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Monday, July 17, 2023

Coming out

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Coming_out

LGBT Movement - April 25, 2017 by Pedro Ribeiro Simões

Coming out of the closet, often shortened to coming out, is a metaphor used to describe LGBT people's self-disclosure of their sexual orientation, romantic orientation or gender identity.

Framed and debated as a privacy issue, coming out of the closet is experienced variously as a psychological process or journey; decision-making or risk-taking; a strategy or plan; a mass or public event; a speech act and a matter of personal identity; a rite of passage; liberation or emancipation from oppression; an ordeal; a means toward feeling LGBT pride instead of shame and social stigma; or even a career-threatening act. Author Steven Seidman writes that "it is the power of the closet to shape the core of an individual's life that has made homosexuality into a significant personal, social, and political drama in twentieth-century America".

Coming out of the closet is the source of other gay slang expressions related to voluntary disclosure or lack thereof. LGBT people who have already revealed or no longer conceal their sexual orientation or gender identity are out of the closet or simply out, i.e., openly LGBT. Oppositely, LGBT people who have yet to come out or have opted not to do so are labelled as closeted or being in the closet. Outing is the deliberate or accidental disclosure of an LGBT person's sexual orientation or gender identity by someone else, without their consent. By extension, outing oneself is self-disclosure. Glass closet means the open secret of when public figures' being LGBT is considered a widely accepted fact even though they have not officially come out.

History

19th-century gay rights advocate Karl Heinrich Ulrichs

Between 1864 and 1869, Karl Heinrich Ulrichs wrote a series of pamphlets—as well as giving a lecture to the Association of German Jurists in 1867—advocating decriminalization of sex acts between men, in which he was candid about his own homosexuality. Historian Robert Beachy has said of him, "I think it is reasonable to describe [Ulrichs] as the first gay person to publicly out himself."

In early 20th-century Germany, "coming out" was called "self-denunciation" and entailed serious legal and reputational risks. In his 1906 work, Das Sexualleben unserer Zeit in seinen Beziehungen zur modernen Kultur (The sexual life of our time in its relation to modern civilization), Iwan Bloch, a German-Jewish physician, entreated elderly homosexuals to self-disclose to their family members and acquaintances. In 1914, Magnus Hirschfeld revisited the topic in his major work The Homosexuality of Men and Women, discussing the social and legal potentials of several thousand homosexual men and women of rank revealing their sexual orientation to the police in order to influence legislators and public opinion. Hirschfeld did not support self-denunciation and dismissed the possibilities of a political movement based on open homosexuals.

The first prominent American to reveal his homosexuality was the poet Robert Duncan. In 1944, using his own name in the anarchist magazine Politics, he wrote that homosexuals were an oppressed minority. The decidedly clandestine Mattachine Society, founded by Harry Hay and other veterans of the Wallace for President campaign in Los Angeles in 1950, moved into the public eye after Hal Call took over the group in San Francisco in 1953, with many gays emerging from the closet.

In 1951, Donald Webster Cory published his landmark The Homosexual in America, exclaiming, "Society has handed me a mask to wear ... Everywhere I go, at all times and before all sections of society, I pretend." Cory was a pseudonym, but his frank and openly subjective descriptions served as a stimulus to the emerging homosexual self-awareness and the nascent homophile movement.

In the 1960s, Frank Kameny came to the forefront of the struggle. Having been fired from his job as an astronomer for the Army Map service in 1957 for homosexual behavior, Kameny refused to go quietly. He openly fought his dismissal, eventually appealing it all the way to the US Supreme Court. As a vocal leader of the growing movement, Kameny argued for unapologetic public actions. The cornerstone of his conviction was that, "we must instill in the homosexual community a sense of worth to the individual homosexual", which could only be achieved through campaigns openly led by homosexuals themselves. With the spread of consciousness raising (CR) in the late 1960s, coming out became a key strategy of the gay liberation movement to raise political consciousness to counter heterosexism and homophobia. At the same time and continuing into the 1980s, gay and lesbian social support discussion groups, some of which were called "coming-out groups", focused on sharing coming-out "stories" (experiences) with the goal of reducing isolation and increasing LGBT visibility and pride.

Etymology

The present-day expression "coming out" is understood to have originated in the early 20th century from an analogy that likens homosexuals' introduction into gay subculture to a débutante's coming-out party. This is a celebration for a young upper-class woman who is making her début – her formal presentation to society – because she has reached adult age or has become eligible for marriage. As historian George Chauncey points out:

Gay people in the pre-war years [pre-WWI] ... did not speak of coming out of what we call "the gay closet" but rather of coming out into what they called "homosexual society" or the "gay world", a world neither so small, nor so isolated, nor, often, so hidden as "closet" implies.

In fact, as Elizabeth Kennedy observes, "using the term 'closet' to refer to" previous times such as "the 1920s and 1930s might be anachronistic".

An article on coming out in the online encyclopedia glbtq.com states that sexologist Evelyn Hooker's observations introduced the use of "coming out" to the academic community in the 1950s. The article continues by echoing Chauncey's observation that a subsequent shift in connotation occurred later on. The pre-1950s focus was on entrance into "a new world of hope and communal solidarity" whereas the post-Stonewall Riots overtone was an exit from the oppression of the closet. This change in focus suggests that "coming out of the closet" is a mixed metaphor that joins "coming out" with the closet metaphor: an evolution of "skeleton in the closet" specifically referring to living a life of denial and secrecy by concealing one's sexual orientation. The closet metaphor, in turn, is extended to the forces and pressures of heterosexist society and its institutions.

Identity issues

When coming out is described as a gradual process or a journey, it is meant to include becoming aware of and acknowledging one's gender identity, gender expression, or non-hetero-normative sexual orientation or attraction. This preliminary stage, which involves soul-searching or a personal epiphany, is often called "coming out to oneself" and constitutes the start of self-acceptance. Many LGBT people say that this stage began for them during adolescence or childhood, when they first became aware of their sexual orientation toward members of the same sex. Coming out has also been described as a process because of a recurring need or desire to come out in new situations in which LGBT people are assumed to be heterosexual or cisgender, such as at a new job or with new acquaintances. A major frame of reference for those coming out has included using an inside/outside perspective, where some assume that the person can keep their identity or orientation a secret and separate from their outside appearance. This is not as simple as often thought, as Diana Fuss (1991) argues, "the problem of course with the inside/outside rhetoric ... is that such polemics disguise the fact that most of us are both inside and outside at the same time".

