How to start and go about the process of securing a residency
position:
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 (application on FSMB) 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 jurisdiction 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 standardized curriculum vitae
b. enter a personal statement
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 ffrom 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 programs in the hospitals that interest you
(2) those programs 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 programs 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 [bleep] 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 . (contact your residency program for further details)
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. 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.
Currently 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 you use expedited processing which can be
achieved by paying an extra $1000 , and the visa will be approved
within approx 14 days.
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:
Here is an overview of the process
8. Costs
• USMLE 1 $825
• USMLE 2 $800
• (USMLE 3 $670 + travel [only if H-visa sought])
• CSA $1200 + travel
• ERAS $185 (Minimum)
• NRMP $40
• 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)
• (total cost can run upto $10,000 depending on how long you stay in
US and how many programs you apply to)
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 than 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
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