The following is an excerpt from the upcoming book, The Physician’s Immigration Handbook by Greg Siskind:
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The primary focus of this book is on physician immigration law. However, as most of the pathways for physicians to immigrate to the US run through graduate medical training programs at American teaching hospitals, a brief primer on the subject is provided here.
The following is intended to provide a basic outline of the requirements that the IMG must meet in order to qualify to train in a program accredited by the Accreditation Council on Graduate Medical Education (ACGME). ACGME accredits US graduate medical education programs and to qualify for a state medical license, an IMG normally needs to train in an ACGME approved program for at least two, and usually, three years or more. Physicians who complete ACGME-accredited programs also qualify to sit for specialty certification examinations that are offered by the various member boards of the American Board of Medical Specialties (ABMS). Many employers require board certification or at least board eligibility and many hospitals require certification before offering doctors hospital privileges. Not surprisingly, the vast majority of physicians in the US have at least one board certification. Physicians obtaining board certifications are required 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 ACGME-accredited residency programs must 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. IMGs can apply to residency programs before the certification is issued as long as they have it before entering the program.
An ECFMG standard certificate verifies the equivalency of an IMG’s educational credentials to what one would obtain in the United States as well as the IMG’s passage of required examinations.
IMGs seeking an ECFMG certificate must first file an application for a USMLE/ECFMG Identification Number and the Application for ECFMG Certification.
Note that up until 2009, an alternative to the ECFMG Certificate was the “Fifth Pathway” Certificate. ECFMG normally requires a final medical diploma from the foreign medical school and this would include completion of an internship/social service requirement. Beginning in 1971, the American Medical Association (AMA) created the “Fifth Pathway” program that allowed students to complete a year of supervised clinical work at a US medical school that could then be followed by entry in to a US residency program and eventually a state medical license. USMLE permitted those with Fifth Pathway certificates to take USMLE examinations. That program ended in December 2009. USMLE will allow individuals with Fifth Pathway certificates issued before December 31, 2009 to participate in the USMLE program through December 31, 2016.
What else does ECFMG do that’s important for IMGs?
ECFMG is involved with many aspects of the IMG’s immigration process including evaluating foreign credentials, serving as the J-1 exchange program sponsoring IMGs and acting as the Dean’s office in assisting IMGs applying to participate in the National Resident Matching Program.
What is the United States Medical Licensing Examination?
After applying for the ECFMG certificate and identification number, the IMG then must sit for the United States Medical Licensing Examination which is comprised of three parts and is administered by the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).[1] According to test administrators, it “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.”[2] Applicants must have at least two years of medical school completed to take the examinations.
There are no published minimum score requirements for the various USMLE Steps and Step Components. 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 you test will be the level used for scoring purposes.”
The first part is the US Medical Licensing Examination (USMLE) Step 1. The USMLE Step 1 tests whether an individual understands concepts of the sciences basic to the practice of medicine.
The second medical science examination is the USMLE Step 2 Clinical Knowledge (CK). Step 2 CK assesses whether a doctor can apply medical knowledge, skills, and understanding of clinical science.
IMGs must also satisfy ECFMG’s clinical skills requirement by passing the USMLE Step 2 Clinical Skills (CS). Step 2 CS uses standardized patients to test medical students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. It is done through simulated patient interactions in which the examinee interacts with patients portrayed by actors. Unlike the USMLE Step 1 and USMLE Step 2 CK which are computer-based and given around the world at designated testing centers, the USMLE Step 2 CS is offered only in the United States and only in five cities – Philadelphia, Chicago, Atlanta, Houston and Los Angeles.
ECFMG will assist applicants seeking a visitor visa to enter the US 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 also a third step of the USMLE which assesses understanding of biomedical and clinical science. According to USMLE, it emphasizes patient management in ambulatory settings and provides a final assessment of physicians assuming independent responsibility for delivering general medical care.[3] Some physicians will need to complete this examination before coming to the US for GME because it is required for an H-1B visa, one of the two types of visas used to pursue training in the US.[4] The other visa, the J-1, only requires passage of USMLE Steps 1 and 2. However, doctors on J-1s interested in remaining in the US after their training is completed will need to pass USMLE Step 3 before their programs are completed. Step 3 is only offered at test centers in the US and US territories.
IMGs must register for USMLE examinations through the ECFMG web site (www.ecfmg.org). ECFMG has an Interactive Web Application (IWA) on its web site which is different than the application used by graduates of US medical schools on the USMLE web site. ECFMG will send an email notifying the physician when the application is received and then will verify eligibility to take the examination requested. According to ECFMG, a three week processing time is typical.[5] Note that ECFMG’s application process differs depending on whether an applicant is in medical school or has already graduated. Details on the differing procedures can be found in the ECFMG Information Booklet.[6] The current fee schedule for IMGs taking USMLE can be found at http://www.ecfmg.org/fees/.
