International Medical Graduates (IMGs) in US

Hello everyone!

I am a foreign medical student who got his green card but not yet his medical degree (a few months thing) in his home country. I was trying to figure out from someone who is knowledgeable whether I am better off going back to my country to complete the last year of my medical studies and then come here to apply for the ECFMG certificate in order to enter later in a residency program, or if I can complete the last year of my studies in some medical school here in the States and then eventually proceed as above (with the ECFMG and USMLE Step 3.)

I am eligible right now to apply for USMLE Step 1 and Step 2 as I am within one year of completing my medical studies in my country, yet I was told that to be able to be certified by the ECFMG one should have the M.D. diploma from the medical school in one's own country. What do you think guys?

Graduate Medical Education system is a multi-step process that begins with certification through the ECFMG. ECFMG certification assures U.S. residebcy programs that physicians trained outside the U.S., Canada and Puerto Rico are qualified and eligible to enter residency training.

The first requirement is passage of the medical science examination. Steps 1 and 2 of the United States Medical Licensing Exam (USMLE) now constitute the medical science exam. Although the ECFMG administers it for IMGs, the USMLE is the same examination used to license United States medical graduates (USMGs). While a passing score on Step 1 is 179 and 170 on Step 2, the competitiveness of many residency programs requires a higher score. Passage itself does not guarantee acceptance into a residency program.

To be eligible to take USMLE Steps 1 and 2, an applicant must be either a medical student at a medical school listed in the current edition of the World Directory of Medical Schools or be a graduate of a medical school listed in the World Directory of Medical Schools at the time of graduation. Current students must have completed a minimum of 2 years of medical school to take Step 1 and be within 12 months of completion of the full didactic curriculum to take Step 2.

Steps 1 and 2, along with Step 3, which will be discussed later, must be passed within a 7-year period.

The second requirement is passage of the ECFMG English test. The English test is given on the second day of the USMLE Step 2 examination. It is a multiple-choice exam, testing comprehension of spoken English, English structure and vocabulary. The only acceptable substitute is a Friday or Saturday administration of the Test of English as a Foreign Language (TOEFL), given by the Educational Testing Service (ETS), provided applicants have already taken an ECFMG English test. ECFMG requires a minimum score of 550 on a single administration of the TOEFL.

The third requirement is evidence of receipt of the final medical diploma from the applicant's country of medical education. It will no longer be necessary to have evidence of licensure to practice medicine in the country of training. Also, an IMG must have completed at least 4 academic years at a medical school listed in the World Directory of Medical Schools. All medical credentials provided to the ECFMG are subject to verification.

Beginning July 1, 1998, the ECFMG instituted a fourth requirement for certification, a 5-hour exam known as the Clinical Skills Assessment (CSA) that will test an applicant's ability to take a patient's history, complete a physical exam, make a differential diagnosis and develop an appropriate care management plan. The CSA will also test written and verbal skills as related to patient care. A strong grasp of the English language is an important part of this exam. An applicant must have passed Steps 1 and 2 of the USMLE and the English language test before being eligible to take the CSA.

Once these requirements are met, an applicant receives a Standard ECFMG Certificate that is valid for 2-years from the date of passage of the English test and which can be used for entry into an Accreditation Council for Graduate Medical Education (ACGME)-accredited GME program. Once the holder of an ECFMG Certificate enters GME, the Certificate is no longer subject to expiration. If the Certificate expires before entering GME, an applicant may pass the ECFMG English test or TOEFL to revalidate the ECFMG Certificate for 2 additional years.

Step 3 of the USMLE, which assesses whether a physician can apply the medical knowledge and understanding of biomedical and clinical science considered essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory settings, is administered by each individual state through its state medical licensing authority. Step 3 of the USMLE is generally taken after the first year of GME; however, the requirements differ from state to state. To be eligible to sit for Step 3, an applicant must meet the requirements imposed by the medical licensing authority administering the exam, obtain the MD degree (or its equivalent) or the DO degree, pass both Steps 1 and 2 of the USMLE (or an acceptable combination) and be ECFMG certified or successfully complete a Fifth Pathway program.

