11.06.2007

the process...how long does it take to become an emergency medicine doctor?


I have the pleasure of mentoring students in various stages of "becoming doctors." A common question asked is "wow, how long does it take to become a doctor?" So I decided to break it down for y'all...

Grade school - middle school.
I've always wanted to be a doctor. My grandmother was an LVN, and my mom an RN. So the next 'natural step' was for me to become a doctor.

I've always been a good student, and was placed in "the good kid pile" very early in grade school. Fortunately I had parents who really advocated for me, and essentially *demanded* that I be placed in 'accelerated' classes. This worked to my benefit...and put me on the 'advanced' pathway to college prep.

In high-school.
I was very active. I played varsity sports...and essentially had a major afterschool activity every season. Fall sport, winter sport, spring sport, and summer activities...including band-camp. My mother was able to guide me to good/practical health related 'volunteer opportunities.' I did all of my homework, and never missed an (entire) day of school...since starting school. I took pride in my school work...and was paranoid about a negative smudge on my 9th grade "permanent record". I had a social life via sports and school activities, boyfriends, etc. I was somewhat of a teacher's pet...always. Took some honors classes...avoided AP classes because I wanted my GPA to be as high as possible. And at our school, honors classes were also graded on a 5.0 scale, without the stress of an AP test in the Spring.

Took the PSAT, SAT, and ACT. Applied to tons of colleges. Got into each one I followed thru on. Decided to go 'away from home' to school some 3000 miles across the country. I also had a few sports scholarship offers...but decided I wasn't really that interested in sports and had only participated in sports to have a social life.

In college.
I had a full academic scholarship...meaning I had to work my ass off to maintain eligibility. One C grade (in any class) would cost me my scholarship. In college I did the 'nerd' thing. Vice president of the chemistry club...tutoring...honor societies. But, I also pledged a sorority...and become increasingly popular and involved with Sorority Life. All the while, doing my homework, and going to class. I certainly hadn't moved 3000 miles to fuck around and flunk school.

I did research...published a paper in toxicology. I volunteered. I became a Girl Scout Troop Leader. I honestly didn't do much in the way of healthcare related activities while in school, however, when I came home for winter/summer I'd do a bit of healthcare volunteering.

My major was chemistry. Many people don't realize that a degree in biology isn't necessary (or even preferred) for medical school application. Actually, an undergraduate degree wasn't required at all....just the fulfilment of the prerequisites (but everyone had a bachelors).
Each summer I had an organized 'activity' planned. A summer enrichment program, a research position, a healthcare related job, etc. I did MCAT prep course...and subsequently took the MCAT.

I was invited to apply to a local medical school early, and was accepted. This was awesome, and meant that I would save a tremendous amount of money by subsequently only applying to medical schools I'd prefer to attend. The deciding factor was location...and ultimately I didn't take the early acceptance, and came back home to attend school close to my family.

Medical school.
Most of the students were much older than me. The average age of our first year class was 30 years old. Many students had PhDs, masters, or other awesome and interesting experiences (such as working as an engineer, architect, running a business, computer programmer, etc.) I certainly felt....intimidated.

Despite having taken the required classes, and even having a chemistry degree with a biology minor...the classes were very...detail oriented. Everything that's taught in undergraduate science is covered in the first 3 lectures in medical school...everything!! On day 4, everyone is on equal ground. I actually don't think the undergraduate classes helped at all...because in medical school they teach you everything they want you to know.

My medical school was a very laid back school. Of course there were the gunners, but overall, everyone helped everyone else (beware - this varies widely from school to school). It was important to do well on all tests - especially the first 2 years. And the testing schedule was mid-term and final, twice a year. Not many opportunities for quizzes or extra-credit.
- If you didn't pass an exam (despite the curve), you had retake the course during the summer...and retake that exam thereafter. If you didn't pass the course in the summer, didn't take the course in the summer, or didn't pass the exam you failed previously after completion of the course...you had to repeat the entire year of medical school.
- If you fail 2 exams...you have to repeat the entire year.
- If you fail an exam in a course that's not offered in the summer...you have to repeat the year.
- And finally, if you fail a course...you have to repeat the entire year.

-this happens to a handful of students each year.

There are about 9 classes in year-1. Gross Anatomy (plus lab), physiology, microbiology/histology (plus lab), pharmacology, introduction to clinical medicine, preventative medicine (statistics - which was hard as hell), biochemistry (which was so difficult, even our PhD *biochemsit* had difficulty), nutrition, primary care/family medicine (their lame attempt to try and persuade us to consider a career of horrible lifestyle and inadequate compensation).... In year 2, and the end of year 1, the subjects were organized into organ systems. First year more normal stuff...and second year learning how/why things go wrong. So, you see, it's quite easy to fail an exam...

Before you can do your clinical rotations in 3rd year, you have to take and pass the USMLE Step 1. You get one chance before you fall behind. If you fail a rotation in 3rd year, you have to repeat that rotation. And if you fail the exam at the conclusion of the rotation, you have to retake the exam...possibly repeat the rotation. (The 3rd-4th years of medical school are much easier than the first 2).

