dxy

:):):)

To those who are interested in USMLE and Residency Program in the US, you may want to read the following. It is a detailed "road-map" of "how-to" from a guy who had gone through the whole process. Hope this will help those interested to gain more detailed "inside-info" about the steps of the applying procedure.

It seems a long, complicated and costly route to march on, but, trust me, I have seen many our countrymen have already succeeded in that path. So ... read it through, be confident with your own instinct if you have determined ... More info you gain, more competitive you will be.

Happy Reading…

:):):)

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I graduated from the Royal College of Surgeons in Ireland in 1997, and moved to Boston after matching at the Brigham and Women's Hospital in 1999 where I completed a medical residency. I'm now a fellow in Endocrinology there, and teach at Harvard Medical School. Matching into an American program is a tough process, and I've put together a few facts that I learned along the way, to make it easier for other foreign graduates to be able to understand the process and plan effectively. This advice and information is given in good faith, but please do confirm its accuracy for yourself.

Please be aware that I receive hundreds of emails a year about this complex process that I try to answer expeditiously and without charge. If you do want to ask a question, please do read the information below thoroughly first.

Foreign Medical Graduates (FMGs) in the USA

FMGs make up 23% of the US physician workforce, and 24% of residents. The heaviest concentrations of FMGs are in New Jersey (50% of the workforce), New York (48%), Florida (42%) and Illinois (38%). Almost half of all FMGs (48%) train in primary care specialties vs. 33% of U.S. graduates. The largest national groups are from India 20%, Pakistan 12%, Philippines 9% Former soviet republics 3%. Of the 196,576 total FMG population, 85% are involved in patient care, the rest in research.

2003 Match statistics for FMGs

Some 8,763 FMGs applied to the NRMP in 2002-3. Of these 1,713 were excluded as they had not completed ECFMG certification by match day. Of the 5,029 FMGs who had certification and submitted a rank order list, 2,799 (56%) were successful in matching. US citizens who completed their medical education abroad had a very similar matching result to FMGs. By comparison, 93% of graduates of US medical schools successfully matched. Nearly half (47%) of all FMGs matched into categorical internal medicine residencies. Family practice took 15% of the FMG applicants, pediatrics took 9%, psychiatry 5% and preliminary surgery 5%.

The specialties who matched the fewest FMGs (ie most competitive) were dermatology (0.8% of matched applicants were FMGs), orthopedic surgery (1%), emergency medicine (1.2%), radiation oncology (1.9%), diagnostic radiology (5.1%) and categorical surgery (5.5%). Few FMGs are accepted into transitional and preliminary medicine programs. The residencies matching the most FMGs were categorical internal medicine (25%), rehabilitation medicine (19%), psychiatry (16%), family practice and pathology (both 15%).

There are a number of essential components to getting a residency

1. Pick your desired residency (internal medicine, surgery, radiology etc.)
2. Send away for an ERAS (Electronic Residency Application System) application
3. Research your destination hospitals (see AMA's FREIDA online and Scutwork.com for help)
4. Complete and dispatch the ERAS application to ECFMG
5. Register as an independent applicant with the National Residency Matching Program.
6. Watch the Automated Document Tracking System (ADTS) for the progress of your ERAS submission
7. Call/e-mail the hospitals that have received your ERAS application, and ask about interview schedules. Request early decisions based on your need to complete international travel
8. Attend for your interviews
9. Rank your favourite programs
10. Submit your rank order list by internet to the National Residency Matching Program
11. While awaiting the match results, research your visa options and send for the licensing application packs for the states that you feel most likely to match with.
12. Obtain your match results (or enter the scramble if unmatched)
13. Sign and return your contract
14. If immigrating on a J1 visa, get the DS2019 form from ECFMG and apply through your local consulate. If immigrating on a H-visa, you'll need to get your state license completed first (requires your ECFMG certificate and a copy of the signed contract with the hospital)
15. Organise accomodation, flights, cargo etc.

