A review
of the necessary prerequisites for Application to residency
1. The USMLE 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 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 . (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.
8. The Residency process:
How to start and go about the process of securing a residency
position?
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)
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 favorite programs in NRMP's ROL (rank order list)
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. Organize accommodation, flights, cargo etc.
The following folw chart will make the process a bit more clear.
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Residency Information (for USMLE cleared)