LGBT identity development

Every coming out story is the person trying to come to terms with who they are and their sexual orientation. Several models have been created to describe coming out as a process for gay and lesbian identity development, e.g. Dank, 1971; Cass, 1984; Coleman, 1989; Troiden, 1989. Of these models, the most widely accepted is the Cass identity model established by Vivienne Cass. This model outlines six discrete stages transited by individuals who successfully come out: identity confusion, identity comparison, identity tolerance, identity acceptance, identity pride, and identity synthesis. However, not every LGBT person follows such a model. For example, some LGBT youth become aware of and accept their same-sex desires or gender identity at puberty in a way similar to which heterosexual teens become aware of their sexuality, i.e., free of any notion of difference, stigma or shame in terms of the gender of the people to whom they are attracted. Regardless of whether LGBT youth develop their identity based on a model, the typical age at which youth in the United States come out has been dropping. High school students and even middle school students are coming out.[20][21][22]

Emerging research suggests that gay men from religious backgrounds are likely to come out online via Facebook and other social networks, such as blogs, as they offer a protective interpersonal distance. This largely contradicts the growing movement in social media research indicating that online use, particularly Facebook, can lead to negative mental health outcomes such as increased levels of anxiety. While further research is needed to assess whether these results generalize to a larger sample, these recent findings open the door to the possibility that gay men's online experiences may differ from heterosexuals' in that it may be more likely to provide mental health benefits than consequences.

Transgender identity and coming out

Transgender people vary greatly in choosing when, whether, and how to disclose their transgender status to family, close friends, and others. The prevalence of discrimination and violence against transgender people (in the United States, for example, transgender people are 28 percent more likely to be victims of violence) can make coming out a risky decision. Fear of retaliatory behavior, such as being removed from the parental home while underage, is a cause for transgender people to not come out to their families until they have reached adulthood. Parental confusion and lack of acceptance of a transgender child may result in parents treating a newly revealed gender identity as a "phase" or making efforts to change their children back to "normal" by utilizing mental health services to alter the child's gender identity.

The internet can play a significant role in the coming out process for transgender people. Some come out in an online identity first, providing an opportunity to go through experiences virtually and safely before risking social sanctions in the real world. However, while many trans people find support online that they may not have in real life, others encounter bullying and harassment when coming out online. According to a study published by Blumenfeld and Cooper in 2012, youth who identify as LGBT are 22 percent less likely to report online bullying due to factors such as parents not believing or understanding them, or fear of having to come out to explain the incident. This further shows the barriers that trans individuals can have when coming out.

Coming out as transgender can be more complex than coming out as a sexual minority. Visible changes that can occur as part of changing one's gender identity – such as wardrobe changes, hormone replacement therapy, and name changes – can make coming out to other people less of a choice. Further, things that accompany a change in gender can have financial, physical, medical, and legal implications. Additionally, transgender individuals can experience prejudice and rejection from sexual minorities and others in the LGBT community, in addition to the larger LGBT bias they can face from mainstream culture, which can feel isolating.

Legal issues

In areas of the world where homosexual acts are penalized or prohibited, gay men, lesbians, and bisexual people can suffer negative legal consequences for coming out. In particular, where homosexuality is a crime, coming out may constitute self-incrimination. These laws still exist in 75 countries worldwide, including Egypt, Iran, and Afghanistan.

People who decide to come out as non-binary or transgender often face more varied and different issues from a legal standpoint. Worldwide, legally changing your documented gender or name based on your identity is often prohibited or extremely difficult. A major negative effect of the inequality in regulations comes in the form of mental effects, as transgender people who have to legally announce a gender they do not identify with or their dead name can face uncomfortable situations and stress.

Effects

In the early stages of the LGBT identity development process, people can feel confused and experience turmoil. In 1993, Michelangelo Signorile wrote Queer in America, in which he explored the harm caused both to a closeted person and to society in general by being closeted.

Because LGBT people have historically been marginalized as sexual minorities, coming out of the closet remains a challenge for most of the world's LGBT population and can lead to a backlash of heterosexist discrimination and homophobic violence.

Studies have found that concealing sexual orientation is related to poorer mental health, physical health, and relationship functioning. For example, it has been found that same-sex couples who have not come out are not as satisfied in their relationships as same-sex couples who have. Findings from another study indicate that the fewer people know about a lesbian's sexual orientation, the more anxiety, less positive affectivity, and lower self-esteem she has. Further, Gay.com states that closeted individuals are reported to be at increased risk for suicide.

Depending on the relational bond between parents and children, a child coming out as lesbian, gay, bisexual or transgender can be positive or negative. Strong, loving relationships between children and their parents may be strengthened but if a relationship is already strained, those relationships may be further damaged or destroyed by the child coming out. If people coming out are accepted by their parents, this allows open discussions of dating and relationships and allows parents to help their children with coping with discrimination and to make healthier decisions regarding HIV/AIDS. Because parents, families, and close others can reject someone coming out to them, the effects of coming out on LGBT individuals are not always positive. For example, teens who had parents who rejected them when they came out showed more drug use, depression, suicide attempts and risky sexual behaviors later on as young adults. Some studies find that the health effects of coming out depends more on the reactions of parents than on the disclosure itself.

A number of studies have been done on the effect of people coming out to their parents. A 1989 report by Robinson et al. of parents of out gay and lesbian children in the United States found that 21 percent of fathers and 28 percent of mothers had suspected that their child was gay or lesbian, largely based on gender atypical behaviour during childhood. The 1989 study found that two-thirds of parents reacted negatively. A 1995 study (that used young people's reactions) found that half of the mothers of gay or bisexual male college students "responded with disbelief, denial or negative comments" while fathers reacted slightly better. 18 percent of parents reacted "with acts of intolerance, attempts to convert the child to heterosexuality, and verbal threats to cut off financial or emotional support".

Homelessness is a common effect among LGBT youth during the coming out process. LGBT youth are among the largest population of homeless youth; this has typically been caused by the self-identification and acknowledgment of being gay or identifying with the LGBT community. About 20 to 30 percent of homeless youth identify as LGBT. Native and Indigenous LGBTQ youth is the largest population to have experienced homelessness at 44 percent, compared to any other race. 55 percent of homeless LGBQ and 67 percent of homeless transgender youth were forced out of their homes by their parents or run away because of their sexual orientation or gender identity and expression. Compared to transgender women and non-binary youth, transgender men have the highest percentage of housing instability. Homelessness among LGBT youth also impacts many areas of an individual's life, leading to higher rates of victimization, depression, suicidal ideation, substance abuse, risky sexual behavior, and participation in more illegal and dangerous activities. A 2016 study on homelessness pathways among Latino LGBT youth found that homelessness among LGBT individuals can also be attributed to structural issues like systems of care and sociocultural and economic factors.

New data has been collected by Amit Paley who is the CEO and executive director of the Trevor Project in regards to how the Covid-19 pandemic affected the LGBTQ youth. The 2021 National Survey on LGBTQ Youth Mental Health shows that Covid-19 had made 80 percent of the LGBTQ youth housing situation much more stressful due to economic struggles, initially impacting safe and secure housing. 

Jimmie Manning performed a study in 2015 on positive and negative behavior performed during the coming out conversation. During his study, he learned that almost all of his participants would only attribute negative behaviors to themselves during the coming out conversations and positive behaviors with the recipient of the conversation. Manning suggests further research into this to figure out a way for positive behaviors to be seen and performed equally by both the recipient and the individual coming out.

