After many years of studying, it’s time for a medical graduate to ask what follows after college. Is it necessary for all students to take on a specialty residency? How does a resident physician become a specialist doctor? What happens after a doctor takes his board exam? And, in particular, how does a specialist physician differ from a primary one? This article addresses the subject of medical staff hierarchy and focuses on how to become a primary care physician, a specialist or a surgeon.

Doctors’ hierarchy in the US

Here are the professional degrees after finishing medical school. Of course, not all are present in every clinic or hospital, but this chain of authority is a standard one.

  • Medical director or hospital dean (usually has a more administrative role, but everybody answers to him or her)
  • Head of department or specialist surgeon (top or senior specialist doctor in his field like orthopedics, cardiology, pediatrics, to name a few)
  • Attending physician or normal specialist (is a specialist doctor with at least three years of residency training for internal medicine, 5 years of residency for general surgery and 7 years of residency experience for neurosurgery)
  • Silent doctors (e.g. anesthesiologists, radiologists and pathologists)
  • Primary care doctor (a third year resident can become a general practitioner or an internist, a family doctor, a pediatrician and an OB/GYN)
  • Fellow (is still a training doctor, although he or she has finished residency he or she is pursuing specialization in a niche like cardiology, endocrinology, gynecologic oncology, to name a few, between 1-3 years)
  • Chief resident (residents are licensed doctors, but they usually practice with supervision until after the third year, then they can also be physician’s assistant)
  • Senior resident (usually third year resident)
  • Junior resident (usually second year resident)
  • Intern (first year residents are licensed doctors at the end of the year)
  • Medical student (internship, they are at the hospital or clinic as part of their studies)

What is the difference between a physician and a doctor?

A lot of people think that the two are synonymous, and they are, but they’re actually different. A physician is a medical doctor, either an M.D., who graduated a classic medical school, or a D.O. if he specialized in osteopathic medicine. So, a physician can be a doctor.

A student which has gotten a PhD in economics is also a doctor. Yet, he doesn’t provide medical care. So, a doctor isn’t always a physician. It all depends on the context.

What do you need to be a physician?


  1. Earn a bachelor’s degree and take the MCAT
  2. Graduated a medical school with an M.D. or a D.O. degree
  3. Complete a residency program and get a license, either USMLE for M.D. or COMLEX-USA for D.O.
  4. Get certified by the American Board of Medical Specialties (ABMS) in one or more of the 24 medical special boards

How to obtain a medical license and board certification?

If you have a medical degree, it doesn’t mean that you are licensed, it means you studied medicine. You can get a medical license after you take the board exam offered by the United States Medical Licensing Examination (USMLE):

  • 1st phase is a test in your second year of medical school that attests your basic knowledge
  • 2nd phase is a test in your fourth year of medical school and has two component – clinical knowledge and clinical skills
  • 3rd step is after the first year of residency and attests if you can put on a diagnosis and offer patients a treatment

A resident, which is a doctor-in-training, can’t practice unsupervised without this license. After the first year of residency, or the internship period, a resident is a licensed doctor. Then, the specialty board certification follows, which is optional.

This is done at the end of the required years of residency for each specialization and needs periodic re-certification. This diploma carries professional value, but doctors can practice without being board certified.

The test depends on each specialization, for example, OB/GYN’s take the American Board of Obstetrics and Gynecology (ABOG) examination. For ABOG you need to pass the qualifying exam which is a written test, you must collect cases reflecting your experience and then you take the certifying exam, which is an oral exam done by a team of experts in the field.

What are some medical specialties?


  1. Allergy & Immunology
  2. Anesthesiology
  3. Dermatology
  4. Diagnostic radiology
  5. Emergency medicine
  6. Family medicine
  7. Internal medicine
  8. Medical genetics
  9. Neurology
  10. Nuclear medicine
  11. Obstetrics and gynecology
  12. Ophthalmology
  13. Pathology
  14. Pediatrics
  15. Physical medicine and rehabilitation
  16. Preventive medicine
  17. Psychiatry
  18. Radiation oncology
  19. Surgery
  20. Urology

Resident physician

Residency takes between three and five years after medical studies. After the first three years, it depends on each specialty, resident doctors can practice on their own family medicine, pediatrics or gynecology. A resident’s salary is somewhere between $50.000 – $65.000 per year.

