Training to become a surgeon (as for other specialties) is accomplished in the following manner. As stated earlier, future specialists are required to pass a special competitive entrance examination called the Internat in their sixth year of studies. When this examination is passed, the medical student has the title of Interne des Hôpitaux, the equivalent of "resident" in the United States. At present, the examination is organized in 2 geographically distinct areas (North and South). Each student can take this special examination in each geographical area twice. Of 5000 students who take this examination each year, about 2000 are appointed resident. According to his or her rank in the entrance examination, the residents can choose among 6 categories of specialization: medical specialties, surgical specialties, biology, psychiatry, public health, and occupational medicine. About 430 students (8.6%) choose surgical specialties per year. Once again according to rank and specialty, the newly appointed resident then chooses the city (according to whether the examination was passed in the North or the South) in which he or she wants to continue to train. The first part of surgical training is called the Diplôme d'Etudes Spécialisées. All future specialists in surgery are required to do six 6-month rotations, at least 2 in visceral and 2 in orthopedic surgery. This part of training is also called the "common trunk." The hospital units in which they work are chosen once again according to rank. During this 3-year period, the resident follows theoretical courses provided by the faculty and has hospital ward responsibilities, is on 24-hour call duty, and assists in operating room procedures. Next comes the Diplôme d'Etudes Spécialisées Complémentaire, another series of 6-month rotation periods that last for a total of 3 years (2 as an interne and 1 as a chef-de-clinique), where the apprentice surgeon is in his or her area of specialization, for instance, digestive or gastrointestinal tract, orthopedic, vascular, or other surgery. At the end of the first 3-year period, the student obtains his or her diploma in general surgery, as long as at least 4 rotations were either in general, gastrointestinal tract, or orthopedic surgery. At the end of the 6-year period, the surgeon has to present a "memoir." All along these 6 years are courses provided once a month concerning theoretical and practical aspects of surgery. The essential formal operative training, however, is taught in the hospitals. Other training courses are sometimes affiliated with national meetings. Human cadaver dissection, whenever available, is highly recommended. For laparoscopic training, several university-associated training programs called university diplomas are available with hands-on training with pigs.