In/out metaphors

Dichotomy

The closet narrative sets up an implicit dualism between being "in" or being "out" wherein those who are "in" are often stigmatized as living false, unhappy lives. Likewise, philosopher and critical analyst Judith Butler (1991) states that the in/out metaphor creates a binary opposition which pretends that the closet is dark, marginal, and false and that being out in the "light of illumination" reveals a true (or essential) identity. Nonetheless, Butler is willing to appear at events as a lesbian and maintains that "it is possible to argue that ... there remains a political imperative to use these necessary errors or category mistakes ... to rally and represent an oppressed political constituency".

Criticisms

In addition Diana Fuss (1991) explains, "the problem of course with the inside/outside rhetoric ... is that such polemics disguise the fact that most of us are both inside and outside at the same time". Further, "To be out, in common gay parlance, is precisely to be no longer out; to be out is to be finally outside of exteriority and all the exclusions and deprivations such outsiderhood imposes. Or, put another way, to be out is really to be in—inside the realm of the visible, the speakable, the culturally intelligible." In other words, coming out constructs the closet it supposedly destroys and the self it supposedly reveals, "the first appearance of the homosexual as a 'species' rather than a 'temporary aberration' also marks the moment of the homosexual's disappearance—into the closet".

Furthermore, Seidman, Meeks, and Traschen (1999) argue that "the closet" may be becoming an antiquated metaphor in the lives of modern-day Americans for two reasons.

  1. Homosexuality is becoming increasingly normalized and the shame and secrecy often associated with it appears to be in decline.
  2. The metaphor of the closet hinges upon the notion that stigma management is a way of life. However, stigma management may actually be increasingly done situationally.

National Coming Out Day

Observed annually on 11 October, by members of the LGBT communities and their allies, National Coming Out Day is an international civil awareness day for coming out and discussing LGBT issues among the general populace in an effort to give a familiar face to the LGBT rights movement. This day was the inspiration for holding LGBT History Month in the United States in October. The day was founded in 1988, by Robert Eichberg, his partner William Gamble, and Jean O'Leary to celebrate the Second National March on Washington for Lesbian and Gay Rights one year earlier, in which 500,000 people marched on Washington, DC, United States, for gay and lesbian equality. In the United States, the Human Rights Campaign manages the event under the National Coming Out Project, offering resources to LGBT individuals, couples, parents, and children, as well as straight friends and relatives, to promote awareness of LGBT families living honest and open lives. Candace Gingrich became the spokesperson for the day in April 1995. Although still named "National Coming Out Day", it is observed in Canada, Germany, the Netherlands, and Switzerland also on 11 October, and in the United Kingdom on 12 October. To celebrate National Coming Out Day on 11 October 2002, Human Rights Campaign released an album bearing the same title as that year's theme: Being Out Rocks. Participating artists include Kevin Aviance, Janis Ian, k.d. lang, Cyndi Lauper, Sarah McLachlan, and Rufus Wainwright.

Media

Highly publicized comings-out

Government officials and political candidates

Athletes

The first US professional team-sport athlete to come out was former NFL running back David Kopay, who played for five teams (San Francisco, Detroit, Washington, New Orleans and Green Bay) between 1964 and 1972. He came out in 1975 in an interview in the Washington Star. The first professional athlete to come out while still playing was Czech-American professional tennis player Martina Navratilova, who came out as a lesbian during an interview with The New York Times in 1981. English footballer Justin Fashanu came out in 1990 and was subject to homophobic taunts from spectators, opponents and teammates for the rest of his career.

In 1995 while at the peak of his playing career, Ian Roberts became the first high-profile Australian sports person and first rugby footballer in the world to come out to the public as gay. John Amaechi, who played in the NBA with the Utah Jazz, Orlando Magic and Cleveland Cavaliers (as well as internationally with Panathinaikos BC of the Greek Basketball League and Kinder Bologna of the Italian Basketball League), came out in February 2007 on ESPN's Outside the Lines program. He also released a book Man in the Middle, published by ESPN Books (ISBN 1-933060-19-0) which talks about his professional and personal life as a closeted basketball player. He was the first NBA player (former or current) to come out.

In 2008, Australian diver Matthew Mitcham became the first openly gay athlete to win an Olympic gold medal. He achieved this at the Beijing Olympics in the men's 10 meter platform event.

The first Irish county GAA player to come out while still playing was hurler Dónal Óg Cusack in October 2009 in previews of his autobiography. Gareth Thomas, who played international rugby union and rugby league for Wales, came out in a Daily Mail interview in December 2009 near the end of his career.

In 2013, basketball player Jason Collins (a member of the Washington Wizards) came out as gay, becoming the first active male professional athlete in a major North American team sport to publicly come out as gay.

On 15 August 2013, WWE wrestler Darren Young came out, making him the first openly gay active professional wrestler.

On 9 February 2014, former Missouri defensive lineman Michael Sam came out as gay. He was drafted by the St. Louis Rams on 10 May 2014, with the 249th overall pick in the seventh round, making him the first openly gay player to be drafted by an NFL franchise. He was released by St. Louis and waived by the Dallas Cowboys practice squad. Sam was on the roster for the Montreal Alouettes, but has since retired from football.

On 21 June 2021, Las Vegas Raiders defensive end Carl Nassib announced on his Instagram account that he is gay, becoming the first active NFL player to come out publicly.

In October 2021, professional soccer player Josh Cavallo came out as gay via videos posted to his team's social media accounts, becoming the only openly gay top-level professional soccer player in the world.

Artists and entertainers

In 1997 on The Oprah Winfrey Show, American comedian Ellen DeGeneres came out as a lesbian. Her real-life coming out was echoed in the sitcom Ellen in "The Puppy Episode", in which her character Ellen Morgan outs herself over the airport public address system.

On 29 March 2010, Puerto Rican singer Ricky Martin came out publicly in a post on his official web site by stating, "I am proud to say that I am a fortunate homosexual man. I am very blessed to be who I am." Martin said that "these years in silence and reflection made me stronger and reminded me that acceptance has to come from within and that this kind of truth gives me the power to conquer emotions I didn't even know existed." Singer Adam Lambert came out after pictures of him kissing another man were publicly circulated while he was a participant on the eighth season of American Idol. In January 2013, while accepting the honorary Golden Globe Cecil B. DeMille Award, American actress and director Jodie Foster made the first public acknowledgment of her sexual orientation, saying; "I already did my coming out a thousand years ago, in the Stone Age, in those very quaint days when a fragile young girl would open up to friends and family and co-workers then gradually to everyone that knew her, everyone she actually met."

Military personnel

In 1975, Leonard Matlovich, while serving in the United States Air Force, came out to challenge the US military's policies banning service by homosexuals. Widespread coverage included a Time magazine cover story and a television movie on NBC.