* * *

The Fifth Pathway program was developed by the American Medical Association (AMA) in 1971 for U.S. citizens or permanent residents who wish to return to the U.S. for GME after attending a foreign medical school, generally in Mexico. This program is available to those who completed their premedical work in a U.S.-accredited college, studied medicine in a foreign medical school listed in the World Directory of Medical Schools and have completed all requirements for admission to practice medicine except internship and/or social service in the foreign country. IMGs who meet these criteria are then able to substitute the Fifth Pathway program for internship and/or social service in the foreign country. After receiving a Fifth Pathway certificate from an accredited U.S. medical school, an IMG may then apply for the first year of GME in the U.S. It is important to note there is no eligibility for the Fifth Pathway after graduating from medical school.

* * *



-------------------------------------

Page Location: http://www.ama-assn.org/ama/pub/category/1552.html

Taking a closer look at this thread I'd say that although at first it may seem the question asked by "darndoctor" does not have to do with immigration issues, I was able to figure out that this person should take care not to stay for more than 6-months at a time outside the U.S. or else her/his green card will be lost. So in case s/he decides to go back to her/his home country to get the medical diploma, s/he should take care to enter the US once (before the six-months absence period is completed) to keep the green card.

Regarding the "Fifth Pathway" program:

This is an academic year of supervised clinical education provided by an LCME-accredited medical school and is available to persons who meet all of the following conditions:

- have completed, in an accredited US college or university, undergraduate premedical work of the quality acceptable for matriculation in an LCME-accredited US medical school;

- have studied medicine in a medical school located outside the United States/Canada that is listed in the International Medical Education Directory (IMED) of the Foundation for Advancement of International Medical Education and Research (FAIMER®), and that requires an internship and/or social service after completing the school's academic requirements and before receiving the final medical credential;

- have completed all of the formal requirements of the non-US medical school except internship and/or social service. (Those who have completed all of these requirements for graduation are not eligible.)

Students who have completed the academic curriculum in residence at a non-US medical school and who meet the above conditions may be offered the opportunity to substitute, for an internship and/or social service required by a non-US medical school, an academic year of supervised clinical training in a medical school accredited by the LCME.

Any medical school accredited by the LCME can provide Fifth Pathway education. * * * As of the release of this bulletin, the only medical school known to provide such education is New York Medical College in Valhalla, New York.* * *

*Source: GMED Companion: An Insider's Guide to Selecting a Residency Program, 2002/2003, American Medical Association

------------------------------

http://www.usmle.org/bulletin/2003/eligibility.htm

How did you get your green card?

My parents who came in the US years ago petitioned for me to get a green card.

So, darndoctor, I guess you figured out for yourself that you'd have to go to New York, should you decide not to return to your home country.

Wrong assumption blackema: NYMD in Valhalla, NY does not accept non-US citizens for the Fifth Pathway program:

http://www.nymc.edu/depthome/fifth.asp

I am a foreign-trained physician as well - could someone provide some facts about residency programs?

An alien acquaintance of mine came in the US in August 1996 after having studied for 4 years Medicine in his home country. He had completed coursework in preclinical medical subjects that was lost when he landed in the US. From 1996 - 1998, he had basically a waste of time -- he needed some time to find out how things work in this country. Later he entered a quite good public university and earned in a two-years period an BS in Biochemistry (they recognized almost two years of his previous studies in his home country.) In 2000 he entered Medical School that he'll hopefully finish by 2003. He has not made his mind as to what specialty might be right for him.

I mentioned this example to let you know that you are well in track with your plan to get the medical diploma from your home country and then come here and try to get the ECFMG certification to be able to enter a residency program. I mean, as you see the guy I talked you about would have been in the US for 7 years by June 2003 -- the time by when he will have earned his M.D. degree (after having spent 4 years studying in his home country.) to be able to enter a residency program. If you go back to your home country for only one year to finish up your medical studies and get the medical diploma, you'd need much more less time to get ECFMG-certified (usually it takes about 2 years including the time you'll have to study for the three exams.) It simply does not make sense to begin once again from the beginning studying medicine in the US when you'll have completed the program in your country -- and believe me -- the exams are not *that* difficult, there's a technique involved in taking them (multiple-choice questions mostly) that you can master in a relatively short period of time. I have seen *a lot* of foreign medical graduates being successful in taking those exams in a period of time less than 2 years. Good Luck to you!

