jay71483
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Hello everyone,

I have been trying to correlate and correspond the American and British Postgraduate Medical Training Structures. And that is giving me a real headache.

Pre-residency education is straightforward in both the nations, just that in the US you have to compulsorily do a BS before you could study medicine. But the main problem occurs in comparing postgraduate training (or at least that occurs to me).

I am going to ask specific, precise yet diverse questions to get my confusion solved so I expect people from diverse medical backgrounds (not just one specialty) will be collectively able to answer this. Here goes the diverse question list:

(1) In the US, you can become an abdominal transplant surgeon by doing a residency in General Surgery (5 years) followed by a fellowship in abdominal transplant surgery (2 years). How exactly do you become the total equivalent of that in the UK?

(2) In the US, you can become a cardiothoracic transplant surgeon by doing a General Surgery residency (5 years) followed by cardiothoracic surgery fellowship (2-3 years) followed by a cardiothoracic transplant surgery fellowship (2 years). How do you become the total equivalent of that in the UK?

(3) In the US you become an Ophthalmologist by undertaking 1 transitional year (internship) followed by 3 years of Ophthalmology training. But UK training is 7 years long. Too long I guess? Do UK Ophthalmologists subspecialise in their chosen area during their training? Same with OBGYN (US 4 yrs, UK 7 yrs) and Neurology (US 4 yrs; UK 7 yrs)

(4) Since surgical specialty training is 8 years long in the UK, does this mean that it incorporates within it subspecialty training? To take an example, do ENT or say Urology specialist trainees choose in the middle of their training in which subspecialist area they will subspecialise, unlike "uncoupled" and "separate" US fellowships that are distinct from residencies?

Thanks!
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artful_lounger
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https://www.gmc-uk.org/education/sta...cula/curricula

Before entering specialty training and after graduating from medical school, all UK medical trainees complete the two year foundation programme. Importantly, medical graduates are not licensed to practice medicine in the UK until after the first year of this programme (FY1). During FY1 and FY2 you will rotate between different specialties to get some broader familiarity with them, and I believe it's typical to complete some professional exams at this stage (MRCP/MRCS)?

After the foundation programme you begin specialty or GP training - for specialty training this is rendered ST1, ST2, etc for years 1, 2 and so on, respectively. Surgical training in all specialties except neurosurgery and cardiothoracic surgery is based on completing the two year core surgical training (CST) after the foundation programme, comprising ST1 and ST2 of specialty training. Neurosurgery is only available via run-through training beginning in ST1 and does not follow the CST curriculum. CT surgery is available in some areas as run through training beginning in ST1, but otherwise is entered at ST3 after CST. I thought trauma and orthopaedic surgery was also run-through but it seems not...

Standalone fellowship training doesn't really exist in the same way in the UK as I understand, and usually subspecialty training occurs towards the end of specialty training before earning the certificate of completion of training (CCT). I think some specialties require you to develop a subspecialty to earn the CCT? Things like speciifcally becoming a transplant subspecialist would normally take place at this later stage (e.g. in ST7/8 I believe).

UK medical training as a graduate takes longer than in the US in part because of the foundation programme, which takes two years, and in part because generally I believe UK medics are trained in a broader range of disciplines than their US counterparts early in their career, presumably to better meet the needs of the NHS. Bear in mind that the entire healthcare system/sector is fundamentally different in the US compared to the UK so inevitably training is going to be arranged differently.


ecolier,or nexttime might be able to advise more and/or correct any of the above which is incorrect?
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jay71483
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(Original post by artful_lounger)
https://www.gmc-uk.org/education/sta...cula/curricula

Before entering specialty training and after graduating from medical school, all UK medical trainees complete the two year foundation programme. Importantly, medical graduates are not licensed to practice medicine in the UK until after the first year of this programme (FY1). During FY1 and FY2 you will rotate between different specialties to get some broader familiarity with them, and I believe it's typical to complete some professional exams at this stage (MRCP/MRCS)?

After the foundation programme you begin specialty or GP training - for specialty training this is rendered ST1, ST2, etc for years 1, 2 and so on, respectively. Surgical training in all specialties except neurosurgery and cardiothoracic surgery is based on completing the two year core surgical training (CST) after the foundation programme, comprising ST1 and ST2 of specialty training. Neurosurgery is only available via run-through training beginning in ST1 and does not follow the CST curriculum. CT surgery is available in some areas as run through training beginning in ST1, but otherwise is entered at ST3 after CST. I thought trauma and orthopaedic surgery was also run-through but it seems not...