In 2011, as the US prepared to lift restrictions on service by openly gay people, Senior Airman Randy Phillips conducted a social media campaign to garner support for coming out. The video he posted on YouTube of the conversation in which he told his father he was gay went viral. In one journalist's summation, he "masterfully used social media and good timing to place himself at the centre of a civil rights success story".

Pastors

In October 2010, megachurch pastor Bishop Jim Swilley came out to his congregation. The YouTube video of the service went viral. Interviews with People magazine, Joy Behar, Don Lemon ABC News and NPR focused on the bullycides that prompted Bishop Swilley to "come out". One year later, he confirmed the costs but also the freedom he has experienced. "To be able to have freedom is something that I wouldn't trade anything for." "Being married as yourself, preaching as yourself and living your life as yourself is infinitely better than doing those things as someone else." Bishop Swilley's son, Jared Swilley, bass player and front man of Black Lips said, "It was definitely shocking, but I was actually glad when he told me. I feel closer to him now". Bishop Swilley's other son, Judah Swilley, a cast member on the Oxygen show Preachers of Atlanta, is confronting homophobia in the church.

Journalists

In August 2019, a sportswriter and broadcaster contributing at The Guardian and ESPN came out, informing that she is now Nicky Bandini and was previously writing under the name Paolo Bandini. The football journalist highlighted through a Twitter video and an accompanying article on The Guardian that it took her several years to come out as transgender publicly. Bandini also went through gender dysphoria for three-and-a-half decades before finally admitting it to the world.

Depictions of coming out

In 1996, the acclaimed British film Beautiful Thing had a positive take in its depiction of two teenage boys coming to terms with their sexual identity. In 1987, a two-part episode of the Quebec television series Avec un grand A, "Lise, Pierre et Marcel", depicted a married closeted man who has to come out when his wife discovers that he has been having an affair with another man. In the Emmy Award-nominated episode "Gay Witch Hunt" of The Office, Michael inadvertently outs Oscar to the whole office.

Author Rodger Streitmatter described Ellen DeGeneres's coming out in the media as well as an episode of Ellen, "The Puppy Episode", as "rank[ing], hands down, as the single most public exit in gay history", changing media portrayals of lesbians in Western culture. In 1999, Russell T Davies's Queer as Folk, a popular TV series shown on the UK's Channel 4 debuted and focused primarily on the lives of young gay men; in particular on a 15-year-old going through the processes of revealing his sexuality to those around him. This storyline was also featured prominently in the US version of Queer as Folk, which debuted in 2000.

The television show The L Word, which debuted in 2004, focuses on the lives of a group of lesbian and bisexual women, and the theme of coming out is prominently featured in the storylines of multiple characters.

Coming Out, which debuted in 2013, is the first Quebec television program about being gay.

The third season of the Norwegian teen drama series Skam focused on a main character coming out and his relationship with another boy.

The film Love, Simon, based on the book Simon vs. the Homo Sapiens Agenda, debuted in 2018 and is the first major studio film about a gay teenager coming out.

Recently there has been a second adaption playing off of the Love, Simon film and the Simon vs. the Homo Sapiens Agenda book called Love, Victor on Hulu. The series originally aired in 2020 and premiered its third season in 2022. The series continued and expanded its original story with another young and closeted student.

Extended use in LGBT media, publishing and activism

"Out" is a common word or prefix used in the titles of LGBT-themed books, films, periodicals, organizations, and TV programs. Some high-profile examples are Out magazine, the defunct OutWeek, and OutTV.

Non-LGBT contexts

In political, casual, or even humorous contexts, "coming out" means by extension the self-disclosure of a person's secret behaviors, beliefs, affiliations, tastes, identities, and interests that may cause astonishment or bring shame. Some examples include: "coming out as an alcoholic", "coming out as a BDSM participant", "coming out of the broom closet" (as a witch), "coming out as a conservative", "coming out as disabled", "coming out as a liberal", "coming out as intersex", "coming out as multiple", "coming out as polyamorous", "coming out as a sex worker", and "coming out of the shadows" as an undocumented immigrant within the United States. The term is also used by members of online body integrity dysphoria communities to refer to the process of telling friends and families about their condition.

With its associated metaphors, the figure of speech has also been extended to atheism, e.g., "coming out as an atheist". A public awareness initiative for freethought and atheism, entitled the "Out Campaign", makes ample use of the "out" metaphor. This campaign was initiated by Robin Elisabeth Cornwell, and is endorsed by prominent atheist Richard Dawkins, who states "there is a big closet population of atheists who need to 'come out'".

Residency (medicine)

From Wikipedia, the free encyclopedia
Anesthesia residents being led through training with a patient simulator

Residency or postgraduate training is a stage of graduate medical education. It refers to a qualified physician (one who holds the degree of MD, DO, MBBS, MBChB), veterinarian (DVM or VMD), dentist (DDS or DMD), podiatrist (DPM) or pharmacist (PharmD) who practices medicine, veterinary medicine, dentistry, podiatry, or clinical pharmacy, respectively, usually in a hospital or clinic, under the direct or indirect supervision of a senior medical clinician registered in that specialty such as an attending physician or consultant. In many jurisdictions, successful completion of such training is a requirement in order to obtain an unrestricted license to practice medicine, and in particular a license to practice a chosen specialty. In the meantime they practice "on" the license of their supervising physician. An individual engaged in such training may be referred to as a resident, registrar or trainee depending on the jurisdiction. Residency training may be followed by fellowship or sub-specialty training.

Whereas medical school teaches physicians a broad range of medical knowledge, basic clinical skills, and supervised experience practicing medicine in a variety of fields, medical residency gives in-depth training within a specific branch of medicine.

Terminology

A resident physician is more commonly referred to as a resident, senior house officer (in Commonwealth countries), or alternatively, a senior resident medical officer or house officer. Residents have graduated from an accredited medical school and hold a medical degree (MD, DO, MBBS, MBChB). Residents are, collectively, the house staff of a hospital. This term comes from the fact that resident physicians traditionally spend the majority of their training "in house" (i.e., the hospital).

Duration of residencies can range from three years to seven years, depending upon the program and specialty. A year in residency begins between late June and early July depending on the individual program and ends one calendar year later.

In the United States, the first year of residency is known as an internship with those physicians being termed interns. Depending on the number of years a specialty requires, the term junior resident may refer to residents that have not completed half their residency. Senior residents are residents in their final year of residency, although this can vary. Some residency programs refer to residents in their final year as chief residents (typically in surgical branches). Alternatively, a chief resident may describe a resident who has been selected to extend his or her residency by one year and organize the activities and training of the other residents (typically in internal medicine and pediatrics). In dermatology generally one of the final year residents is chosen as chief, to add administrative duties to the normal learning in the last year.