In 4th year you take USMLE Step 2. Some schools require you pass this exam before they grant a degree. Ours did not require passage, only that you sit for it. During years 3-4 you're doing rotations that interest you, and trying to pin down great letters of recommendation. You're trying to meet people in your field of interest by going to mixers, and department meetings/gatherings. You're trying to honor the rotation (by doing everything asked of you, being very humble, and taking the abuse). Perhaps, if the specialty is competitive, you're also participating in relevant research that will lead to publications with prominent staff. You may be working to qualify for consideration for an invitation into AOA (Alpha Omega Alpha) the medial honor society that's recognized nationally. The evaluation comments written by your professors/attendings is content for the Dean's Letter (the letter that the medical school will send to the residency programs when you apply...kinda like a final report card).

There's the very cumbersome process of residency application via ERAS. Very expensive interview travel. My specialty choice largely depended on what was locally available as I had no desire to move out of my house, much less to another city or state. In SoCal, everything is available. I matched locally...didn't have to move...and started internship.

Internship.
Was what everyone says it would be. But when you're 26, single, and totally psyched to be a doctor FINALLY...it wasn't so bad. During internship you have to take the USMLE Step 3...and pass it. This must be done to apply for a California State Medical license. And, you have to have a State license to advance to your 3rd post-graduate year (as an American graduate). FMG have an extra year.

-this causes programs here to lose a handful of residents depending on the competitiveness of the specialty. Unfortunately primary care spots have a high proportion of FMGs and consist of more 'borderline' students who may not test well...hence their inability to secure a more competitive residency. So, many of the FM, peds, IM, and psych residencies lose residents as they fail Step 3.

Residency.
In addition to the long hours, and scut work...there are monthly 'progress' exams in preparation for the inservice exam. The inservice is a board-like exam...and some programs will use this exam to determine whether to allow you to graduate from the program. Also, the residency programs have to give you *permission* to sit for your boards after you've completed the program. If you do poorly on the inservice, they may not allow you to sit for the board exam.

While a resident you may decide to work hard for chief resident consideration. This will give you a tremendous edge on fellowship applications, or on specialty job applications.
After residency you become board *eligible*...meaning you're eligible to sit for the specialty board exam. Many specialties only offer the exam once a year, and may consist of 2 or more parts. Written, oral, practical, etc. So, certification may take 2-3 years. And some board exams have an exceptionally low pass rate...so multiple attempts are expected. (All the EM jobs make very little distinction between board eligible and board certified in their hiring practices or priveleges granted...however, some places will pay more once you become certified.)

After residency completion.
For Emergency Medicine, there is an ABEM written exam in November. If you pass it, you then apply for a spot to take the Oral component. The Oral component is offered in Chicago, twice a year. You are randomly assigned to Spring or Fall. If you pass the Oral component...you are then BOARD CERTIFIED - a diplomat of the American Board of Emergency Medicine. After becoming board certified, and meeting other 'experience criteria' you are allowed to add FACEP and/or FAAEM after your "MD" to indicate that you are a residency trained, board certified, practicing, competent, ER doc...(which we all know may or may not be true).
***
So, to go from high school to board certification:
4 years of college - prerequisite classes and the MCAT.
4 years of medical school - Class exams. Rotations. Ass-kissing. USMLE Steps 1 and 2.
1 internship year - USMLE Step 3. Medical license.
2-7 residency years - Inservice exams each year. 80+ hours a week of indentured servitude.
After graduation 1-2 years - Board eligible. Board exam components.
*optional fellowship 1-3 years - take specialty board exam (written and oral); then take sub-specialty board exam after fellowship completion.
Board certification - 13+ years after graduating from high-school. FACEP. FAAEM.

Take a deep breath, relax, and pace yourself...becoming board certified physician is a marathon indeed!!

21 comments:

Sage said...

Wow, I had no idea it took so long. It's no wonder you doctors seem so bitter when people devalue what you do. I understand better.

Personally, I think you're crazy to go through all that. Why not just settle for PA or nurse practitioner.

Thanks for the insightful post.

ten out of ten said...

Wow, I think I'll give myself a little pat on the back for all I've accomplished. It's easy to lose sight of what we've done I think because we're surrounded by people who have been through the exact same thing.

All those hoops to jump through, and we just have one more to go. Still have my fingers crossed waiting for the board results to return...

Anonymous said...

I must be insane, I'm knee deep in the the first of TWO fellowships! I'll be triple boarded in just 2 more years...

The Happy Hospitalist said...

Great summary. Congratulations.

Don't forgot, every couple of years after your national boards you need at least 50 or so hours of education, which cost money, and every 10 years you must recertify your board exams with a very expensive test just so insurance companies can pay you pennies on the dollar of your going fee, and patients can complain that you won't see them without their copay (I know that doesn't REALLY apply in ED medicine).

Being a doctor is an art, not a book.

