The Real Reason It Takes So Long To Become A Doctor

Before 1910, there weren't really any standards for medical education in the US. Someone could go to school, get a degree, hang a shingle somewhere and call themselves whatever they liked.
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Why does it take so many years to become a surgeon or doctor? originally appeared on Quora: The best answer to any question.

Answer by Patrick Connolly, neurosurgeon, on Quora.

Before 1910, there weren't really any standards for medical education in the US. Someone could go to school, get a degree, hang a shingle somewhere and call themselves whatever they liked. After the Flexner Report, medical education was reformed and hospital based residencies came about, so called because the trainees lived in the hospital. At the same time there was an explosion in scientific discovery and technical advances. Training became longer in order to incorporate that, and specialties formed because no one could keep up with all of the new knowledge in medicine. Specialty boards emerged to oversee practitioner quality and to certify us as qualified in our field. Certification by a board is far beyond the basic competence that licensure establishes, and it is the culmination of training for many physicians. For example, I became board certified in neurosurgery in 2008, 21 years after finishing high school, 17 years after college, 10 years after medical school and 4 years after finishing residency. I have to recertify in three more years. It is a lifelong commitment to continually renew your knowledge. You are never really "finished."

Med school requires a bachelors degree with at least 10 semesters of undergraduate laboratory science and math. The first two years are preclinical courses. During that time there is a parallel introductory course on interviewing patients, then you begin to interact with patients as you learn fundamental physical examination skills. Third and fourth year are clinical clerkships where you begin to put those things together and form ranked lists of diagnoses in order of likelihood. You are heavily supervised and make no treatment decisions. Med school is a general overview of all things medicine. By the end of third year you should know what kind of residency you will apply for.

Clinical training and real responsibility begin after you earn a medical degree, so it is not until residency that you begin to take shape as a clinician. Physicians in their first year out of med school are often called interns or more kindly, PGY-1. They can write orders, do a history and physical exam and come up with a diagnosis, but only with close guidance, and work under a provisional medical license. They may propose treatment options, but make few treatment decisions until PGY-2. I found going from intern to junior resident much more challenging than med student to intern. There is a lot more thinking to do as a junior neurosurgery resident. As interns we were mostly implementers of plans. While we learned basic tissue handling skills as interns, and learned to think and troubleshoot in a surgical way, there was no real operating until PGY-2. Surgery adds another dimension to caring for your patient over and above physical diagnosis and management. It's your hands directly responsible. There is no intermediary, such as a nurse or a therapist. Over seven years of neurosurgery residency the complexity of surgery that you are able to do grows, always with supervision, and all along you cultivate surgical judgement and professional standards. This is a big part of why training takes so long. When do you recommend surgery, when not? How do you prepare the patient, what are the risks, how likely? How do you prepare the OR staff? Does surgery need to happen in the middle of the night? Can it wait until morning? How do you know when the operation is done? What does it look like when you've achieved your surgical objective and it's time to close? How do you get out of trouble? How do you avoid trouble? What will yield a satisfactory result without overexposing the patient to risk? How do you talk to a family, particularly when there is a complication? It takes awhile to develop a sensibility about these things. Even after residency is done, it takes some time to become comfortable making treatment recommendations to your own patients, because you don't have a good predictive model for what's going to happen. Residency is heavily oriented toward being in the hospital and taking care of patients acutely. There is some office, but you don't get to know patients on a year to year time scale.

I am a current and voltage guy, so I did a one year fellowship in movement disorders, such as Parkinsons disease. The objective of this particular type of surgery is to put a 1.2mm wire into an almond sized structure 7cm below the brain surface with a 0.5mm error. This takes some practice. Much more than your own technical capability, you also have to understand how to organize the systems around you so that you can achieve the best outcome for your patients. To do this, you have to have a pretty good idea of how a hospital works, what to ask administrators for and understand their constraints.

I can train a physician assistant, a masters level professional, sewing and basic tissue handling skills in about a year. The extra training of a physician is about understanding basic science, respecting the scientific method, using it to improve your practice, doing a good operation, avoiding and escaping trouble, recognizing when you're actually in trouble, figuring out who you can help with surgery, being the ultimate responsible party for the outcome, and cultivating professional standards and behavior. In some countries medical education is bundled into a six year program out of high school. However, I think that college provides a bit of seasoning that helps a lot when treating patients. Gifted observers of the human condition such as Shakespeare, Hemingway, Rousseau, Confucius and many others unmentioned can help us to understand the personal and social dimensions of illness.

Training in medicine takes so long because it is incremental, adding responsibility very gradually. You want to see as many permutations of a problem as possible so that you have a good chance of working it safely on your own when the time comes. Good judgement comes from experience, and experience comes from bad judgement, so it's important to see and do as much as you can before you go out into the world on your own without anyone looking over your shoulder.

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