<P> In the nineteenth century, there were over four hundred medical schools in the United States . By 1910, the number was reduced to one hundred and forty - eight medical schools and by 1930 the number totaled only seventy - six . Many early medical schools were criticized for not sufficiently preparing their students for medical professions, leading to the creation of the American Medical Association in 1847 for the purpose of self - regulation of the profession . Abraham Flexner (who in 1910 released the Flexner report with the Carnegie Foundation), the Rockefeller Foundation, and the AMA are credited with laying the groundwork for what is now known as the modern medical curriculum . The restriction of the supply of physicians that resulted from the Flexner Report has been criticized by classical economists as one of the principal factors in the increased prices relative to quality observed in medicine over the past 100 years . </P> <P> The standard U.S. medical school curriculum is four years long . Traditionally, the first two years are composed mainly of classroom basic science education, while the final two years primarily include rotations in clinical settings where students learn patient care firsthand . Today, clinical education is spread across all four years with the final year containing the most clinical rotation time . The Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS) has published mandatory rules, obliging on all inpatient and outpatient teaching settings, laying down the guidelines for what medical students in the United States may do, if they have not completed a clerkship or sub-internship . These rules apply to when they are in the clinical setting in school, not when they are, for example, helping staff events or in other non-formal educational settings, even if they are helping provide certain clinical services along with nurses and the supervising physicians - for example, certain basic screening procedures . In the formal clinical setting in school, they can only assist with certain patient evaluation and management tasks, after the vital signs, chief complaint and the history of present illness have been discerned, but prior to the physical examination: reviewing the patient's signs and symptoms in each body system, and then reviewing the patient's personal medical, genetic, family, educational / occupational, and psychosocial history . The student's supervising physician (or another physician with supervisory privileges if the original doctor is no longer available, for some reason) must be in the room during the student's work, and must conduct this same assessment of the patient before performing the actual physical examination, and after finishing and conferring with the student, will review his or her notes and opinion, editing or correcting them if necessary, and will also have his or her own professional notes; both must then sign and date and I.D. the student's notes and the medical record . They may observe, but not perform, physical examinations, surgeries, endoscopic or laparoscopic procedures, radiological or nuclear medicine procedures, oncology sessions, and obstetrics . The patient must give consent for their presence and participation in his or her care, even at a teaching facility . Depending on the time they have completed in school, their familiarity with the area of medicine and the procedure, and the presence of their supervisor, and any others needed, in the room or nearby, they may be allowed to conduct certain very minor tests associated with the physical examination, such as simple venipuncture blood draws, and electrocardiograms and electroencephalograms, for learning and experience purposes, especially when there is no intern or resident available . </P> <P> Upon successful completion of medical school, students are granted the title of Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.). Residency training, which is a supervised training period of three to seven years (usually incorporating the 1st year internship) typically completed for specific areas of specialty . Physicians who sub-specialize or who desire more supervised experience may complete a fellowship, which is an additional one to four years of supervised training in their area of expertise . </P> <P> Unlike those in many other countries, US medical students typically finance their education with personal debt . In 1992, the average debt of a medical doctor after residency was $25,000 . For the class of 2009, the average debt of a medical student is $157,990 and 25.1% of students had debt in excess of $200,000 (prior to residency). For the past decade the cost of attendance has increased 5 - 6% each year (roughly 1.6 to 2.1 times inflation). </P>

When does a medical student become a doctor