To the commentor of becoming a PA or NP, I refer you to my comments on my blog . I Am an Artist.

Lavender Maohmi said...

How do you guys stay encouraged and motivated to go through all of that?

Surely it can't be 100% on drive and passion alone for the field right?

ER doctor said...

No, you don't stay motivated and encouraged the entire time.

At first you're on 'auto-pilot'...going to school and just doing your work. Your parents are expecting you to go to college, and you're expecting that of yourself. No matter what you end up doing, college is your first step.

Then, in college, it's very easy to get caught up in the "I'm a pre-med" thing. Everyone is gunning for a medical school spot...and this 'group therapy' is your motivation.

In medical school...you're so psyched to be there. That adrenaline just carries you….

...for about 3 months.

Then....then...

...you start to feel a bit frustrated and tired. You start to feel the impact of ‘missing out’ on your life. Your ‘friends’ stop inviting you places. Your significant other…doesn’t understand. You miss Thanksgiving dinner. You feel alone at times…and the days of your life are ‘passing you by’. Studying is hazardous to your personal life…and you feel the *full impact* of that as a medical student.

Then, you find better study techniques, and incorporate more 'personal time' into your life away from school (even if that means just watching a TV show instead of studying one hour a week!!). Things get better as you make friends, study *smarter*, pass some exams, and balance your time better. This all make it more doable.

And you tell yourself, "Let me just graduate medical school...and then I'll reconsider. I don't have to do medicine with my MD...but I need to just finish this degree.” You think to yourself, “I'll teach kindergarten...or work at Starbucks with my MD!!" So many days I'd peer into the windows of Starbucks...actually *jealous* of the baristas because they got to go home at night...and didn't have to stay cooped up in the library for 12+ hours a day. Everyone on the street seemed to have this awesome life consisting of ample free time and cool jobs that allowed them to see (at least see) the sunshine….

But, by the time you realize how fucked up medicine can be...and question your choice (whether or not your sacrifice is/would be worth it)...you're completely trapped. You're a junior/senior medical student, and you already owe tons of money to various banks/schools...and you don't think you'll ever pay it all back doing anything but medicine. So you (sometimes reluctantly) keep stepping.

Internship, resurge of energy occurs...for about a week!! As a resident things get better. And before you can really get depressed (again) about how stupid you were to choose medicine...you only have "1 more year." You just can't quit now.

And so it goes...

...there are certainly times I regretted...not so much choosing medicine...but rather *not* choosing something else.

But, then I complain to the wrong (or rather 'right') people/person...and they "remind me" that I actually have a cool job. They’ll tell me how most people hate their jobs more than I ever could. They’ll tell me that 9a-5p *sucks*!! They remind me of the (many) great things about being a doctor…and how (despite my tales of woe) I don’t really have it that bad!! Besides, what else would I have done instead?

And I am happy once again!!

Anonymous said...

wait, so if you don't specialize then you're residency is just 2 years. but if you specialize then the specializations lead to the 3-7 years?

ER doctor said...

if you don't specialize...and opt to be what we call a general practitioner, theoretically you can hang a shingle, or work as a generalist. But practically, since almost everyone does an entire residency, you're competing with board eligible/certifed docs...and will likely find yourself struggling to find a job. Not to mention the liability issues of not *really* knowing anything about anything....

But simply, one year of internship is required to obtain a California license, and with this you can do medicine.

To specialize, you have to complete a residency. This usually includes the intern year...and is 3+ years (intern year included).

Hope that clarifies a bit....

Justin said...

To clarify even more, a family medicine, peds, or IM residency is 3 years. The first year is called the internship. You can technically practice with just the internship but you run into the problems mentioned above.

Specialties like surgery, pathology, ob/gyn are 4-5+ years long by themselves. With a subspecialty these can get extended many years.

Bostonian in NY said...

Great post and comment about the waves of demotivation that wash over us every 45 minutes or so. Very well expressed.

I recently talked to a group of local 10th graders about what is entailed in a medical career and they were all shocked that my life was nothing like Grey's anatomy or ER and that the past 7 years of my life have been a whole lot of work. It was fun, but I feel like I crushed a lot of dreams that day.

hizaleus said...

Although medical school debt is a motivation to continue in medicine, it needs to be kept in perspective. A small business owner has a similar debt without expectation of a guaranteed 6 figure salary the first year out.

Although doctors work long hours, so do most small business owners. The working poor often work longer and harder, without a near-certain future of good earnings. I know; I've been all three. Doctors don't have it so bad.

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sensen said...

I'm 26 and just getting started, finished my first year of Prerequisite. I'm goin for ER Doctor, still have a long way to go. Your story discouraged me a little, is it a good idea to keep going at my age, i want to start a family but from what you said its going to be impossible.

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Tracy Lawechresh said...

how can i apply to pre-med school? i am a micronesian student studying at com-fsm college. and i have no idea how or where to start???

Tracy Lawechresh said...

how can i get into pre-med school? i am stuyding at the college of micronesia. and how and where can i get into fro pre-med school?