Standalone fellowship training doesn't really exist in the same way in the UK as I understand, and usually subspecialty training occurs towards the end of specialty training before earning the certificate of completion of training (CCT). I think some specialties require you to develop a subspecialty to earn the CCT? Things like speciifcally becoming a transplant subspecialist would normally take place at this later stage (e.g. in ST7/8 I believe).

UK medical training as a graduate takes longer than in the US in part because of the foundation programme, which takes two years, and in part because generally I believe UK medics are trained in a broader range of disciplines than their US counterparts early in their career, presumably to better meet the needs of the NHS. Bear in mind that the entire healthcare system/sector is fundamentally different in the US compared to the UK so inevitably training is going to be arranged differently.


ecolier,or nexttime might be able to advise more and/or correct any of the above which is incorrect?
Dear artful_lounger,

Thank you for your answer!

Let's see what ecolier and nexttime might want to say on this.

Kind regards,

Jay
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nexttime
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(Original post by jay71483)
Hello everyone,

I have been trying to correlate and correspond the American and British Postgraduate Medical Training Structures. And that is giving me a real headache.

Pre-residency education is straightforward in both the nations, just that in the US you have to compulsorily do a BS before you could study medicine. But the main problem occurs in comparing postgraduate training (or at least that occurs to me).

I am going to ask specific, precise yet diverse questions to get my confusion solved so I expect people from diverse medical backgrounds (not just one specialty) will be collectively able to answer this. Here goes the diverse question list:

(1) In the US, you can become an abdominal transplant surgeon by doing a residency in General Surgery (5 years) followed by a fellowship in abdominal transplant surgery (2 years). How exactly do you become the total equivalent of that in the UK?

(2) In the US, you can become a cardiothoracic transplant surgeon by doing a General Surgery residency (5 years) followed by cardiothoracic surgery fellowship (2-3 years) followed by a cardiothoracic transplant surgery fellowship (2 years). How do you become the total equivalent of that in the UK?
I tried to answer those two in your previous thread. Transplant fellowships do exist and we talked about how trainees can try to seek specific experience as part of their registrar training. However, I am not 100% sure about that specific job.

(3) In the US you become an Ophthalmologist by undertaking 1 transitional year (internship) followed by 3 years of Ophthalmology training. But UK training is 7 years long. Too long I guess? Do UK Ophthalmologists subspecialise in their chosen area during their training? Same with OBGYN (US 4 yrs, UK 7 yrs) and Neurology (US 4 yrs; UK 7 yrs)

(4) Since surgical specialty training is 8 years long in the UK, does this mean that it incorporates within it subspecialty training? To take an example, do ENT or say Urology specialist trainees choose in the middle of their training in which subspecialist area they will subspecialise, unlike "uncoupled" and "separate" US fellowships that are distinct from residencies?
Its for a few reasons 1) Breadth of training is greater in the UK - if you want to be a neurologist you don't even start doing neurology until 5 years out of med school (and training is 9 years by the way - also 9 for OBGYN. You're forgetting the two FY years). 2) intensity of training - US doctors work longer hours than UK 3) possibly degree of service provision in the UK versus actual training. You more... learn on the job, in the UK, rather than being taught. But I get the impression the US isn't so different.
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jay71483
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(Original post by nexttime)
I tried to answer those two in your previous thread. Transplant fellowships do exist and we talked about how trainees can try to seek specific experience as part of their registrar training. However, I am not 100% sure about that specific job.



Its for a few reasons 1) Breadth of training is greater in the UK - if you want to be a neurologist you don't even start doing neurology until 5 years out of med school (and training is 9 years by the way - also 9 for OBGYN. You're forgetting the two FY years). 2) intensity of training - US doctors work longer hours than UK 3) possibly degree of service provision in the UK versus actual training. You more... learn on the job, in the UK, rather than being taught. But I get the impression the US isn't so different.
Thank you so much nexttime for responding to this thread as well!