For applicants taking USMLE Step 1 and Step 2 CK, ECFMG will require applicants to select a three month eligibility period to take the examination. A one-time extension may be granted. Physicians applying for Step 2 CS are assigned a 12-month period of eligibility (which is not surprising given doctors have to get to the United States to meet that requirement). An extension is not permitted. ECFMG will issue an examination scheduling permit and physicians can then schedule examinations at test centers on a first-come, first-served basis.
ECFMG also cautions doctors to apply early for examinations to meet deadlines for participating in the National Resident Matching Program (NRMP).
ECMFG requires that all tests must be completed within a seven-year period. And USMLE allows no more than six attempts to pass each USMLE Step or Step Component and no more than three retakes within a 12 month period. Fourth and later attempts must be at least 12 months after the first try and at least six months after the most recent attempt.
As noted above, individuals coming to the United States to take USMLE examinations enter with visitor visas.
What are the educational requirements for ECFMG certification?
To meet the educational credential requirements for ECFMG certification, an IMG must
- be a graduate of a medical school listed in the World Directory of Medical Schools (World Directory)[7] which can be found online at wdoms.org and have graduated in a year included in the school’s World Directory listing
- have been awarded credit for at least four academic years by a medical school listed in the World Directory
- document the completion of all requirements for, and receipt of the final medical diploma.[8]
ECFMG must receive all copies of the IMG’s final medical school transcripts and “primary source verification” of the IMG’s diploma and transcript. This involves ECFMG communicating directly with authorized officials of the applicants’ medical schools. It also involves ECFMG reviewing the submitted credential and comparing it to previously verified samples from the particular institution.
Any documents that are not in English must be translated and the translation must meet various requirements set by ECFMG in its annually published handbook (which can be downloaded at www.ecmfg.org.
In 2012, ECFMG launched an electronic credentials evaluation pilot program with 20 international medical schools. ECFMG expects the system to result in faster turnaround times for processing certifications.
What types of graduate medical training programs are available in the US?
According to the AMA[9], there are four types of graduate medical training programs most IMGs pursue:
- Residents in one-year transitional programs rotate through different hospital departments every couple of months. While a transitional program counts as a year of training, it may not provide enough credits to move into the second year of residency training.
- Preliminary programs are also one-year programs for those wishing to specialize who need a year of internal medicine training.
- Categorical programs are three-year programs that may allow you to train up to board eligibility if your performance is satisfactory. Categorical programs are seen as the more traditional program and are mainly hospital-based.
- Primary care programs provide increased emphasis on ambulatory care experience in the community and are becoming more prevalent. Those who are sure that they will be working as a generalist are advised to apply to a primary care program. Those who wish to fully train in internal medicine and then have the opportunity to train in a specialty should apply for a categorical position. While it is preferable to be in a categorical or primary care program, training in a transitional or preliminary program is better than being in no program at all. It is highly advisable to choose the program that best suits your needs and goals.
IMGs seeking to train in the US will typically complete a basic medical or surgical residency program and many then select a specialty pursue admission to a fellowship program accredited by the American Council for Graduate Medical Education (ACGME). ACGME specialty programs number in the thousands and are located at universities, Veterans Administration and military facilities, for profit hospitals, government facilities and religiously 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 how many residency positions the program is authorized to fill.
What is the Electronic Residency Application Service?
Physician seeking residency positions can participate in the Electronic Residency Application Service (https://www.aamc.org/students/medstudents/eras/) run by the Association of American Medical Colleges (AAMC). ERAS provides for the electronic transmission to residency program directors of residency applications and supporting documents including letters of recommendation, transcripts and student evaluations. Applicants normally 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 provides applicants with a special 14-digit, alpha-numeric identification number that can be obtained on ECFMG’s Online Applicant Status and Information System (OASIS) known as a token that allows applicants to fill out the ERAS application.[10] 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)
- Photograph
- ECFMG Status Report
- USMLE Transcript
- Postgraduate Training Authorization Letter (PTAL) or “California Letter”
- Fifth Pathway Certificate[11]
ECFMG transmits the information to the residency programs selected by the IMG 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. Otherwise, the applicant should contact the program regarding the procedure for filing a paper application. For a list of specialties participating in ERAS, go to https://services.aamc.org/eras/erasstats/par/.
After the application is submitted via ERAS, applicants may then be invited to interview with a residency program.
What is “The Match”?
Residency programs in the US have a highly regimented structure. They all work on the same academic year – July 1st to June 30th. They are almost entirely funded by American taxpayers through the Medicare system and the budget allocation of Medicare dollars determines how many residency positions open up each year. Admission to residency programs is primarily determined by a computerized system called the National Residency Matching Program (NRMP), commonly referred to as “the Match”, where teaching hospitals interview prospective residents and then select their top choices. Physicians also select their top choices of teaching hospitals.
The application period for the Match opens up on September 15th and the Match occurs the following March. The Match involves applicants submitting a list of their top residency programs and residency program directors submitting lists of their top choices of applicants. A computer then makes selections based on the preferences. IMGs must have passed the exams required for ECFMG certification before registering for the Match even if they have not yet received the ECFMG certificate.