A review of the necessary ingredients:

1. The Exams

The USMLEs (United States Medical Licensing Examinations) are a set of medical exams designed to evaluate your readiness to safely enter the American medical system. The organisation that watches over the application of foreign nationals to the American Medical system is the ECFMG (Educational Commission for Foreign Medical Graduates) and they administer the USMLEs outside of the USA.
USMLE are multiple choice exams that are now only held on computer. There are three parts, or steps, to completing the USMLE exams. The computers that you can take them are available in a large number of cities across the world on every working day of the year - you register with the ECFMG who administer the test internationally, and reserve a place at your local centre for a time when you feel ready to take the examination. Your nearest site can be found here.
The first part, USMLE step 1, is a multiple choice exam consisting of about 300 questions taken over eight hours in one day at the test center. The step 1 covers all of the basic sciences - Anatomy, Biochemistry, Physiology, statistics, Behavioural science, microbiology, pharmacology, pathology, ethics - and it is typically taken in the first half of the medical school curriculum at a time when these subjects have been covered. Scores are reported as two digit (NOT %) and three digit scores. The percentage required to pass is determined based not on a population curve, but on the relative difficulty of the items as determined by the test committee. That pass % is then set as being equal to a two digit score of 75. The mean three digit score is 200. Many programs look for two digit scores of at least 80-85 for entry. 66% of international medical graduates pass this exam with each sitting, while 91% of US medical students do.

The second part was recently divided into two parts, USMLE step 2ck (clinical knowledge) and USMLE step 2cs (clinical skills). USMLE step 2 ck+cs is the examination that American medical students take before being allowed to graduate from medical school. USMLE step 2ck consists of a similar one day computer based examination, and covers all of the clinical sciences including medicine, surgery, paediatrics, obstetrics and gynaecology, psychiatry, forensics, emergency care, ENT, ophthalmology, tropical health, ethics. It is usually taken in the final year of medical school, or beyond. 75% of international medical graduates/students pass this on first sitting, while 95% of american medical students do.
The USMLE Step 2cs examination is a newer requirement for ECFMG certification. The USMLE step 2cs is an expensive ($1200) examination is held in only a few American cities throughout the year. It brings examinees face-to-face with ten simulated ('standardized') patients - ie actors pretending to have specific complaints. You are tested on your ability to rapidly assess a patient, communicate your thoughts to them, and to write a note about your assessment and plans. Application is presently through the ECFMG only. As of November 2002 (when the exam was called the CSA), the pass rate was 80%, with 60% of failures being due to language difficulties. As a result of this new examination, the TOEFL will no longer be required. However the USMLE step 2cs will have an expiry date for the first time.

USMLE step 3 is taken by American students during their residency program within a year or so of graduation. International students only need to take the USMLE part 3 if they plan to immigrate on a H-1B visa (recommended over a J-1). This exam is only given in the United States, requiring you to travel here to take it. Also, only a few states (California, Connecticut, Louisiana, New York, Utah, or West Virginia) allow you to take the part 3 in their juristiction without being in an American residency program. It is largely similar in scope to the USMLE step 2 with more emphasis on practical management. The computerized test can be taken geographically in any US state at a testing center as long as you are sitting the test FOR Connecticut or New York. Application is through the state medical board. This means you can take the test in New Jersey having applied to the state medical board of Connecticut, and having passed the exam, use that result to start residency in Massachusetts.

The English Examination is not run by ECFMG any longer. If you have taken the CSA you will be required to take a TOEFL (test of english as a foreign language) examination. If you take the USMLE step 2cs, you do not have to take an additional english examination. The TOEFL is run in most countries by the Educational Testing Service. Click here for more information on the TOEFL examination.

2. The ECFMG Certificate

This sounds straightforward but can be unexpectedly time consuming. The ECFMG (Educational Commission for Foreign Medical Graduates) certificate is a document proving that you have fulfilled the education requirements needed to practice medicine in the USA.