If a physician finishes a residency and decides to further his or her education in a fellowship, they are referred to as a "fellow". Physicians who have fully completed their training in a particular field are referred to as attending physicians, or consultants (in Commonwealth countries). However, the above nomenclature applies only in educational institutes in which the period of training is specified in advance. In privately owned, non-training hospitals, in certain countries, the above terminology may reflect the level of responsibility held by a physician rather than their level of education.

History

Residency as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th century from brief and informal programs for extra training in a special area of interest. The first formal residency programs were established by Sir William Osler and William Stewart Halsted at the Johns Hopkins Hospital. Residencies elsewhere then became formalized and institutionalized for the principal specialties in the early 20th century. But even mid-century, residency was not seen as necessary for general practice and only a minority of primary care physicians participated. By the end of the 20th century in North America though, very few new doctors went directly from medical school into independent, unsupervised medical practice, and more state and provincial governments began requiring one or more years of postgraduate training for medical licensure.

Residencies are traditionally hospital-based, and in the middle of the twentieth century, residents would often live (or "reside") in hospital-supplied housing. "Call" (night duty in the hospital) was sometimes as frequent as every second or third night for up to three years. Pay was minimal beyond room, board, and laundry services. It was assumed that most young men and women training as physicians had few obligations outside of medical training at that stage of their careers.

The first year of practical patient-care-oriented training after medical school has long been termed "internship". Even as late as the middle of the twentieth century, most physicians went into primary care practice after a year of internship. Residencies were separate from internship, often served at different hospitals, and only a minority of physicians did residencies.

Afghanistan

In Afghanistan, the residency (Dari, تخصص) consists of a three to seven years of practical and research activities in the field selected by the candidate. The graduate medical students do not need to complete the residency because they study medicine in six years (three years for clinical subjects, three years clinical subjects in hospital) and one-year internship and they graduate as general practitioner. Most students do not complete residency because it is too competitive.

Argentina

In Argentina, the residency (Spanish, residencia) consists of a three to four years of practical and research activities in the field selected by both the candidate and already graduated medical practitioners. Specialized fields such as neurosurgery or cardio-thoracic surgery require longer training. Through these years, consisting of internships, social services, and occasional research, the resident is classified according to their residency year as an R1, R2, R3 or R4. After the last year, the "R3 or R4 Resident" obtains the specialty (especialidad) in the selected field of medicine.

Australia

In Australia, specialist training is undertaken as a registrar; The term 'resident' is used synonymously with 'hospital medical officer' (HMO), and refers to unspecialised postgraduate medical practitioners prior to specialty training.

Entry into a specialist training program occurs after completing one year as an intern (post-graduate year 1 or "PGY1"), then, for many training programs, an additional year as a resident (PGY2 onward). Training lengths can range from 3 years for general practice to 7 years for paediatric surgery.

Canada

In Canada, Canadian medical graduates (CMGs), which includes final-year medical students and unmatched previous-year medical graduates, apply for residency positions via the Canadian Resident Matching Service (CaRMS). The first year of residency training is known as "Postgraduate Year 1" (PGY1).

CMGs can apply to many post-graduate medical training programs including family medicine, emergency medicine, internal medicine, pediatrics, general surgery, obstetrics-gynecology, neurology, and psychiatry, amongst others.

Some residency programs are direct entry (family medicine, dermatology, neurology, general surgery, etc.), meaning that CMGs applying to these specialties do so directly from medical school. Other residencies have sub-specialty matches (internal medicine and pediatrics) where residents complete their first 2–3 years before completing a secondary match (Medicine subspecialty match (MSM) or Pediatric subspecialty match (PSM)). After this secondary match has been completed, residents are referred to as fellows. Some areas of subspecialty matches include cardiology, nephrology, gastroenterology, immunology, respirology, infectious diseases, rheumatology, endocrinology and more. Direct entry specialties also have fellowships, but they are completed at the end of residency (typically 5 years).

Colombia

In Colombia, fully licensed physicians are eligible to compete for seats in residency programs. To be fully licensed, one must first finish a medical training program that usually lasts five to six years (varies between universities), followed by one year of medical and surgical internship. During this internship a national medical qualification exam is required, and, in many cases, an additional year of unsupervised medical practice as a social service physician. Applications are made individually program by program, and are followed by a postgraduate medical qualification exam. The scores during medical studies, university of medical training, curriculum vitae, and, in individual cases, recommendations are also evaluated. The acceptance rate into residencies is very low (~1–5% of applicants in public university programs), physician-resident positions do not have salaries, and the tuition fees reach or surpass US$10,000 per year in private universities and $2,000 in public universities. For the reasons mentioned above, many physicians travel abroad (mainly to Argentina, Brazil, Spain and the United States) to seek postgraduate medical training. The duration of the programs varies between three and six years. In public universities, and some private universities, it is also required to write and defend a medical thesis before receiving a specialist degree.

France

In France, students attending clinical practice are known as "externes" and newly qualified practitioners training in hospitals are known as "internes". The residency, called "Internat", lasts from three to six years (it depends on the speciality) and follows a competitive national ranking examination. It is customary to delay submission of a thesis. As in most other European countries, many years of practice at a junior level may follow.

French residents are often called "doctor" during their residency. Literally speaking, they are still students and become M.D. only at the end of their residency and after submitting and defending a thesis before a jury.

Greece

In Greece, licensed physicians are eligible to apply for a position in a residency program. To be a licensed physician, one must finish a medical training program which in Greece lasts for six years. A one-year obligatory rural medical service (internship) is necessary to complete the residency training. Applications are made individually in the prefecture where the hospital is located, and the applicants are positioned on first-come, first-served basis. The duration of the residency programs varies between three and seven years.

India

In India, after completing MBBS degree and one year of integrated internship, doctors can enroll in several types of postgraduate training programs: D.M. (DOCTOR OF MEDICINE) in: Cardiology, Endocrinology, Medical Gastroenterology, Nephrology, and Neurology. M.Ch. (MASTER OF CHIRURGIE) in: Cardio vascular & Thoracic Surgery, Urology, Neurosurgery, Paediatric Surgery, Plastic Surgery. M.D. (DOCTOR OF MEDICINE) in: Anesthesiology, Anatomy, Biochemistry, Community Medicine, Dermatology Venereology and Leprosy, General Medicine, Forensic Medicine, Microbiology, Pathology, Paediatrics, Pharmacology, Physical medicine and rehabilitation, Physiology, Psychiatry, Radio diagnosis, Radiotherapy, Tropical Medicine, and, Tuberculosis & Respiratory Medicine. M.S. (MASTER OF SURGERY) in: Otorhinolaryngology, General Surgery, Ophthalmology, Orthopaedics, Obstetrics & Gynecology. Or diploma in: Anesthesiology (D.A.), Clinical Pathology (D.C.P.), Dermatology Venereology and Leprosy (DDVL), Forensic Medicine (D.F.M.), Obstetrics & Gynaecology (D.G.O.), Ophthalmology (D.O.), Orthopedics (D.Ortho.), Otorhinolaryngology (D.L.O.), Paediatrics (D.C.H.) Psychiatry (D.P.M.), Public health (D.P.H.), Radio-diagnosis (D.M.R.D.), Radiotherapy (D.M.R.T.)., Tropical Medicine & Health (D.T.M. & H.), Tuberculosis & Chest Diseases (D.T.C.D.), Industrial Health (D.I.H.), Maternity & Child Welfare (D. M. C. W.)