In March prior to the beginning of the academic year, a computer algorithm will match hospitals and physicians. Those physicians not matching are afterward eligible to apply for unmatched positions.
The Match is a streamlined way to get doctors in to 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, 26,392 residency slots were made available and 96% of those slots ended up being filled through the Match (as opposed to the positions remaining open and filled afterwards by doctors who did not match). 93.7% of the 17,487 US medical school graduates matched and nearly 80% of US graduates were matched to one of their top three choices. Over 5,000 American graduates of foreign medical schools also applied with just over 50% of them matching.[12] And according to the latest NRMP match results:
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.[13]
Over the last three decades the percentage of non-US citizen IMGs matching has fluctuated from 21% to 64%.[14]
Couples can enter the Match as a unit so that they have a better chance of ending up at the same teaching hospital. 935 couple applied for the Match in 2013 and more than 95% of them matched.[15]
The NRMP program has a new program called the Supplemental Offer and Acceptance Program (SOAP) to help unfilled programs match with doctors unsuccessful in the initial Match. SOAP is a series of rounds where GME programs make offers to unmatched applicants who have expressed preferences in ERAS. In 2013, more than 40% of the 13,808 SOAP applicants were non-US citizen IMGs.[16]
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. That contract or letter will be important for visa processing.
Upon completion of medical school, IMGs are required to submit copies of their final medical diploma to ECFMG[17] 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 the IMG’s medical school verify the diploma and also provide a final medical school transcript.[18] ECFMG requires any documents submitted to them be in English or accompanied by an English translation meeting 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?
Physicians engaged in clinical care in the United States are required to be licensed. While licensing of IMGs will be discussed more extensively in later chapters of The Physician’s Immigration Handbook – including a chart listing each state’s licensing requirements – it is worth mentioning here 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 GME programs and those licenses may be linked to a particularly residency program. Also, some states require physicians who are in the middle of training to obtain unrestricted licenses to continue progressing in his or her training program. Some states also have additional requirements for IMGs. Physicians are advised to check with a state’s medical licensing board to determine licensing requirements before pursuing residency training in that state.
Disclaimer: This newsletter is provided as a public service and not intended to establish an attorney client relationship. Any reliance on information contained herein is taken at your own risk.
[1] ECFMG will also accept passing scores in various formerly offered examinations including the ECFMG Examination, the Visa Qualifying Examination (VQE), the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS) and the Part I and Part II Examinations of the National Board of Medical Examiners (NBME). ECFMG will accept combinations of exams are also acceptable. But note that immigration and licensing rules may differ.
[2] USMLE Bulletin of Information – 2014. http://www.usmle.org/pdfs/bulletin/2014bulletin.pdf .
[3] USMLE Bulletin of Information – 2014. http://www.usmle.org/pdfs/bulletin/2014bulletin.pdf
[4] Up until 2013, many state medical boards barred taking USMLE until some US training had occurred. Some physicians were able to avoid this dilemma by taking the examination in a state other than the one where they would pursue a residency. On October 14, 2013, the Federation of State Medical Boards announced that the USMLE program would no longer require physicians to apply for Step 3 under the eligibility requirements of a state licensing authority and minimum training requirements do not apply. http://www.usmle.org/announcements/default.aspx?ContentId=124 .
[5] ECFMG 2014 Information Booklet. http://www.ecfmg.org/2014ib/2014ib.pdf.
[6] Id.
[7] In 2014, the International Medical Education Directory merged with the Avicenna Directory. The IMED was phased out as of June 30, 2015 and replaced by the World Directory of Medical Schools. http://www.ecfmg.org/news/2014/12/16/world-directory-medical-schools-replace-international-medical-education-directory-imed-2015-purposes-determining-eligibility-ecfmg-certification/#sthash.b7fp4Wzu.dpbs
[8] A medical student may still take USMLE, but ECFMG has a set procedure to verify that a final diploma was issued.
[9] https://www.ama-assn.org/education/international-medical-education/residency-program-requirements-international-medical
[10] ECFMG issues tokens for residency applications only and a new token must be issued in each residency season. Those seeking a fellowship through the ERAS Fellowships Documents Office (EFDO).
[11] http://www.ecfmg.org/eras/applicants-documents-index.html. Note that some foreign medical schools are authorized to submit documents directly to ERAS.
[12] National Resident Matching Program. Results and data: 2013 main residency match. Washington, DC: National Resident Matching Program, 2013 (p. 1).
[13] Id.
[14] Id at p. 19.
[15] Id at p. 1.
[16] Id at p. 45.
[17] The name of the diploma can be found in the document “Reference Guide for Medical Education Credentials” at www.ecfmg.org as well as information on how a photocopy of the diploma should look.
[18] If ECFMG cannot obtain the transcripts, it will request the IMG to provide two copies meeting ECFMG specifications to ECFMG and ECFMG will then send a copy of the transcript to the medical school for verification. ECFMG 2014 Information Booklet p. 81 available at www.ecfmg.org.