by Congress to study the impact of long hours on medical errors. New ACGME rules went into effect on 1 July 2011, limiting first-year residents to 16-hour shifts.^[58] The new ACGME rules were criticized in the journal Nature and Science of Sleep^[59] for failing to fully implement the IOM recommendations.^[60]

Research requirement

The Accreditation Council for Graduate Medical Education clearly states the following three points in the Common Program Requirements for Graduate Medical Education:^[61]

1. The curriculum must advance residents' knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.
2. Residents should participate in scholarly activity.
3. The sponsoring institution and program should allocate adequate educational resources to facilitate resident involvement in scholarly activities.

Research remains a nonmandatory part of the curriculum, and many residency programs do not enforce the research commitment of their faculty, leading to a non-Gaussian distribution of the Research Productivity Scale.

Financing residency programs

The Department of Health and Human Services, primarily Medicare, funds the vast majority of residency training in the US. This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education, or DME, payments. Medicare also uses taxes for Indirect Medical Education, or IME, payments, a subsidy paid to teaching hospitals that is tied to admissions of Medicare patients in exchange for training resident physicians in certain selected specialties.^[62] Overall funding levels, however, have remained frozen over the last ten years, creating a bottleneck in the training of new physicians in the US, according to the AMA.^[63] On the other hand, some argue that Medicare subsidies for training residents simply provide surplus revenue for hospitals, which recoup their training costs by paying residents salaries (roughly $45,000 per year) that are far below the residents' market value.^[64][65] Nicholson concludes that residency bottlenecks are not caused by a Medicare funding cap, but rather by Residency Review Committees (which approve new residencies in each specialty), which seek to limit the number of specialists in their field to maintain high incomes.^[66] In any case, hospitals trained residents long before Medicare provided additional subsidies for that purpose. A large number of teaching hospitals fund resident training to increase the supply of residency slots, leading to the modest 4% total growth in slots from 1998 to 2004.^[63]

Changes in postgraduate medical training

Many changes have occurred in postgraduate medical training in the last fifty years:

1. Nearly all physicians now serve a residency after graduation from medical school. In many states, full licensure for unrestricted practice is not available until graduation from a residency program. Residency is now considered standard preparation for primary care (what used to be called "general practice").
2. While physicians who graduate from osteopathic medical schools can choose to complete a one-year rotating clinical internship prior to applying for residency, the internship has been subsumed into residency for MD physicians. Many DO physicians do not undertake the rotating internship since it is now uncommon for any physician to take a year of internship before entering a residency, and the first year of residency training is now considered equivalent to an internship for most legal purposes. Certain specialties, such as ophthalmology, radiology, anesthesiology, and dermatology, still require prospective residents to complete an additional internship year, prior to starting their residency program training.
3. The number of distinct residencies has proliferated, and there are now dozens. For many years, the principal traditional residencies included internal medicine, pediatrics, general surgery, obstetrics and gynecology, neurology, ophthalmology, orthopaedics, neurosurgery, otolaryngology, urology, physical medicine and rehabilitation, and psychiatry. Some training once considered part of internship has also now been moved into the fourth year of medical school (called a subinternship) with significant basic science education being completed before a student even enters medical school (during their undergraduate education before medical school).
4. Pay has increased, but residency compensation continues to be considered extremely low when one considers the hours involved. The average annual salary of a first year resident is $45,000 for 80 hours a week of work, which translates to $11.25 an hour. This pay is considered a "living wage". Unlike most attending physicians (that is, those who are not residents), they do not take calls from home; they are usually expected to remain in the hospital for the entire shift.
5. Call hours have been greatly restricted. In July 2003, strict rules went into effect for all residency programs in the US, known to residents as the "work hours rules". Among other things, these rules limited a resident to no more than 80 hours of work in a week (averaged over four weeks), no more than 24 hours of clinical duties at a stretch with an additional 6 hours for transferring patient care and educational requirement (with no new patients in the last six), and call no more often than every third night. In-house call for most residents these days is typically one night in four; surgery and obstetrics residents are more likely to have one in three call. A few decades ago, in-house call every third night or every other night was the standard. While on paper, this has decreased hours, in many programs, there has been no decrease in resident work hours, only a decrease in hours recorded. Even though many sources cite that resident work hours have decreased, residents are commonly encouraged or forced to hide their work hours to appear to comply with the 80-hour limits.
6. For many specialties an increasing proportion of the training time is spent in outpatient clinics rather than on inpatient care. Since in-house call is usually reduced on these outpatient rotations, this also contributes to the overall decrease in the total number of on-call hours.
7. For all ACGME accredited programs since 2007, there was a call for adherence to ethical principles.^[67]

Residency salary