ABCs of Immigration: Qualifying for Graduate Medical Training in the United States

[This month’s ABCs of Immigration issue is adapted from Greg Siskind’s book, co-authored by Elissa Taub, The Physician Immigration Handbook.]

The following is intended to act as a basic outline of the requirements that the International Medical Graduate (IMG) needs to meet in order to qualify to train in a program accredited by the Accreditation Council on graduate Medical Education (ACGME). ACGME accredits United States graduate medical training programs. In order to qualify for a state medical license, an IMG generally needs to train in an ACGME-accredited program for at least two years. Once the physician completes the ACGME accredited program, he or she also qualifies to sit for specialty certification examinations offered by the various member boards of the American Board of Medical Specialties (ABMS). It is common for employers to require board certification or at least board eligibility, and many hospitals require certification prior to offering hospital privileges to physicians. The vast majority of physicians in the United States, understandably, have at least one board certification. It is a requirement for physicians obtaining board certification to participate in Maintenance of Certification educational and examination programs.

What is an ECFMG certificate and why do I need it?

IMGs seeking to participate in residency programs sponsored by the ACGME need to hold a standard certificate issued by the Educational Commission on Foreign Medical Graduates (ECFMG). Since 1956, ECFMG, a private organization, has been charged with evaluating the readiness of foreign-educated physicians to train in the United States. As long as they have the certification beforehand, IMGs are able to apply to residency programs before the certification is issued.

An ECFMG standard certificate confirms the equivalency of an IMG’s educational credentials to those that one would obtain in the United States, in addition to the IMG’s passage of required examinations.

IMGs seeking an ECFMG certificate needs to first file an application for a U.S. Medical Licensing Examination (USMLE)/ECFMG Identification Number and the application for ECFMG certification.

It is worth noting that until 2009, there was an alternative to the ECFMG Certificate, which was known as the “Fifth Pathway” certificate. ECFMG generally has a requirement for a final medical diploma from the foreign medical school, which would include the completion of an internship/social service requirement.

Beginning in 1971, the American Medical Association (AMA) created the “Fifth Pathway” program, allowing students to complete a year of supervised clinical work at a U.S. medical school which could then be followed by entry to a United States residency program and eventually a state medical license. USMLE permitted those with Fifth Pathway certificates to take USMLE examinations, but that program was discontinued in December 2009.

USMLE will allow individuals who have Fifth Pathway certificates which were issued before December 31, 2009 to participate in the USMLE program through December 31, 2016.

What else does ECFMG do that is important for IMGs?

ECFMG is involved in many aspects of the IMG’s immigration process including evaluating foreign credentials, serving as the IMG’s J-1 exchange program sponsor, and acting as the dean’s office liaison in assisting IMGs applying for the National Resident Matching Program/

What is the United States Medical Licensing Examination (USMLE)?

Once the IMG has applied for the ECFMG certificate and identification number, the IMG must then sit for the USMLE, comprised of three parts and is administered by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).

Test administrators state that the test, “assesses a physician’s ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care.” Applicants must have a minimum of two years of medical school completed in order to take the examinations.

Though there are no minimum score requirements published, according to page 24 of the USMLE’s 2014 Bulletin of Information, “The USMLE program provides score users with a recommended pass or fail outcome for all Step examinations. Recommended performance standards for the USMLE are based on a specified level of proficiency. As a result, no predetermined percentage of examinees will pass or fail the examination. The recommended minimum passing level is reviewed periodically and may be adjusted at any time. Notice of such review and any adjustments will be posted on the USMLE website. The recommended minimum passing level in place on the day [the ING] test[s] will be the level used for scoring purposes.”

The first part is the USMLE Step 1. The USMLE Step 1 tests whether an individual understands concepts of the sciences fundamental to the practice of medicine.

The second is Step 2 Clinical Knowledge (CK). This step determines an individual’s ability to apply medical knowledge, skills, and understanding of clinical science.

IMGs need to also satisfy ECFMG’s clinical skills requirement by passing the USMLE Step 2 Clinical Skills (CS). Step 2 CS uses simulated patient interactions in which the IMG interacts with patients portrayed by actors. This assesses medical students’ and graduates’ ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues.

While USMLE Step 1 and Step 2 CK are computer-based and administered around the world at designated testing centers, Step 2 CS is offered exclusively in the United States, in Atlanta, Chicago, Houston, Los Angeles, and Philadelphia.

ECFMG assists applicants who seek a visitor visa to enter the United States to take the USMLE Step 2 CS. According to the ECFMG handbook on certification:

Upon request, ECFMG provides Step 2 CS applicants with a letter that may assist during the process of applying for a visa. The letter indicates that the applicant is registered for Step 2 CS, one of the exams required for ECFMG Certification. The letter also indicates that the applicant is required to travel to the United States to take the exam and provides the date by which the applicant must complete the exam. You can request this letter when you apply for Step 2 CS. After completion of the registration process, ECFMG will issue the letter, and it will be available to you through IWA [interactive Web Applications]. If you are unable to obtain the appropriate visa to enter the United States to take Step 2 CS, you may request a full refund of the exam fee.