Resident’s responsibilities depend on each medical institution, but here’s an example. First year residents have to shadow specialists from different domains in rotation, like neurosurgery, neuro intensive care, surgical intensive care, interventional neuroradiology, neuro-ophthalmology and they can’t see patients on their own.

Second year residents follow specialists in areas like tumor, spine, general or trauma, and radiosurgery and they start to focus more on surgical skills. The third year is all about tumor, vascular, spine and pediatric neurosurgery. If they want to specialize in other categories like neurology, general surgery, or cardiology, they have to continue residency and even longer, with a fellowship.

Resident doctors’ training is done in accredited health care units for postgraduate medical education, under the guidance of a program leader with the highest degree of teaching in the respective field. No doctor can be resident in several specialties at the same time, but after completing a residency and gaining a specialty, the doctor may choose to follow a new residency for the second specialty.  

Of course, like with anything, there are some exceptions. For example, there are some programs that let you do a double specialization. Emergency medicine, pediatrics and internal medicine each can be done along anesthesiology.

Primary care doctor

Primary care doctors take the same student path as any doctor. They go through medical residency for at least three years. Then, they take the board accreditation exam, but it’s not mandatory. They stop their specialized studies and take on patient care responsibilities on their own. A primary care doctor, an internist and a pediatrician’s salary varies between $150.000 – $250.000 per year.

Their responsibilities are in a way similar, they are all physicians who offer first care medicine. They assess the patient’s needs first and make recommendations for simple treatments or for further analysis by a specialist doctor.

Primary care doctors or family doctors work in a family practice treating patients of any age for general conditions, like the flu or a rash. They can work in a general practice with similar responsibilities, but here they can also be osteopaths offering holistic treatments.

Another option is to work in internal medicine treating only adults in prevention and management of diseases and chronic conditions. And, similar, they can work only in pediatrics, as the first doctor to call with a minor child emergency, like giving medicine recommendations for vaccinations.

Specialist physician

Residents can obtain the title of specialist physician when they promote the exam at the end of their residence. The exam is an evaluation by superiors looking for medical knowledge, patient care, professionalism, interpersonal and communication skills, systems-based practice and practice-based learning.

Some examples of specialties are internal medicine (3 years/residency) and pediatrics (3 years/residency) as mentioned above. Then come emergency medicine (3-4 years/residency), anesthesiology (4 years/residency), dermatology (4 years/residency), neurology (4 years/residency), obstetrics and gynecology (4 years/residency), pathology (4 years/residency), psychiatry (4 years/residency), radiology (4-5 years/residency), and general surgery (5 years/residency).

Other specialties don’t end in residency, they need 1-3 more years of study and practice, but here residents are called fellows. A specialist physician continues his studies to be able to become a top surgeon in his field. Usually, a surgeon takes care of everything related to the operating room and can work alongside a specialist physician that takes care of the patient before and after surgery.

A specialist physician can continue his studies in a hospital – fellowship, take the board certification exam or start working in his field at a public hospital or a private clinic. A specialist doctor’s salary varies by state, gender or specialization and can be between $200.000 – $650.000 per year.

What are a specialist physician’s responsibilities?


  • Supervising residents, assistants and nurses
  • Offering specialized diagnosis and consultations
  • Prescribe treatments, prepare prescriptions or identify hospitalization need
  • Create patients’ admission forms and define special care measures
  • Check patients and supervise prescribed treatments
  • Update patient records
  • Inform patients about treatments and potential risks
  • Keep informed about effective methods of diagnosis and treatment in their field
  • Take part in hospital’s meetings and conferences
  • Takes responsibility for the quality of medical services (e.g. patience, politeness, respecting privacy)
  • Provide first aid in medical emergencies
  • Respect the rules (e.g. physician’s code of ethics, patient rights, clinic’s internal rules)

What is the difference between a specialist physician and a senior specialist?

Everything is in the name, a senior specialist doctor is a specialist in the field, he or she has more experience. It usually requires at least five years after finishing a residency or fellowship to be a top attending in your field. A top specialist can coordinate a team with more specialist doctors and his supervisor is the medical director.

An experienced physician’s responsibilities are the same as a specialist. But the salary of a top doctor can be higher because of more years in the field, more responsibility (some take on administrative chores at their workplace) and even popularity, over $350.000 per year.