You mentioned that one of the reasons might be the breadth of training, citing that you don't even get into hardcore neurology until at least 5 years after graduation from medical school. Thanks for mentioning the 2 FY years. BUT, why isn't that the case with other specialties? Like Rheumatology? In the US, you do internal medicine (3 yrs) residency and then 2-3 year Rheumatology fellowship. Total around 6 years. In the UK it is 7 years (let us exclude the 2 foundation years as they are merely internship and post-internship experiences rather than focused specialty training as is in the first year of US residency). Why no breadth of training here? Same in Cardiology. US: 3 internal med. + 3 cardio. = 6; UK = 7 yrs (2yr core med. + 5 yr cardio or now 3 yr. internal med training + 4 yr. cardio.) Not much of a difference even if we do consider other factors like almost half working hours, learning on the job, NHS staffing needs, service provision??? You see what I am asking? Probably the answer is it really depends on the specialty and there is no generalization that THIS is UK training structure and THAT is the American one??

Thanks once again. ecolier might want to add if they know anything new.

Best,

Jay
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ecolier
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(Original post by jay71483)
...Thanks once again. ecolier might want to add if they know anything new.
I don't really have anything to add.

You mentioned that one of the reasons might be the breadth of training, citing that you don't even get into hardcore neurology until at least 5 years after graduation from medical school. Thanks for mentioning the 2 FY years. BUT, why isn't that the case with other specialties? Like Rheumatology?
It is the case with Rheumatology though - it's 2 years foundation year, 3 years internal medicine training before you can train in Rheum (like all other internal medicine specialty). Read https://www.st3recruitment.org.uk/specialties/overview for a list of all internal medical specialties.

In the US, you do internal medicine (3 yrs) residency and then 2-3 year Rheumatology fellowship. Total around 6 years. In the UK it is 7 years (let us exclude the 2 foundation years as they are merely internship and post-internship experiences rather than focused specialty training as is in the first year of US residency).
It's 2 years FY, 3 years IMT and then 4-5 years of specialty training here - so 9-10 years after medical school with no breaks in training. (For medical specialties)

For other specialties the times are different - surgery is still 2 years CST; so 2 years FY, 2 years CST and then 5-6 years of specialty training; GP is the shortest: 2 years FY and then 3 years GPST.

Why no breadth of training here? Same in Cardiology. US: 3 internal med. + 3 cardio. = 6; UK = 7 yrs (2yr core med. + 5 yr cardio or now 3 yr. internal med training + 4 yr. cardio.)
There is, compared to most of Europe. Over there they specialise towards the end of medical school, and the consultants literally only learn about their specialty from graduation. At least in the UK the trainees are sort of forced to do some training in internal medicine whatever specialty they end up doing, and have to pass the MRCP exam. Same for surgeons.

Not much of a difference even if we do consider other factors like almost half working hours, learning on the job, NHS staffing needs, service provision??? You see what I am asking? Probably the answer is it really depends on the specialty and there is no generalization that THIS is UK training structure and THAT is the American one??...
I have no experience with the American system, so can't really comment. I do know that their trainees work harder (pre-rounds anyone? Here we're lucky if the trainees are on time at 9am!).
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jay71483
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(Original post by ecolier)
There is, compared to most of Europe. Over there they specialise towards the end of medical school, and the consultants literally only learn about their specialty from graduation. At least in the UK the trainees are sort of forced to do some training in internal medicine whatever specialty they end up doing, and have to pass the MRCP exam. Same for surgeons.
@ecolier In the US too they learn the full aspects of internal medicine before they can proceed to subspecialties like Rheumatology or Cardiology. That is they have to be board certified in internal medicine, which is, definitely more rigorous compared to the MRCP.

The question is that if all surgical specialties, other specialties like OBGYN, Emergency Medicine etc...have very long training programs because of short working hours and service provision/NHS needs, which is in itself the explanation to why the same training is considerably longer compared to the US, why do other specialties like cardiology have almost the same length of training?
US: 3 int. med. + 3 cardio.; UK: 3 IMT + 4 cardio. ? It is necessary here to recognize that foundation training years do NOT contribute in this counting as they are extremely broad base training having really no significant contribution to specialty training. We are talking about specialty training. FY 1 and 2 are merely internship and post-internship "experiences" of "various unrelated specialties". While in the US, they immediately start rigorous and focused specialty training right after graduation. So do not count Foundation years in the counting for specialty training length.