There is a third step of the USMLE, which assesses the understanding of biomedical and clinical science. According to the USMLE, it emphasizes patient management in ambulatory settings and provides a final assessment of physicians assuming independent responsibility for delivering general medical care. It may be necessary for some physicians to complete this examination prior to their departure to the United States for graduate medical training, since it is required for an H-1B visa, one of the two type of visas used to pursue training in the United States. The other visa, the J-1, only requires passing the USMLE Steps 1 and 2, but doctors on J-1s who wish to remain in the United States after their training is complete need to pass the USMLE Step 3 before the completion of their programs. Step 3 is only offered at test centers in the United States and U.S. territories.

IMGs need to register for USMLE examinations through the ECFMG website, at www.ecfmg.org. ECFMG has an Interactive Web Application on its website which is different from the application used by graduates of U.S. medical schools on the USMLE website. ECFMG will notify the physician through email once the application has been received and then will verify the physician’s eligibility to take the requested examination. A three-week processing time is to be expected, according to ECFMG.

ECFMG will require Physicians who are taking USMLE Step 1 and 2 CK to select a three-month eligibility period to take the examination. It is possible that a one-time extension may be granted. Physicians who apply for Step 2 CS are assigned a 12-monthn eligibility period (unsurprising when considering that doctors need to come to the United States in order to meet that requirement).

An extension is not permitted for the Step 2 CS examination. ECFMG will issue an examination scheduling permit, at which point physicians can schedule examinations at test centers on a first come, first served basis.

In order to meet deadlines for participating in the National Resident Matching Program, ECFMG also warns doctors that they need to apply for examinations as early as possible.

ECFMG has a seven-year period in which all tests must be completed. USMLE does not allow more than six attempts to pass each USMLE Step or Step Component; however, in any given 12-month period, no more than three re-takes are allowed. The fourth and subsequent attempts have to be at least 12 months after the first try and at least six months after the most recent attempt.

What are the educational requirements for ECFMG certification?

In order to meet the educational credential requirements for ECFMG certification, an IMG needs to:

• Be a graduate of a medical school listed in the International Medical Education Directory (IMED) and have graduated in a year included in the school’s IMED listing;
• Have been awarded credit for at least four academic years by a medical school listed in IMED; and
• Have documentation for the completion of all requirements and receipt of the final medical diploma.

ECFMG must receive all copies of the IMG’s final medical school transcripts and “primary source verification” of the IMG’s diploma and transcript. In order to do so, ECFMG must communicate directly with authorized officials from the applicant’s medical schools. Additionally, this involves ECFMG reviewing the submitted credential and comparing it to previously verified samples from the particular institution.

If any document is in a language other than English, it must be translated in accordance with the various requirements put forth by ECFMG in its annually published Information Booklet.

In 2012, ECFMG launched an electronic credentials evaluation pilot program with 20 international medical schools. ECFMG expects this system to result in quicker turnaround times for processing certifications.

What types of graduate medical training programs are available in the United States?

The American Medical Association states that there are four types of graduate medical training programs most IMGs pursue:

1. Residents in one-year transitional programs rotate through different hospital departments every couple of months. Though a transitional program would count as a year of training, it is possible it wouldn’t provide enough credits to progress into the second year of medical training.
2. Preliminary programs are for individuals who wish to specialize, such as those who need a year of internal medicine training.
3. Categorical programs are three-year programs which may allow IMGs to train up to board eligibility contingent upon satisfactory performance. Seen as more traditional, categorical programs are mainly hospital-based.
4. Primary-care programs provide increased emphasis on ambulatory care experience in the community and are becoming more prevalent.

It is in the best interest of individuals who are certain that they will be working as a generalist to apply to a primary-care program. Those wanting to fully train in internal medicine and then have the opportunity to train in a specialty should apply for a categorical program.

IMGs who want to train in the United States generally complete a basic medical or surgical residency program. From there, many will then select a specialty and pursue admission to a fellowship program accredited by ACGME.

There are thousands of ACGME specialty programs which are located at universities, Veterans Administration and military facilities, for-profit hospitals, government facilities, and religious-affiliated institutions.

The American Medical Association’s Graduate Medical Education Directory, commonly referred to as, “The Green Book,” lists all of the ACGME-accredited programs and the number of residency positions the program is authorized to fill.

What is the Electronic Residency Application Service?

Physicians who seek residency positions can participate in the Electronic Residency Application Service (ERAS) which is run by the Association of American Medical Colleges (AAMC). ERAS can be found at http://bit.ly/1MEA7z8.