Mexico

In Mexico physicians need to take the ENARM (National Test for Aspirants to Medical Residency) (Spanish, Examen Nacional de Aspirantes a Residencias Medicas) in order to have a chance for a medical residency in the field they wish to specialize. The physician is allowed to apply to only one speciality each year. Some 35,000 physicians apply and only 8000 are selected. The selected physicians bring their certificate of approval to the hospital that they wish to apply (Almost all the hospitals for medical residency are from government based institutions). The certificate is valid only once per year and if the resident decides to drop residency and try to enter to a different speciality she will need to take the test one more time (no limit of attempts). All the hosting hospitals are affiliated to a public/private university and this institution is the responsible to give the degree of "specialist". This degree is unique but equivalent to the MD used in the UK and India. In order to graduate, the trainee is required to present a thesis project and defend it.

The length of the residencies is very similar to the American system. The residents are divided per year (R1, R2, R3, etc.). After finishing the trainee may decide if he wants to sub-specialize (equivalency to fellowship) and the usual length of sub-specialty training ranges from two to four years. In Mexico the term "fellow" is not used.

The residents are paid by the hosting hospital, about US$1000–1100 (paid in Mexican pesos). Foreign physicians do not get paid and indeed are required to pay an annual fee of $1000 to the university institution that the hospital is affiliated with.

All the specialties in Mexico are board certified and some of them have a written and an oral component, making these boards ones of the most competitive in Latin America.

Pakistan

In Pakistan, after completing a MBBS degree and further completing a one year house job, doctors can enroll in two types of postgraduate residency programs. The first is a MS/MD program run by various medical universities throughout the country. It is a 4–5-year program depending upon the specialty. The second is a fellowship program which is called Fellow of College of Physicians and Surgeons Pakistan (FCPS) by the College of Physicians and Surgeons Pakistan (CPSP). It is also a 4–5-year program depending upon the specialty.

There are also post-fellowship programs offered by the College of Physicians and Surgeons Pakistan as a second fellowship in subspecialties.

Spain

All Spanish medical degree holders need to pass a competitive national exam (named 'MIR') in order to access the specialty training program. This exam gives them the opportunity to choose both the specialty and the hospital where they will train, among the hospitals in the Spanish Healthcare Hospital Network. Currently, medical specialties last from 4 to 5 years.

There are plans to change the training program system to one similar to the UK's. There have been some talks between Ministry of Health, the Medical College of Physicians and the Medical Student Association but it is not clear how this change process is going to be.

Sweden

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. 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 schoolsUppsala 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. 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. 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.

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—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.

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.

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.

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

Base specialties and subspecialties

Medical base specialties and subspecialties in Sweden as of 2015
Specialty classes Base specialties Subspecialties
Pediatric specialties Pediatrics Pediatric allergology
Pediatric hematology and oncology
Pediatric cardiology
Pediatric neurology including habilitation
Neonatology
Imaging and functional medicine specialties Clinical physiology
Radiology Neuroradiology
Independent base specialties Emergency medicine
General practice
Occupational and environmental medicine
Dermatology and venereology
Infectious diseases
Clinical pharmacology
Clinical genetics
Oncology
Rheumatology
Forensic medicine
Social medicine
Internal medicine specialties Endocrinology and diabetology
Geriatrics
Hematology
Internal medicine
Cardiology
Pulmonology
Medical gastroenterology and hepatology
Nephrology
Surgical specialties Anesthesiology and intensive care
Pediatric surgery
Hand surgery
Surgery
Vascular surgery
Obstetrics and gynecology
Orthopedics
Plastic surgery
Thoracic surgery
Urology
Ophthalmology
Otorhinolaryngology Disorders of hearing and balance
Disorders of voice and speech
Laboratory specialties Clinical immunology and transfusion medicine
Clinical chemistry
Clinical microbiology
Clinical pathology
Neurological specialties Clinical neurophysiology
Neurosurgery
Neurology
Rehabilitation medicine
Psychiatric specialties Pediatric psychiatry
Psychiatry Forensic psychiatry

Add-on Specialties

Allergology

To train in the add-on specialty of allergology a physician must first be a specialist in general practice, occupational and environmental medicine, pediatric allergology, endocrinology and diabetology, geriatrics, hematology, dermatology and venerology, internal medicine, cardiology, clinical immunology and transfusion medicine, pulmonology, medical gastroenterology and hepatology, nephrology or otorhinolaryngology.

Occupational medicine

To train in the add-on specialty of occupational medicine a physician must first be a specialist in one of the pediatric class specialties, one of the independent class specialties (excluding clinical pharmacology, clinical genetics, forensic medicine, and social medicine), one of the internal medicine class specialties, one of the neurological class specialties (excluding clinical neurophysiology) or one of the psychiatric class specialties.

Addiction medicine

To train in the add-on specialty of addiction medicine a physician must first be a specialist in pediatric psychiatry or psychiatry.

Gynecologic oncology

To train in the add-on specialty of gynecologic oncology a physician must first be a specialist in obstetrics and gynecology or oncology.

Nuclear medicine

To train in the add-on specialty of nuclear medicine a physician must first be a specialist in clinical physiology, oncology or radiology.

Palliative medicine

To train in the add-on specialty of palliative medicine a physician must first be a specialist in one of the pediatric class specialties, one of the independent class specialties (excluding occupational and environmental medicine, clinical pharmacology, clinical genetics, forensic medicine, and social medicine), one of the internal medicine class specialties, one of the surgical class specialties, one of the neurological class specialties (excluding clinical neurophysiology) or one of the psychiatric class specialties.

School health

To train in the add-on specialty of school health a physician must first be a specialist in general practice, pediatrics or pediatric psychiatry.

Pain medicine

To train in the add-on specialty of pain medicine a physician must first be a specialist in one of the pediatric class specialties, one of the independent class specialties (excluding clinical pharmacology, clinical genetics, forensic medicine, and social medicine), one of the internal medicine class specialties, one of the surgical class specialties, one of the neurological class specialties (excluding clinical neurophysiology) or one of the psychiatric class specialties.

Infection control

To train in the add-on specialty of infection control a physician must first be a specialist in infectious diseases or clinical microbiology.

Geriatric psychiatry

To train in the add-on specialty of geriatric psychiatry a physician must first be a specialist in geriatrics or psychiatry.

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.

Factors

Apart from the requirement that candidates are graduates from approved medical programs and, in the case of residency, licensed as medical doctors, there are no specific criteria an employer has to consider in hiring for an internship or residency position. This system for recruiting has been criticized by The Swedish Medical Association for lacking transparency as well as for delaying time to specialist certification of physicians.