So why exactly is the training time for cardiology almost the same in the UK and US though there are huge differing factors like shorter working hours (less intensive than US of course), more service provision than learning on the job etc. while these factors do reflect longer training duration for other specialties like surgical ones (ENT:- US = 5; UK = 8 {again, remember FY contributes negligibly to specialty training/residency}, Ophthalmology:- US = 4; UK = 7; General Surgery:- US = 5; UK = 8, Urology:- US = 5; UK = 8, Plastic surgery:- US = 6; UK = 8....)?

Thanks ecolier for your participation.
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artful_lounger
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(Original post by jay71483)
@ecolier In the US too they learn the full aspects of internal medicine before they can proceed to subspecialties like Rheumatology or Cardiology. That is they have to be board certified in internal medicine, which is, definitely more rigorous compared to the MRCP.

The question is that if all surgical specialties, other specialties like OBGYN, Emergency Medicine etc...have very long training programs because of short working hours and service provision/NHS needs, which is in itself the explanation to why the same training is considerably longer compared to the US, why do other specialties like cardiology have almost the same length of training? US: 3 int. med. + 3 cardio.; UK: 3 IMT + 4 cardio. ? It is necessary here to recognize that foundation training years do NOT contribute in this counting as they are extremely broad base training having really no significant contribution to specialty training. We are talking about specialty training. FY 1 and 2 are merely internship and post-internship "experiences" of "various unrelated specialties". While in the US, they immediately start rigorous and focused specialty training right after graduation. So do not count Foundation years in the counting for specialty training length.

So why exactly is the training time for cardiology almost the same in the UK and US though there are huge differing factors like shorter working hours (less intensive than US of course), more service provision than learning on the job etc. while these factors do reflect longer training duration for other specialties like surgical ones (ENT:- US = 5; UK = 8 {again, remember FY contributes negligibly to specialty training/residency}, Ophthalmology:- US = 4; UK = 7; General Surgery:- US = 5; UK = 8, Urology:- US = 5; UK = 8, Plastic surgery:- US = 6; UK = 8....)?

Thanks ecolier for your participation.
In the last two years of training UK cardiology trainees undertake advanced specialist modules - this is probably similar to a 1 year fellowship in the US over that two year period (although may be more or less broad than a focused fellowship). Combined with the working hours directive etc, it's probably broadly comparable.

Is there a reason you want an exact correspondence between US and UK medical training? As I said they're fundamentally different healthcare systems, and while the clinical skills may be similar the way in which they're taught need not be. Also you can (or sensibly only would) do one of the two schemes, which is usually dependent one which country you get your medical degree in.

As an IMG applying to US residencies you would have a negligible chance of getting into a competitive specialty like any surgical specialty, radiology, urology, and even probably IM in many places (and almost certainly more competitive IM specialties later like cardiology). Usually IMGs are somewhat limited to less competitive specialties like family medicine or psychiatry in the US. Also regardless of which area you specialise in or if you're successful, if you did do a residency in the US you would need to contend with e.g. 48/72 hour shifts, 80+ hour weeks as standard, etc. Your quality of life during your postgraduate training would be very low, even before considering QoL generally being lower in most areas of the US due to crumbling infrastructure, food deserts, long commutes, etc.
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jay71483
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(Original post by artful_lounger)
In the last two years of training UK cardiology trainees undertake advanced specialist modules - this is probably similar to a 1 year fellowship in the US over that two year period (although may be more or less broad than a focused fellowship). Combined with the working hours directive etc, it's probably broadly comparable.
I am wondering this so deeply how is it possible that trainees working 48 hours (around) per week versus those working 80 hours end up finishing internal medicine, cardiology, and advanced specialist modules (fellowship training after cardiology in the US) in the same time? (For example, an interventional cardiologist's timeline would be:- US: 3+3+1; UK: 3+4 {the last 4 years here includes the advanced specialist modules which includes interventional cardiology})

I understand that as an IMG there is truly negligible chance for competitive specialties in the US but so is for UK as well except that the UK does not discriminate candidates based on where they graduated from or who they like to take in the program. But the UK has the RLMT which the US doesn't, and RLMT prevents me from applying to competitive specialties like surgical ones in the first round, while it never reaches the second round! So practically it is all the same where are more chances of you getting accepted as an IMG, the US or the UK, no matter what specialty, competitive or not. As an IMG with so many hurdles in the path, the only thing that really matters is my ability and competitiveness. When I checked about the two systems, I was completely confused, but honestly, I am comfortable with understanding the American one because that is how it is in my home country.