I doubt it's possible to transfer from foreign medical school to the US school. Your best option is to get MD degree at home, get certified by ECFMG, and enter US residency program. Make sure to maintain your status of LPR while away from US.

Hello,

I graduated from a medical school in Ireland in 1997, and moved to Boston after matching in 1999 where I completed a medical residency. I'm now a fellow in Endocrinology. 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 have an easier time than I did. This advice and information is given in good faith and is based on my own personal experiences. Let me know if you found it useful or if you have any ideas to improve it.

Foreign Medical Graduates in the USA

FMGs make up 23% of the US physician workforce, and 24% of residents.

The heaviest concentration of FMGs is in

-New York (48%),
-Florida (42%) and
-New Jersey (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%
-Ex-USSR 3%.

Of the 196,576 total FMG population, 85% are involved in patient care, the rest in research.



1. The USMLEs, CSA and TOEFL

The USMLEs 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.

The first part, USMLE step 1, is a multiple choice exam consisting of about 300 questions taken over 8 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 first sitting, while 91% of US medical students do.

The second part, USMLE step 2 , is the examination that American medical students take before being allowed to graduate from medical school. It 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.

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 Clinical Skills Assessment is a newer requirement for ECFMG certification. The CSA is an expensive ($1200) examination is held only in Philadelphia and Atlanta throughout the year, and nowhere else (as of Nov 2002). 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 through the ECFMG only. As of November 2002, the pass rate was 80%, with 60% of failures being due to language difficulties.

The English Examination is not run by ECFMG any longer. You will be required to take a TOEFL (test of english as a foreign language) examination. It is run in most countries by the Educational Testing Service.


2. The ECFMG Certificate

This sounds straightforward but is far from being so. 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 verified by ECFMG
2. - passed USMLE 1 and 2
3. - passed the clinical skills assessment
4. - passed a TOEFL english examination
5. - paid ECFMG

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 2) 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 2 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.


3. ERAS

The electronic residency application system (ERAS) is a method of centralised, computerised application for residency. After writing to and paying ERAS, you will get sent a disk containing a computer program that does a number of things: It allows you to

a. enter your personal details in a standarised curriculum vitae
b. enter a personal statement
c. register a photograph
d. dispatch your examination transcript
e. enter your references
f. designate the residency programs you wish to have your application sent to

ECFMG who act as your "dean's office" will scan your paper documents and photo, match it to your disk items and e-mail the lot to the residency programs you selected. 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.

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. Most program directors are listed in the AMA green book, and online at FREIDA.

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.

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". 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 (March 20, 2003 is next), 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 2 days before the official results and can participate in the 'Scramble' where unmatched physicians telephone unmatched residency programs in an attempt to find jobs.

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


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.

There are two types of physicians: The M.D.-Doctor of Medicine - and the D.O. - Doctor of Osteopathic Medicine. M.D.s also are known as allopathic physicians. While both M.D.s and D.O.s may use all accepted methods of treatment, including drugs and surgery, D.O.s place special emphasis on the body's musculoskeletal system, preventive medicine, and holistic patient care. About 30% of M.D.s - and more than 50% of D.O.s -are PCPs (primary care physicians.) They practice general and family medicine, general internal medicine, or general pediatrics and usually are the first health professionals patients consult. Primary care physicians tend to see the same patients on a regular basis for preventive care and to treat a variety of ailments. When appropriate, primary care physicians refer patients to specialists, who are experts in medical fields such as obstetrics and gynecology, cardiology, psychiatry, or surgery.