The Necessary components are to have
1. - your medical degree and transcript verified by ECFMG (can take a long time)
2. - passed USMLE 1 and 2ck
3. - passed the clinical skills assessment (or step 2cs)
4. - passed a TOEFL english examination (or step 2cs)
5. - paid ECFMG in full
All of these components must be valid at the time when you apply for final certification. This certificate testifies to the fact that you have fulfilled the requirements for entry into clinical training in the USA.
Remember that the ECFMG certificate is only valid as long as its components (eg USMLE step 1) remain valid; each component has an expiry date. Your ECFMG certificate must be VALID when you apply for a visa or start your training. The english examination component expires after two years. Remember that if you have to revalidate your english test, the results of a repeat english examination will take some time to be processed to revalidate your certificate (this delayed my visa application).

3. ERAS
The electronic residency application system (ERAS) is a method of centralised, computerised application for residency. After you have paid the required application fee and requested a 'Token' via the On-line Applicant Status and Information System (OASIS), ECFMG will send a unique identification number ('a Token') by e-mail. This Token will permit the applicant to access the AAMC's ERAS website to complete his/her ERAS application on-line. Simultaneously, you'll have to mail photocopies of your supporting documents to ECFMG. On this online site you have to
a. enter your personal details in a standarised curriculum vitae
b. enter a personal statement (click here for advice about creating your personal statement) and...
c. designate the residency programs you wish to have your application sent to.

The supporting documents that you have send in the mail include
1. your photograph
2. your examination transcript and
3. your letters of reference
4. your dean's letter /medical student performance evaluation

Foreign medical graduates send these paper items to the ECFMG who act as your "dean's office". They scan your paper documents and photo, match it to your online application items and e-mail the lot to the residency programs you selected. You can select up to four letters of recommendation to each program. You can follow this process on the Automated Document Tracking System (ADTS) which allows you to see when your application documents are downloaded by the residency programs. ERAS, the ADTS and the NRMP are all run my the AAMC (American Association of Medical Colleges). You should complete all of the ERAS application procedures as soon as possible, but by December 1st in your year of application at the latest.

The question of where to apply is frequently asked. Almost all hospitals will take the best applicants they can get, no matter their origin. There is therefore no such thing as 'FMG friendly' hospitals, only hospitals that cannot recruit american graduates, and have a preponderance of FMGs working there. You would do well to try and avoid such institutions since there is often a reason that they are deserted by American grads. If you do want to find such places, you can find them listed in the unfilled list at scutwork.com. The best advice is to discuss your plans with colleagues who know your field, and get their advice about where you would best be suited. You can use resources on AMA's FREIDA online to narrow your search, and obtain contact information.

4. Interviews

The most difficult part in your application will be securing an interview. Many program directors find it difficult to evaluate foreign graduates, so are reluctant to make the effort to interview them: there is certainly little doubt that there is substantial variablility in the quality of graduates from disparate medical schools.

There are no guaranteed methods to getting an interview at any of the top hospitals. However you can increase your chances by

- doing an elective
- getting good USMLE scores
- doing well in your own medical school
- having a research publication
- having very strong letters of reference from your dean and referees

Never assume that your application is actually being reviewed by the hospital you applied to. Make sure you get in touch with the program coordinator after you have seen them download your items from ERAS, asking when you can expect to hear about whether you will be given an interview. All program directors are listed in the AMA green book, and online at FREIDA. It is true that planning international travel is more complicated than local travel, so you really will benefit from an early decision. If you do get an interview, you should be able to negotiate a day that works in your interviewing schedule, but this can be variable.

The interview day itself usually starts the night before, where you'll be hosted to a casual dinner with members of that residency. This is where you get to ask all the hard questions about what life is really like working in that hospital and program. Many residency programs do look for feedback from those who have met you at these dinners, so be on your best behavior.

The actual interview day will usually involve hearing a presentation about the program, going to morning report/conference, and then meeting individually with some of the selection committee during the day. You may not be scheduled to meet with the program director themself, but it is worth asking (given you have travelled so far) to meet directly with them at the end of the day, to find out how you got on, and whether you're in with a good chance at this program.

Do follow up with the program director by email or letter after you have left to solidify your intent or interest.