Thanks.
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artful_lounger
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(Original post by jay71483)
I am wondering this so deeply how is it possible that trainees working 48 hours (around) per week versus those working 80 hours end up finishing internal medicine, cardiology, and advanced specialist modules (fellowship training after cardiology in the US) in the same time? (For example, an interventional cardiologist's timeline would be:- US: 3+3+1; UK: 3+4 {the last 4 years here includes the advanced specialist modules which includes interventional cardiology})

I understand that as an IMG there is truly negligible chance for competitive specialties in the US but so is for UK as well except that the UK does not discriminate candidates based on where they graduated from or who they like to take in the program. But the UK has the RLMT which the US doesn't, and RLMT prevents me from applying to competitive specialties like surgical ones in the first round, while it never reaches the second round! So practically it is all the same where are more chances of you getting accepted as an IMG, the US or the UK, no matter what specialty, competitive or not. As an IMG with so many hurdles in the path, the only thing that really matters is my ability and competitiveness. When I checked about the two systems, I was completely confused, but honestly, I am comfortable with understanding the American one because that is how it is in my home country.

Thanks.
The US has a similar law to the RLMT where companies can only sponsor visas if they can demonstrate there are no qualified US residents/citizens that can do the job. This is part of why it's hard for IMGs to get into competitive specialties in the US - you need to be better than every US person applying, as well as better than most of the international applicants on top of that!
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jay71483
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(Original post by artful_lounger)
The US has a similar law to the RLMT where companies can only sponsor visas if they can demonstrate there are no qualified US residents/citizens that can do the job. This is part of why it's hard for IMGs to get into competitive specialties in the US - you need to be better than every US person applying, as well as better than most of the international applicants on top of that!
In the US they choose the applicants they want in their programs, so they obviously will like to prefer US graduates over IMGs, so you are right. I am wondering how can they demonstrate that no suitable US citizen is there for the residency job when actually there are, and its just that they want to choose the IMG as he/she is better than others though in real sense all other applicants are going to be great doctors?
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jay71483
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(Original post by nexttime)
I tried to answer those two in your previous thread. Transplant fellowships do exist and we talked about how trainees can try to seek specific experience as part of their registrar training. However, I am not 100% sure about that specific job.
nexttime By the way, the link you gave me previously about the Cardiothoracic Transplant surgery fellowship mentions that the eligibility for the fellowship is completion of FRCS (CT) and achievement of competences upto the ST6 level (the program continues upto ST8). This means that interested people can apply to this program after they are eligible and train in the sub specialty. (1) But after the sub specialty training in transplantation, do they have to return to where they left, that is, they left from ST6 so they return at ST7 and complete the remaining 2 years in service and regular cardiothoracic surgery training (ST7 and ST8)? {I am really not familiar with the UK system, please help me solve this mystery:ms:} (2) Or is the training deemed to be completed (and CCT awarded) right after the subspecialty fellowship? (3) In this way, doctors "use" their final years of specialty training to subspecialise (US fellowships) if I am not wrong. But what about those who don't wish to subspecialise but simply practice their core specialty, here cardiothoracic surgery? Are they forced to work for the remaining ST7 and ST8 even if they are very competent in all aspects of CT surgery (as they would've given their FRCS and completed ST6, which itself is the eligibility requirement for the Transplantation fellowship)?

Knowing information on this would solve many of my confusions.

artful_lounger ecolier have any idea on this?

Thank you
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ecolier
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(Original post by jay71483)
...artful_lounger ecolier have any idea on this?

Thank you
I really have no idea why this is the case. I am (dare I say it) very familiar with how the UK specialty training system works, but have not a single clue about how the US system works beyond the names of the grades (intern, resident, attending etc.) - I don't know how long it takes over there, nor how competitive things are. To be perfectly honest, I have no desire whatsoever to work in the US so I don't really need to know!
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