ERAS provides for the electronic transmission of residency applications and supporting documents to residency program directors, including but not limited to letters of recommendation, transcripts and student evaluations. Typically, applicants designate a medical school dean’s office to transmit documents to residency programs through ERAS.

For IMGs, ECFMG is the designated dean’s office. ECFMG supplies applicants with a specific 14-digit, alpha-numeric identification number which is obtained through ECFMG’s Online Applicant Status and Information System (OASIS). This is known as a token, which allows applicants to complete the ERAS application online. Applicants can send ECFMG the following documents via OASIS for scanning in to ERAS:

• Medical Student Performance Evaluation (MSPE);
• Medical school transcript;
• Letters of Recommendation (LoRs);
• A digital photograph;
• ECFMG status report;
• USMLE transcript;
• Postgraduate Training Authorization Letter (PTAL) or “California Letter”; and
• Fifth Pathway certificate.

ECFMG transmits that information to whatever residency programs the IMG selects and can later provide updates regarding the granting of ECFMG certification. ECFMG also sends the applicant’s USMLE documentation via ERAS.

If a specialty participates in ERAs, the applicant to a program must use ERAS, or else the applicant should contact the program regarding the procedure for filing a paper application.

Once the application is submitted via ERAS, applicants may then be invited to interview with a residency program.

What is “the Match”?

In the United States, residency programs have a highly regimented structure. They all operate on the same academic calendar, from July 1 to June 30. They are almost entirely funded by American taxpayer dollars, via the Medicare system, and the budget allocation of Medicare dollars determines the number of available residency programs annually.

Admission to residency programs is primarily determined by a computerized system called the National Resident Matching Program, commonly referred to as, “The Match.” In The Match, teaching hospitals interview prospective residence and then select their top choices, and physicians select their top choices of teaching hospitals.

The Match’s application period opens on September 15, with the Match occurring the following March. The Match involves applicants submitting a list of their top residency programs along with residency program directors submitting lists of their top choices of applicants. The selections are then made by a computer, which takes into account the preferences. It is a requirement that the IMG have already passed all exams required for ECFMG certification prior to Match registration, but the IMG can register for the Match before they have received the ECFMG certificate.

In March, before the beginning of the academic year, a computer algorithm matches hospitals and physicians, and physicians who do not match are eligible to apply for unmatched positions.

The Match is a streamlined method of getting doctors into residency programs. All graduate medical programs participating in the Match agree that all of their residency positions will be included. In the 2013 main match, 96 percent of the 26,392 residency slots were filled via the Match.

Furthermore, 93.7 percent of the 17,487 U.S. medical school graduates were matched, with 80 percent of U.S. graduates being matched to one of their top three schools. More than 5,000 American graduates of foreign medical schools also applied with just over half of them matching. According to the latest match results from the National Resident Matching Program:

The number of active applicants who were non-U.S. citizen students/graduates of international medical schools increased from 6,828 in 2012 to 7,568 this year. The match rate for this group rose markedly from 40.6 percent in 2012 to 47.6 percent in 2013, the highest since 2006.

Over the course of the past 30 years, the percentage of non-U.S. citizen IMGs matching has fluctuated dramatically, from 21 to 64 percent.

The National Resident Matching Program has a new program called the Supplemental Offer and Acceptance Program (SOAP) to help match unfilled programs with doctors who were unsuccessful in the initial Match.

SOAP is a series of rounds where graduate medical education programs make offers to unmatched applicants, who have expressed preferences in ERAS. In 2013, more than 40 percent of the 13,808 SOAP applicants were non-citizen IMGs.

Once an IMG matches, he or she will obtain a contract or an official letter of offer for a position in an approved graduate medical education or training program, which will be vital for visa processing.

Upon completion of medical school, IMGs are required to submit copies of their final medical diploma to ECFMG, as well as the ECFMG Medical Education Credentials Submission Form (Form 344), and two copies of the Medical School release Request (Form 345). ECFMG will request verification of the diploma from the IMG’s medical school and a final medical school transcript.

ECFMG requires any documents to either be submitted in English or accompanied by an English translation adhering to various requirements, such as being prepared by a government official or professional translator and having a certification from the translator.

Do physicians training in residency and fellowship programs require licenses?

It is required of physicians engaged in clinical care in the United States to hold a license, and it is worth noting that physicians participating in licensing programs are often treated under different rules.

Each state has its own licensing requirements. Some states require training or restricted licenses or permits for physicians participating in graduate medical education programs, and those licenses can be linked to a particular residency program. Furthermore, some states may require a physician who is in the middle of training to obtain unrestricted licenses to continue progressing in his or her training program, while some states have additional requirement for IMGs. It is imperative that a physician check with a particular state’s medical licensing board before pursuing residency in order to determine licensing requirements.

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