| Applying
for a Residency in the USA |
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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.
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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).
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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. |
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| From
the author |
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.
Graham
McMahon MB BCh |
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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.
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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.
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.
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 . More
info on the scramble process
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.
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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.
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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.
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. Specific
information on J-1 visa waivers. .Again,
please consider coming on a H1B visa to avoid these problems.
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. Specific
information about H-visa applications.
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.
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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)
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.
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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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Graham
McMahon MD
Original
version of the article
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