5. The Match

The Match is a centralised computer program that matches a physician's highest ranked residency program with a hospital that ranks them highly.
It is organised by the National Residency Matching Program (NRMP) . Not all of the available spots are listed in the Match, and some of the more competitive specialities participate only in the "Early Match". See the NRMP site for more information. As an international applicant, you must register as an 'independent applicant' before December 1st of your year of application at the latest

What happens in the Match is .....
(1) You apply to the programmes in the hospitals that interest you
(2) those programmes that are interested in you will invite you for an interview
(3) after the interview, the hospital ranks you among all those they've interviewed
(4) After all your interviews, you rank the programmes that you want and
(5) on a certain date in March, all of these preferences are chewed on by a computer and the hospitals are matched with the applicants.

Those that do not 'Match' are notified two days before the official results and can participate in the 'Scramble' where unmatched physicians contact unmatched residency programs by phone and fax in an attempt to find jobs. You can find the list of programs that failed to fill all of their positions at scutwork.com or click here . For more info on the scramble process click HERE.

You will optimise your chances of matching by...
(1) Being organised and ready
(2) having good grades, USMLE scores and references
(3) performing well at interview
(4) having done an elective at the hospital you're applying to
(5) knowing about your visa plans

Residencies can fill their positions in the match, before the match, or in a brief 'scramble' after the match. On the Monday of match week before the specific match results are available (always a Thursday), unmatched applicants and unfilled programs are told (by email) that they did not match/fill, and the listing of unfilled programs is released. Unmatched applicants then have those next three days to convince program directors of unfilled programs that they are the right candidate to fill that job. Most use faxes, and phonecalls since program directors are usually so overwhelmed as to ignore email.
You can obtain a position before the match too. This happens when programs are sufficiently impressed with you (or sufficiently desperate for applicants) that in the days or weeks after the interview, they offer you a position directly, providing you agree to withdraw from the match right there and then, and sign the paperwork. This works well for less competitive candidates who are very unsure about their potential to match through the ranking process, and are happy with the offer.

6. State Medical Licences

After you've successfully matched you need to secure your medical license and your visa. The medical license is specific to the state of your employing hospital. Information on contacting the state medical boards is included in the USMLE/ECFMG Bulletin of Information, and is also located at the Federation of State Medical Boards Web Page. States differ significantly on their processing times and requirements for licensure. You should check out the details, including requirements for USMLE 3 eligibility at the AMA GME handbook .

7. Your Immigration Visa

Doctors who have graduated from foreign medical schools seeking U.S. residency training (who do not qualify for permanent resident status in the U.S.) usually seek either of two visas from the Immigration and Naturalization Service (INS), the J-1 or the H-1B visas. Several recent events affect the use of those two visas by foreign graduates.

7A. The J-visa
The J-1 non-immigrant visa permits completion of an accredited residency or fellowship program of up to seven years duration which leads to board certification. Following this, the resident *must* return to his/her native country or country of last residence for a period of at least two years. ECFMG issues a form called a DS2019 which tells the consulate that you are eligible to enter the US. The American consulate in your own country will decide whether to issue the visa.
Your governmental health office must sign a document indicating the need in your home country for physicians trained in your prospective speciality. Occasionally (this is often an issue for Canadians)the country does not recognize a need for residents in a particular area and refuses to issue the form, but for most it is a simple formality. J-1 visa applications are usually processed quickly, though some countries have a longer processing time due in part to the events of Sept 11, 2001.

It is important to note that coming to the US on a J-1 visa absolutely limits you to staying here only until the completion of any training (be that six months or five years) up to a MAXIMUM of seven years. This is a training visa, so you cannot use to practice independently as an attending. If you think there is a chance that you would like the opportunity to stay in the USA after your training, you should take the USMLE 3 and come on a H1B visa.
There are four ways to stay in the US on a 'waiver' of this two year home residency requirement. For most, the only practical way to avoid having to return to your home country is to agree to practice in an underserved area for three years after you have completed your training. These positions are competitive and the competition for them is expensive. For specific information on J-1 visa waivers, click HERE .Again, please consider coming on a H1B visa to avoid these problems.