There are nevertheless factors that most employers will consider, the most important being how long a doctor has been in active practice. After completing nine out of a total of eleven semesters of medical school a student may work as a physician on a temporary basis—e.g. during summer breaks from university. This rule enables medical graduates to start working as physicians upon graduating from university without yet being licensed, as a way of building experience to be able to eventually be hired into an internship. According to a 2017 survey by The Swedish Medical Association, interns in the country as a whole had worked an average of 10.3 months as physicians before starting their internships, ranging from an average of 5.1 months for interns in the Dalarna region to an average of 19.8 months for interns in the Stockholm region.

In recruitment for residency positions less emphasis is often placed on the number of months a candidate has worked after finishing their internship, but it is common for physicians to work for some time in between internship and residency, much in the same way as between medical school and internship.

Thailand

In Thailand, postgraduate medical training is monitored by the Medical Council of Thailand (TMC) and conducted by their respective "Royal Colleges".

Thailand has a significant issue with an imbalance of medical personnel between Bangkok and the remaining 76 provinces. As a primate city, the majority of specialists wish to remain in Bangkok after training. Each year, the TMC outlines the requirements for application to a certain specialty, depending on the needs of the country for staff within that field. Specialities are therefore classified into tiers depending on national demand. The duration spent in the national internship program depends on the specialty the graduate wishes to study. Specialties classified as 'lacking' may require only one year of internship, whilst more competitive specialties often require the full three-year duration of internship to meet the application criteria. Fields classified as 'severely lacking' may not require internship training at all.

Application to residency may be done on contract with a government hospital or without a contract, namely 'free-training'. Government hospitals may sign contracts to sponsor residency training for specialist doctors they require. In these cases, the duration for internship required in more popular fields may be reduced. For example, a residency in internal medicine requires three years of internship if applying without contract, but is reduced to two years if applying under contract. However at the end of training, specialists under contract must return to work at that particular hospital for a minimum of the duration of residency.

Most residency programs in Thailand consist of three to four years of training. The duration of training may be up to five or six years in certain specialties. Applications are sent to the Royal College overseeing their desired specialty and candidates may apply to no more than five institutes that conduct training in that specialty. As of 2022, there were 40 base specialties and 49 subspecialties. Subspecialty training (fellowship) requires initial training in the respective base specialty and is generally 1-2 years in duration.

Base specialties

Base Specialties in Thailand as of 2022
Tier Notes Base Specialties
Tier 1.1 Internship training not required. Medical school graduates can apply directly after graduation.

Generally classified as 'severely lacking'.

Anatomical Pathology
Clinical Pathology
Transfusion Medicine
Tier 1.2 One year of internship training required.

Generally classified as 'lacking'.

Psychiatry
Child and Adolescent Psychiatry
Addiction Psychiatry
Forensic Medicine
Neurosurgery
Radiation Oncology
Nuclear Medicine
Emergency Medicine
Family Medicine
Oncology
Hematology
Tier 2.1 One year of internship if applying under government contract.

Two years of internship if applying without contract.

Rehabilitation Medicine
Diagnostic Radiology
Anesthesiology
Pediatric Hematology and Oncology
Pediatric Surgery
General Surgery
Cardiothoracic Surgery
Obstetrics and Gynaecology
Tier 2.2 One year of internship if applying under government contract.

Three years of internship if applying without contract.

Pediatrics
Internal Medicine
Neurology
Orthopedics
Otorhinolaryngology
Urology
Preventive Medicine (Epidemiology)
Preventive Medicine (Aviation Medicine)
Preventive Medicine (Clinical Preventive Medicine)
Preventive Medicine (Occupational Medicine)
Preventive Medicine (Travel Medicine)
Preventive Medicine (Maritime Medicine)
Preventive Medicine (Traffic Medicine)
Preventive Medicine (Public Health)
Preventive Medicine (Community Mental Health)
Tier 3.1 Two years of internship if applying under government contract.

Three years of internship if applying without contract.

Ophthalmology
Tier 3.2 Three years of internship required. Dermatology
Plastic Surgery

United Kingdom

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 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 vary with specialty but there are five broad categories:

  • Themed core specialties (A&E, 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 (such as core medical training) which makes them eligibile 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 (such as the Royal College of Physicians (MRCP), or the 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 (such as radiology, public health or histopathology), but there are also a few traditionally surgical specialities which can be entered directly without completing core surgical training – neurosurgery, obstetrics & gynaecology and 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, but 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).

United States

Jackson Memorial Hospital in Miami, the primary teaching hospital for the Leonard M. Miller School of Medicine at the University of Miami, July 2010

Medical licensure in the United States is governed by individual state boards of medicine. In most states, graduates of U.S. medical schools may obtain a full medical license after passage of the third step of the USMLE, and at least one year of postgraduate education (i.e., one year of residency; usually called an internship However, in most states, International medical graduates are required longer periods of training as well as passage of the third and final step of the USMLE, to obtain a full medical license. Those in residency programs who have full medical licenses may practice medicine without supervision ("moonlight") in settings such as urgent care centers and rural hospitals. However, while performing the requirements of their residency, residents are supervised by attending physicians who must approve their decisions.

Specialty selection

Specialties differ in length of training, availability of residencies, and options. Specialist residency programs require participation for completion ranging from three years for family medicine to seven years for neurosurgery. 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. In 2023 there were 11893 internal medicine positions (around 9725 categorical, 1715 preliminary, and 453 primary care positions). The second largest specialty is family medicine with 5,088 positions in 2022.

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.

Length of medical residency training in the United States
Years Medical specialties
Three
Four
Five
Six
Seven

Application process

Factors

There are many factors that can go into what makes an applicant more or less competitive. According to a survey of residency program directors by the NRMP in 2020, the following five factors were mentioned by directors over 75% of the time as having the most impact:

Factors for obtaining a medical residency in the United States
Factor 2012 2020
Step 1 score 82% 90%
Letters of recommendation in specialty 81% 84%
Personal statement 77% 78%
Step 2 CK score 70% 78%
Medical School Performance Evaluation (MSPE/Dean's Letter) 68% 76%

Between 60% and 75% also mentioned other factors such as core clerkship grades, perceived commitment to specialty, Audition elective/rotation within your department, any failed attempt in USMLE, class ranking/quartile, personal prior knowledge of the applicant, perceived interest in program and passing USMLE Step 2 CS.

These factors often come as a surprise to many students in the preclinical years, who often work very hard to get great grades, but do not realize that only 45% of directors cite basic science performance as an important measure.

Written

Applicants begin the application process with ERAS (regardless of their matching program) at the beginning of their fourth and final year in medical school.

At this point, students choose specific residency programs to apply for that often specify both specialty and hospital system, sometimes even subtracks (e.g., Internal Medicine Residency Categorical Program at Mass General or San Francisco General Primary Care Track).