Here it is an % distribution of M.D.s by specialty:



Internal medicine 16.1
General and family practice 10.7
Pediatrics 7.5

Medical specialties

Allergy 0.5
Cardiovascular diseases 2.5
Dermatology 1.2
Gastroenterology 1.3
Obstetrics and gynecology 4.9
Pediatric cardiology 0.2
Pulmonary diseases 1.0

Surgical specialties

Colon and ****** surgery 0.1
General surgery 4.9
Neurological surgery 0.6
Ophthalmology 2.2
Orthopedic surgery 2.7
Otolaryngology 1.1
Plastic surgery 0.7
Thoracic surgery 0.1
Urological surgery 1.3

Other specialties

Aerospace medicine 0.1
Anesthesiology 4.4
Child psychiatry 0.7
Diagnostic radiology 2.6
Emergency medicine 2.8
Forensic pathology 0.1
General preventive medicine 0.4
Neurology 1.5
Nuclear medicine 0.2
Occupational medicine 0.4
Pathology 2.3
Physical medicine and rehabilitation 0.8
Psychiatry 4.9
Public health 0.2
Radiology 1.0
Radiation oncology 0.5
Other specialty 0.7
Unspecified/unknown/inactive 16.0


Physicians and surgeons held about 600,000 jobs in 2000. About 7 out of 10 were in office-based practice and about 2 out of 10 were employed by hospitals. Others practiced in the Federal Government, most in U.S. Department of Veterans Affairs hospitals and clinics or in the Public Health Service of the Department of Health and Human Services.

A growing number of physicians are partners or salaried employees of group practices. Organized as clinics or as groups of physicians, medical groups can afford expensive medical equipment and realize other business advantages. Also, hospitals are integrating physician practices into healthcare networks that provide a continuum of care both inside and outside the hospital setting.

It takes many years of education and training to become a physician:

- 4 years of undergraduate school,
- 4 years of medical school (a few medical schools offer a combined undergraduate and medical school program that lasts 6 years instead of the customary 8 years.) and
- 3 to 8 years of internship and residency, depending on the specialty selected.

Following medical school, almost all M.D.s enter a residency-graduate medical education in a specialty that takes the form of paid on-the-job training, usually in a hospital. Most D.O.s serve a 12-month rotating internship after graduation before entering a residency which may last 2 to 6 years. All States, the District of Columbia, and U.S. territories license physicians. To be licensed, physicians must graduate from an accredited medical school, pass a licensing examination, and complete 1 to 7 years of graduate medical education. Although physicians licensed in one State can usually get a license to practice in another without further examination, some States limit reciprocity. Graduates of foreign medical schools usually can qualify for licensure after passing an examination and completing a U.S. residency. M.D.s and D.O.s seeking board certification in a specialty may spend up to 7 years-depending on the specialty-in residency training. A final examination immediately after residency, or after 1 or 2 years of practice, also is necessary for board certification by the American Board of Medical Specialists (ABMS) or the American Osteopathic Association (AOA). There are 24 specialty boards, ranging from allergy and immunology to urology. For certification in a subspecialty, physicians usually need another 1 to 2 years of residency.

Physicians have among the highest earnings of any occupation. According to the latest data available from the AMA, median income, after expenses, for allopathic physicians was about $160,000 in 1998. The middle 50% earned between $120,000 and $240,000 a year. Self-employed physicians-those who own or are part owners of their medical practice - had higher median incomes than salaried physicians. Earnings vary according to number of years in practice, geographic region, hours worked, and skill, personality, and professional reputation.

All physicians $160,000
Surgery 240,000
Radiology 230,000
Anesthesiology 210,000
Obstetrics/gynecology 200,000
Emergency medicine 184,000
Pathology 184,000
General internal medicine 140,000
General/Family practice 130,000
Psychiatry 130,000
Pediatrics 126,000

I would say that a foreign national that has completed 4 years of medical studies in his home country, like the one you talked about, would not have to start studies in the US at the undergraduate level -- he may had very well transfered those credits (after having them evaluated) and eventually apply directly to medical school here in the U.S. This would be the course of action in case one feels it is feasible getting the M.D. degree from one's own country and then get ECFMG-certified in the U.S. as this thread's starter plans to do (my advise as well.)

Sorry, the last sentence of my post shoud read:

This would not be the course of action in case one feels it is feasible getting the M.D. degree from one's own country and then get ECFMG-certified in the U.S. as this thread's starter plans to do (my advise as well.)