So it's generally understood that U.S. doctors tend to make more money (see our other article for more details about U.S. doctor salaries), but what about the actual quality of training? Alongside the desire for better pay, one of the more common answers given for why people want to transition their medical career to the U.S. is the fact that it may provide better quality training.

But what does that actually mean, and is it even true?

What do we mean by 'better quality'?

The crux of the answer to this question rests somewhat on how we define 'better quality'. Naturally, the question of training quality is always going to be somewhat more subjective than something numerical like salaries/length of training. For example, some people may really value the idea that physicians in the UK spend a lot more of their time comparatively drawing lab work, placing catheters and IV lines. To those people, these techniques count as 'skills' and the fact that UK doctors are no doubt far more proficient at doing these means that UK training may be 'better' in this respect.

On the flip side, another opinion might be that these kinds of routine tasks (blood work, catheters, IV lines) are not core tenets of being a physician, and time spent on these each day is time wasted when residents should instead be discussing underlying medical problems/management, the latest guidelines, and having bedside teaching.

Who is 'right' here is an impossible question to answer. In much the same way, there are some fundamental differences between how physician training is carried out in for example the UK as compared to the U.S., which, depending on your perspective, can either make U.S. training 'better' or 'worse'.

Specialism vs Generalism

It really comes down to the fundamental question - do you want to become really good at one thing, or do you value being generally good at a lot of things (and then specialising in one much later in your career). Because it's impossible for us to do an article comparing U.S. training to all other health systems, for the purpose of this article we'll be comparing and contrasting it with the UK's system. So let's describe how these two systems approach training their residents.

In the UK, every medical student when they graduate becomes a 'Foundation Year' doctor. There are 2 foundation years, 'FY-1' and 'FY-2'. During these two years, no matter what specialty you would ultimately like to practice for the rest of your career, you will be rotated through a variety of different medical/surgical specialties in 4 month blocks of time. So, taking theoretical Dr. James as an example, he would rotate through General Surgery, A&E (emergency medicine), Obsterics & Gynecology, Geriatrics, Psychiatry and GP, each for 4 months, through his 2 year 'Foundation Year' training immediately after medical school. In some cases, it's possible to try to get one rotation out of those 2 years in a field you may be more interested in (there's a system of 'ranking' preferred jobs in each geographic location, so you could for example rank all the jobs with an orthopedic surgery rotation in it as your top choices, with no gurantee that you would get one of those but an increased likelihood). Aside from that small amount of personal choice, on the whole, even if you have zero intention of doing something like Psych, OBGYN or Anaesthesia, you may end up spending a year of your life working in those 3 jobs.

Following the conclusion of these Foundation Years 1-2, doctors in the UK then generally narrow down their scope of practice into either 'Core Medical Training' (CMT - the starting point for all careers like general medicine, nephrology, cardiology, oncology etc.), 'Core Surgical Training' (CST - the starting point for all careers in surgical specialties like orthopedic surgery, general surgery, plastic surgery etc.), 'Primary Care' (a 3 year training program to become a GP). They then spend 2-3 years rotating through various medical/surgical specialties depending on which path they chose to follow. This still means that, if Dr. James dreamt of being an orthopedic surgeon, he may still spend 2 years rotating through GI surgery, vascular surgery, ENT surgery etc., still not being able to focus on his true passion. AFTER these CST/CMT years are complete, UK doctors finally begin actual specialist training in their field of choice e.g. ENT, dermatology, orthopedic surgery etc. There are a handful of exceptions to the above, with specialties such as ophthalmology and radiology having direct training pathways following Foundation Year 1-2 completion. However, on the whole, it is fairly typical for UK based doctors to have spent 2-4 years post-graduation rotating through a multitude of medical/surgical specialties, with very minimal choice, and perhaps without having spent any time training in the field they are truly passionate about.

In contrast, the U.S. system is such that people directly apply for specialised resideny training immediately out of medical school. For a few specialties like dermatology, ophthalmology, radiology, rad onc etc. there is a requirement to complete a 'prelim' year of general medicine/surgery, but this is just 1 year. It is unheard of in the U.S. training system for a graduate to be more than 1 year out of medical school without then being immersed in their specialty of choice.

Comparing like for like, a UK doctor passionate about dermatology 4 years after graduation may very well have seen 0 dermatology specific patients. In contrast, a U.S. doctor in the same position would have finished 3 years of dedicated dermatology training, having seen >1000 patients, and having become American Board Certified to become a dermatology Attending. However, the UK doctor would certainly be more capable when it came to reading radiology, understanding outpatient psychiatry, perhaps having delivered babies or repaired broken bones.

So you have to ask yourself, do you value being a 'jack of all trades' for a few years before later trying to become a master of one? Or would you rather just try to become a master of one earlier on in your career and then keep that head start?

Structured Teaching in Residency

While in the above section we spoke a lot about how so much of deciding what is 'better training' is subjective, there are certain fundamental objective differences when it comes to residency training in the U.S. vs the UK training system that is hard to argue against. In the vast majority of U.S. programs, some type of structured didactics/teaching schedule is a fundamental part of your training years. In most programs, it is typical to have a 'Morning Report'/ case based learning that is around 1 hour daily, in addition to a 'Noon Conference' lecture that is also around  1 hour each day. Alongside this, there is typically a 'Grand Rounds' lecture that is also 1 hour each week. Typically this is 'protected' teaching time in that the work days are organized so that in anything but emergency situations, residents really are attending these teaching sessions and not carrying out clinical/ward duties. This means that U.S. residents will have on average 5-10 hours of structured, protected teaching time each week.