7B. The H-1B Visa
The H-1B visa allows the prospective trainee to avoid the J-1 visa requirement to leave the U.S. for two years by petitioning for permanent resident status in the U.S. while in residency training. An applicant for an H-1B visa must be

(1) ECFMG certified (ie have passed USMLE 1, 2ck and 2cs);
(2) must have ALSO passed USMLE step 3 AND
(3) must hold a license to practice in a U.S. state before application (it takes about three weeks to get a training license after your match).

Residency programs decide individually which type of visa they will support for their candidates for residency training. Previously most did NOT support H-1b applications, although the new visa laws passed in October 2000 mean that now many that previously did not offer them should do so. You should ask your programs directly which they will consider for you. Remember that many have the default position of refusing such visas (and even note such decisions on residency and hospital websites), but if you learn about them, and talk to the international officers at these institutions, many will reverse their decision and apply for this visa on your behalf. For specific information about H-visa applications, click HERE

Fortunately, many of you reading this will avoid the problems that I had to go through in securing my H1B visa, as now all academic institutions have unrestricted access to H1B visas, without a cap. This means that your H1B visa is likely to be easily available, and processed quickly (though some can still take up to six months). A standard H1b application can still takes about 2-3 months for processing, so to be ready for a July 1st start, you have to be quick about your license and your visa application right after you match, unless your employer will use expedited processing for you. Expedited visa application can be achieved by paying an extra $1000 (your employer must pay this), and the visa will be approved within approx 14 days.

I would urge you to seek the most accurate and timely information available. This analysis my own present understanding of the status of the J-1 and H-1B visas. Foreign medical graduates should verify this information themselves and make every effort to stay up to date on changes in these regulations which may affect your ability to be employed. You should liase closely with your employing hospital in this regard and may wish to retain an immigration attorney to handle the process if your hospital does not have an international office.

You will have to think carefully about which visa is right for you. Note that the Match takes place in mid-March, and for a July start you would likely have only a short time to secure a state medical license and submit your H-1B visa application.

Some good visa sites for physicians are as follows:

Samia Law Harvard graduated immigration attorney who handles visa issues/applications online for reasonable fee
Carl Shusterman's Immigration site
Udall's Immigration site

8. Costs

USMLE 1 $660+140

USMLE 2 $660+155

(USMLE 3 $570 + travel [only if H-visa sought])

TOEFL $110

CSA $1200 + travel

ERAS $185

NRMP $90

State license $240

Interviews $1000 + travel

ESTIMATED TOTAL $5,000 + travel to the US (two trips if H-visa sought - one for USMLE 3, one for CSA with interviews)

9. What about Observerships?
Many residency programs look for letters of recommendation from American physicians when reviewing applications. Medical students can get these when they are on electives in US hospitals. It is harder for those who already have their medical degree, since observerships are much less developed that electives.

If you are thinking of trying to come and experience American medical practice as an observer for a few weeks, the best thing to do is to contact the departmental head of your preferred specialty at a hospital that interests you. Your letter should contain an introduction about you, and go on to explain what you hope to achieve by spending time in an American Hospital. You could talk about exploring differences in educational strategies, in medical practice, or system organization. I would not specifically allude to objectives such as getting letters of recommendation or applying to residency. Assure the departmental head that you will obtain your own liability insurance. You should include a copy of your curriculum vitae and a photo. If possible, use contacts from home. If you don't hear back, make personal contact with email or telephone.

10. When should I go?

This is a tough question and there is no "right" answer. What is certain is that if you want to get registered with the Board of the Speciality that interests you, you must do all your training from PGY-1 (post-graduate year one) to speciality in the USA. So for example if you aspire to cardiology and be able to practice as a cardiologist in the USA you must spend 3 years of Internal Medicine Residency followed by 4 years of Cardiology Fellowship. While you can do your basic medical training in your home country and join a US fellowship, you will not be able then to practice as a Cardiologist, as you cannot be 'board certified' without completing a residency first. The point to remember is that if you just want to spend 4 years training in the USA, you can just go over for a fellowship - while if you want to practice in the USA you have to go over for the whole lot.

Good luck!
Graham McMahon

:):):)