After they apply to programs, programs review applications and invite selected candidates for interviews held between October and February. As of 2016, schools can view applications starting 1 Oct.

Interviews

The interview process involves separate interviews at hospitals around the country. Frequently, the individual applicant pays for travel and lodging expenses, but some programs may subsidize applicants' expenses.

International medical students may participate in a residency program within the United States as well but only after completing a program set forth by the Educational Commission for Foreign Medical Graduates (ECFMG). Through its program of certification, the ECFMG assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). The ECFMG does not have jurisdiction over Canadian M.D. programs, which the relevant authorities consider to be fully equivalent to U.S. medical schools. In turn, this means that Canadian MD graduates, if they can obtain the required visas (or are already US citizens or permanent residents), can participate in US residency programs on the same footing as US graduates.

The match

Ranking

Access to graduate medical training programs such as residencies is a competitive process known as "the Match". After the interview period is over, students submit a "rank-order list" to a centralized matching service that depends on the residency program they are applying for:

  • most specialties – the National Resident Matching Program (NRMP) by February (the AOA match used to be a separate option for DOs but was merged with the NRMP match after 2020)
  • Urology Residency Match Program
  • SF Match (Ophth/ Plastics)

Similarly, residency programs submit a list of their preferred applicants in rank order to this same service. The process is blinded, so neither applicant nor program will see each other's list. Aggregate program rankings can be found here, and are tabulated in real time based on applicants' anonymously submitted rank lists.

The two parties' lists are combined by an NRMP computer, which creates stable (a proxy for optimal) matches of residents to programs using an algorithm. On the third Friday of March each year ("Match Day") these results are announced in Match Day ceremonies at the nation's 155 U.S. medical schools. By entering the Match system, applicants are contractually obligated to go to the residency program at the institution to which they were matched. The same applies to the programs; they are obligated to take the applicants who matched into them.

Match Day

On the Monday of the week that contains the third Friday in March, candidates find out from the NRMP whether (but not where) they matched. If they have matched, they must wait until Match Day, which takes place on the following Friday, to find out where.

Supplemental Offer and Acceptance Program

The Supplemental Offer and Acceptance Program (SOAP) is a process for partially matched and fully unmatched applicant through the Match. Previous to the creation of SOAP, applicants were given the opportunity to contact the programs about the open positions in a process informally called "the scramble". This frantic, loosely structured system forced soon-to-be medical school graduates to choose within minutes programs not on their original Match list. In 2012, the NRMP introduced the organized system called SOAP. As part of the transition, Match Day was also moved from the third Thursday in March to the third Friday.

The SOAP occurs during Match week. First the applicants eligible for SOAP, are informed they did not secure a Match position on the Monday of Match Week. The locations of remaining unfilled residency positions are released to the unmatched applicants the following day. Then programs contact applicants for interviews that usually occur via phone calls. After that, programs prepare lists of applicants and the positions open are offered by each program one at a time to the top applicant on their list. The applicant may accept the offer or reject it. If the offer is rejected it will go to the next applicant in the program list during the next round of SOAP. During Match year 2021 there were four rounds of SOAP.

Changing residency

Inevitably, there will be discrepancies between the preferences of the student and programs. Students may be matched to programs very low on their rank list, especially when the highest priorities consist of competitive specialties like radiology, neurosurgery, plastic surgery, dermatology, ophthalmology, orthopedics, otolaryngology, radiation oncology, and urology. It is not unheard of for a student to go even a year or two in a residency and then switch to a new program.

A similar but separate osteopathic match previously existed, announcing its results in February, before the NRMP. However the osteopathic match is no longer available as the ACGME has now unified both into a single matching program. Osteopathic physicians (DOs) may participate in either match, filling either M.D. positions (traditionally obtained by physicians with the MD degree or international equivalent including the MBBS or MBChB degree) accredited by the Accreditation Council for Graduate Medical Education (ACGME), or DO positions previously accredited by the American Osteopathic Association (AOA).

Military residencies are filled in a similar manner as the NRMP but at a much earlier date (usually mid-December) to allow for students who did not match to proceed to the civilian system.

In 2000–2004, the matching process was attacked as anti-competitive by resident physicians represented by class-action lawyers. See, e.g., Jung v. Association of American Medical Colleges et al., 300 F.Supp.2d 119 (DDC 2004). Congress reacted by carving out a specific exception in antitrust law for medical residency. See Pension Funding Equity Act of 2004 § 207, Pub. L. No. 108-218, 118 Stat. 596 (2004) (codified at 15 U.S.C. § 37b). The lawsuit was later dismissed under the authority of the new act.

The matching process itself has also been scrutinized as limiting the employment rights of medical residents, namely whereupon acceptance of a match, medical residents pursuant to the matching rules and regulations are required to accept any and all terms and conditions of employment imposed by the health care facility, institution, or hospital.

The USMLE Step 1 or COMLEX Level 1 score is just one of many factors considered by residency programs in selecting applicants. Although it varies from specialty to specialty, Alpha Omega Alpha membership, clinical clerkship grades, letters of recommendation, class rank, research experience, and school of graduation are all considered when selecting future residents.

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. 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. 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.

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."

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. 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.

Criticisms of limiting the work week include disruptions in continuity of care and limiting training gained through involvement in patient care. 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.

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. 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. The new ACGME rules were criticized in the journal Nature and Science of Sleep for failing to fully implement the IOM recommendations.

Research requirement

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

  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. 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. 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. 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. 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.

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.

Residency salary

Resident compensation

Starting from the first year of postgraduate training residents receive compensation. In 2021 the average salary was $64,000. Salaries increased by $1,000 a year in average during past 10 years. Salary strongly depends on the year of training with up to $8,000 increase every next year. Overall, 43% of trainees were satisfied with their compensation.

Low hourly pay

Compared with other healthcare workers, resident hourly compensation is not high. "Given average resident salaries and an 80-hour work week, resident salaries equate to approximately $15 to $20/hour."

Following a successful residency

In Australia and New Zealand, it leads to eligibility for fellowship of the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, or a number of similar bodies.

In Canada, once medical doctors successfully complete their residency program, they become eligible for certification by the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada (CFPC) if the residency program was in family medicine. Many universities now offer "enhanced skills" certifications in collaboration with the CFPC, allowing family physicians to receive training in various areas such as emergency medicine, palliative care, maternal and child health care, and hospital medicine. Additionally, successful graduates of the family medicine residency program can apply to the "Clinical Scholar Program" in order to be involved in family medicine research.

In Mexico, after finishing their residency, physicians obtain the degree of "Specialist", which renders them eligible for certification and fellowship, depending on the field of practice.

In South Africa, successful completion of residency leads to board certification as a specialist with the Health Professions Council and eligibility for fellowship of the Colleges of Medicine of South Africa.

In the United States, it leads to eligibility for board certification and membership/fellowship of several specialty colleges and academies.

International Court of Justice

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