In the UK, there is not as clearly an established culture of having a structured teaching curriculum for trainee doctors throughout their training. There are still Grand Rounds once a week, but the idea of there being 2 hours of protected/structured teaching in a regular trainee doctor's daily schedule in the UK would be considered laughable. Simply put, there are too many tasks and the staff are generally stretched too thin to be able to set aside that volume of time in a typical day for trainee doctors to be taught. Obviously physicians in the UK do learn, and actually managing patients/conditions is a fantastic way of learning. Likewise, adhoc bedside teaching or being lucky enough to have a supervising Consultant on your team that is passionate about teaching means you may have a lot of this type of training built into your day. However, this really is more scattergun/ luck of the draw in the UK, rather than being something organised/delivered by your training program in the U.S.

By this metric at least, it is fairly clear that the training is better in the U.S.

Investment in Resident Training

This is somewhat linked to the above point, and almost helps to explain it in a way. The recruitment process by which residents out of medical school are placed in different hospitals is starkly different between the U.S. and the UK. In the UK, medical students up and down the country in their final year are given an overall score out of 100. 50 of these points are assigned based on a medical student's performance in their internal exams (their 'decile' ranking), whether they have any extra degrees (e.g. BSc or PhD), their publications etc. The other 50 points are made up by their performance in a 'Situational Judgement Test' exam (the 'SJT'). This exam, by most accounts, has next to no correlation with other exam performance or ultimately physician performance in any known domain. Many, including my professors at Imperial College London, suggested it was designed to play a 'randomising' role, to make sure there wasn't a high concentration of the most competent doctors in traditionally more desirable cities and subpar doctors in the rest of the country. Ultimately, all final year medical students are placed into these centralised, anonymised, numerical system, and distributed throughout the country to hospitals who have no idea who will be hiring them. These doctors then rotate through various departments across a 2 year span of time, after which they usually leave to a different hospital.

Even after this, during a lot of CMT/CST (core medical training/ core surgical training) jobs, physicians rotate around a lot of different sites. It is only really during 'specialist registrar' training that the recruitment process becomes more 'hands on' with in person interviews etc. and then the physician tends to stay in one department for a few years.

Because of this often de-personalised, anonymised and temporary recruitment process, there tends to be very little in the way of genuine investment from hospital/ senior management into their physicians in the UK until the later registrar years. This is understandable. They didn't specifically pick these FY1s/2s, they know that they will likely be gone within 4 months never to be seen again - so what do they have to gain by taking the time to personally invest in/ train these doctors?

In the U.S. in contrast, the application process for residency is extremely personalised. Programs take the time to select a set of applicants to call for in person interviews. They often have these applicants fly in the night before for a dinner/social, then they spend interview day selling the program to them and explaining why this would be a fantastic place for the doctor to train. It's not uncommon for interview commitees on the interview days to know each applicant in meticulous detail - their research, their biographical information, their hobbies. Chairmen/ Program Directors go out of their ways to show applicants that they know them by name.

Ultimately, when a resident 'Matches' into a program, their names/photos are plastered onto emails throughout the department and physically stuck up on notice boards everywhere to introduce them to the current staff. The Program Directors/ Chairmen will then often be an intimate part in resident training/ teaching schedules, sitting in on their sessions each morning and providing their own pearls of clinical wisdom, meeting their residents multiple times each year to ask them about how they're settling in, how their research is going, what their future career plans are. Programs in the U.S. specifically and personally invest in each of their residents because they know that these are their residents - the ones they picked for their rank list, the ones that will be with them for 3 years, and the ones which they may end up hiring at the end of their training as Attendings.

One occasion in which this personal investment can be seen clearly is the legnths to which they go to have guest speakers come and lecture the residents on key topics. In our dermatology program for example, we have had world leaders on immunoblistering diseases, cutaneous T cell lymphoma, Mohs micrographic surgery and allergic contact dermatitis, as well as past and current American Academy of Dermatology Presidents, all flown in from across the U.S. for the sole purpose of lecturing us 26 residents during some of our weekly teaching sessions. They go for dinner with the residents the night before their lectures, then they deliver a set talk, followed by an open Q&A with the residents the following morning. Having these legendary figures physically flown in for discussions with us has provided me with some of the most unique and valuable learning experiences of my entire career. This would only happen in the U.S., where programs have such a vested interest in fostering their hand-picked resident's growth.

In that sense, I would also say that training in the U.S. has the benefit of a personal touch/investment in physician development that often only occurs much later in the UK.

Conclusion

So, to summarise;

• U.S. physicians are given more focused training in their desired specialty area and will have seen more patients in that field than UK physicians of a similar age
• UK physicians are given a more broad range of medical experiences in their early training years
• U.S. programs provide more structured didactics within a regular daily/weekly schedule than UK programs
• U.S. programs invest more in their resident education/development than UK programs because they hand select each of their trainees, whereas in the UK for the first 2-4 years of training, the physicians are simply assigned to hospitals and rotate between many different sites, meaning less personal investment develops between the hospitals and the physicians they have.

How can I find out more about moving my career to the U.S.?

If, based on this article or just generally based on interest you've had from before, you want to find out more about how a doctor/medical student from India, the UK,  Pakistan, South America etc. can actually go about moving their career to the U.S., we can help. We've produced the most thorough, A-Z, step-by-step guide on the process of international medical doctors moving to the U.S. that we've seen anywhere. Check out our 'How To Make It In America' course for more details, including an in-depth discussion of all of the other most common 'pros and cons' of moving your career to the U.S. We also provide insider tips and advice on how to ace the USMLE exams (all 4 of them), to secure electives and make the most of those, how to get incredibe letters of recommendation, the entire 'Match' application process, as well as visas and immigration advice!

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