From Mumbai to Manhattan: My Experiences With Medical Residency in Two Countries

Residency Training in India vs. the US: What Makes Them Different

As a medical student in India, the decision was neither easy nor immediate when faced with the choice of pursuing a residency in India vs. abroad. After much thought and discussion with friends, colleagues, and family, I decided to pursue residency training in the United States (US). The primary reason for this was that I particularly liked the USMLE exam study materials, which I thought suited my study style. Additionally, the Indian postgraduate medical entrance examination (NEET PG) was challenging and competitive. At that time, I felt that with the same amount of work that I would be required to do for the NEET PG in India, I might be able to score well on my USMLE exams. I was also attracted by the seemingly better opportunities for research, clinical training, and mentorship offered by the US. After I completed my mandatory internship in India, where I gained valuable clinical experience, I moved to the US to pursue my residency training. My personal experience with medical education in both countries has given me a unique perspective on the similarities and differences between the two systems, particularly with regard to residency training.

Residency Training in India

In India, the structure of residency training varies by specialty and is governed by the Medical Council of India (MCI). The duration of residency training ranges from 3 to 6 years, depending on the specialty, with additional time required for some subspecialties. For example, a general medicine residency lasts for three years, while a surgical residency can last for up to 6 years.

One of the benefits of residency training in India is the emphasis on hands-on clinical experience. Residents are often given significant responsibilities in patient care, such as performing procedures, managing complex cases, and making treatment decisions along with their senior residents. Attendings merely assume a supervisory role, especially in medical or allied specialties. This provides ample opportunity for residents to hone their clinical skills and gain practical experience in a wide range of medical conditions. Additionally, the sheer volume of patients seen in Indian hospitals provides residents with exposure to a diverse range of cases. For example, a resident in training in any government medical college in India will see the whole gamut of cases that would make up 90% of his future case variety, within the first month of the residency itself. This breadth of pathology, combined with the volume and efficiency required to keep up with it, results in a unique and comprehensive training environment. Needless to say, Indian-trained doctors are some of the very best in the world.

However, there are some drawbacks to residency training in India as well. One of the major concerns is the long work hours and the lack of regulations to prevent excessive workload. Residents may be expected to work long hours, frequently at a stretch of 36 hours or sometimes even more, with minimal breaks for food and sleep. This is a recipe for burnout and reduced quality of care. I hear horror stories of my colleagues in India working to the point they fall asleep standing in the wards. Even as an intern, I have witnessed how shockingly demanding the workload is and what the expectations from the residents’ were. For example, residents in India draw labs, write notes, admit patients, place orders, and sometimes even record vitals and administer medications, all without electronic medical records to support them! It is not infrequent that residents will have to physically go to the lab and hand over blood samples or collect reports. Not much ancillary staff support compounds the problem of excessive workload. A close friend of mine quit his internal medicine residency at a prominent institution in India because the workload was too much, and he was worried about harming his patients because of fatigue and impaired decision-making.

Another issue is the lack of resources, both from a patient perspective and also from a facility perspective. This especially results in limited opportunities for research and scholarly activities. Research funding is often scarce, and the emphasis on clinical experience may take priority over research initiatives. Residents in India must complete a research project or “thesis” as a requirement for graduation. However, no time or financial support is provided for accomplishing the same. The residents usually spend their little spare time from their clinical duty on study design, sample collection, data analysis, and report writing. They often end up with impressive research projects, which is a testament to the residents’ tenacity but does not reflect the system’s support.

Residency Training in the US

In the US, residency training is overseen by the Accreditation Council for Graduate Medical Education (ACGME), and the length of training varies depending on the specialty. Most residencies last for 3-7 years, with additional time required for subspecialties. Residency training in the USA is characterized by a structured curriculum that combines classroom instruction with clinical experience.

One of the benefits of residency training in the US is the focus on evidence-based medicine and research. Residents are expected to participate in research activities and scholarly pursuits, with ample opportunities for funding and mentorship. For example, my residency program had 5000 USD available to residents, which they can avail if they have an IRB-approved study that requires funding. My program also reimbursed article publishing fees, offered to reimburse expenses associated with data analysis and biostatistics support, and travel to conferences for presentations. This focus on research provides residents with a deeper understanding of the science behind the clinical practice and prepares them for careers in academic medicine.

Additionally, residency training in the USA strongly emphasizes work-life balance and limits the number of hours that residents can work. This helps to reduce the risk of burnout and ensures that residents have adequate time for rest and personal pursuits. For example, as an internal medicine resident in the US, I am mandated to get five days off in five weeks, an average of one day off per week. My duty hours are capped at 80 per week, and I often work much less than the stipulated cap. I am only on call, admitting patients, every fourth day. I see at most ten patients as first-year resident and 20 patients as senior team leader. I also have caps for the maximum number of admissions. I did not do shifts greater than 24 hours; when I do a 24-hour shift, I get at least 24 hours free afterward.

Additionally, my training had an X+Y system where I worked in the clinic for one week every five weeks. When I am in the clinic, I am not pulled in to do inpatient work, and wise versa. This level of compartmentalization resulted in a higher level of wellness during my training. There is a greater emphasis on teamwork and communication skills, with programs designed to promote a collaborative work environment. I also had lectures on humanities in medicine, how to develop and protect yourself from empathy, how to improve communication in a team, how to break the bad news to a patient, etc.

However, residency training in the US also has its drawbacks. Focusing on classroom instructions and research can sometimes lead to less hands-on clinical experience, particularly in certain specialties. I would assume that if I went back to India after my residency training, I would find it difficult to sync into the demanding work environment where I will have to see many more patients in a short time.

Additionally, there are inherent differences in how medicine is practiced in the US and India. In the US, because of the highly litigious nature of the medical field, there is often a lot of focus on accurate documentation, which I think is not just for accurate patient care but also for the physicians to defend themselves in court in the event of litigation. I noticed that while practicing medicine in the US, we perform ten times as many investigations as compared to India. In India, there is a lot of focus on history, physical examination, and targeted investigations focusing on what would be the most likely diagnosis. This is because, in a resource-limited setting, we need to make our investigations and their cost count. However, in the US, there is a “rule out” culture where if something is even remotely possible in a patient, we like to investigate for it to rule it out. Again, this stems from a defensive medicine mentality, where clinicians rely on solid, immutable evidence, like a positive or negative test result, instead of clinical suspicion based on history and physical examination. This reflects in the way I am trained as well and would make the transition to practice in an Indian setting initially tricky.

Overall, both systems have their strengths and weaknesses, and the optimal choice of the residency training program will depend on the individual’s goals and priorities. For those seeking intensive clinical experience and exposure to a wide range of medical conditions, residency training in India may be a good choice, especially if they wish to practice in India. On the other hand, residency training in the USA may be a better fit for those interested in pursuing academic medicine or serious clinical research.

I haven’t even touched upon the fact that after residency training, attending physicians in the US are compensated at a higher level relative to their counterparts in India, even considering the cost of living and inflation. Additionally, the work hours of an attending physician are better as well, wherein a hospitalist (internal medicine physician who works strictly in an inpatient setting) works only 50% of the days in a year, typically in a seven on, seven off schedule, and still earn much greater than the median per capita income. Hence, there is an inherent benefit of better financial security and quality of life.

Residency training in India and the USA offers unique opportunities and challenges, and it is essential to consider each system’s pros and cons when deciding carefully. As someone who has experienced both systems firsthand, I believe that combining the best practices from each system can help create a more effective and sustainable model of medical education and residency training. If you decide to pursue residency training in the US, via the USMLE examinations, then we have a step-by-step guide that we hope you would find useful as well.