Medical training is long. Across the globe, students enter the medical school for an initial generic training. When medical students complete this initial 4-5 years of training, they become doctors. However, doctors are required to obtain more training. This additional training is in form of internship, and specialty specific residency. The residency is a staged training, and in India lasts from three to six years. First three years are of Junior residency, and next three years of a senior residency. In some systems, senior most resident is the “chief” or a “chief resident”. It is indeed intriguing to know, who started this system of staged training, which is now an inherent part of medical teaching.
William Osler it was
William Osler, obtained his initial medical education from McGill University in Montreal, Canada in 1872. For next two years, he trained under Rudolf Virchow in Germany, and in 1874 he returned to McGill as a faculty. Ten years later in 1884 he moved to US to became a chair of medicine at Pennsylvania University in Philadelphia. He was already a physician of repute when in 1889, he along with other chosen few colleagues established the newly opened John Hopkins Medical School in Baltimore USA.
\It is evident from Osler’s journey that there was no residency system in place. Training was unstructured, and young doctors trained under senior ones, before they chose an independent working. Europe was a place to be, and those who had received their training in Europe, were sought after in the US.
John Hopkins: A new medical school in 1889
John Hopkins died in 1873, and had made a fortune in liquor and railroad construction business. He left a 7 million USD legacy, to set up a university and a medical college. While hospital opened in 1889, it started medical training in 1893.
John Hopkins and Beginnings of a Residency system.
William Osler is credited with establishing a system of medical residency. This system took up from Hopkins, and then was adopted across North America and then Europe. The structure was adopted from Germany, which in those times had a better system, as compared to others. The system was termed “residency” as it was a mandate that doctors “sleep-in” hospitals. After a few years came a concept of residence for residents in close vicinity of the hospital.
As designed by Osler, Residency system was a pyramid. First year was “internship” and residents could leave after this, if they did not desire more training. Those who chose to stay, moved from one tier to another. The senior residents were fewer in number, and the one who stayed the longest was “chief resident”. At this time, duration was not finite and the system was about seven years long. A resident who gained enough competency was certified to become a specialist. This was a full-time patient centric learning system. He also established a system, whereby all residents will take a round in the morning, and discuss their patients.
Soon after Osler established a medical residency program, his colleagues started with similar systems. William Halsted started with a Surgical residency, followed by residency in Gynecology (by Kelly) and in Pathology (by Welsh). The structure of these residency programs is described in an interesting paper (See here). Despite, issues with the structure (that got modified in years to come), specialist medical training became a norm.
Evolution of the residency system
In Britain, first year of residency (which was internship in US), was called “houseman-ship”. Later this one year, became a necessary requirement for a medical license. Today medical education ends at four and a half years, and a provisional registration follows. Only after another one year of “internship” is a final license to practice medicine is obtained. This change was done in Britain in 1952 and gradually this “one -year internship” has become more structured.
The “Residency” is today divided in a three year “Junior Residency” that is linked to award of a postgraduate degree (MD/MS). Following these three years, Junior residents enter “Senior Residency”. This period now has a limit of another three years, and depending on the discipline either counts as an experience or leads to award of a super-specialization qualification (DM/Mch). Long training years to become a medical specialist (almost twelve years in total) are a norm across the world. This rigor and duration, is unlike any other profession. This is both a matter of pride for the medical profession, as well as a debate within the community.
William Osler’s legacy
Medical Residency program at John Hopkins is called “Osler residency program“. This program has Aequanimitas as its motto. This word is based on Osler’s essay on quality fo a good physician. The term means “imperturbability” or “calmness amid storm, clearness of judgment in moments of grave peril.” These qualities of a good physician is what is inculcated in long training programs. Many medical signs and syndromes are named after Osler. Greatest of these however is the structure, we almost follow till date.