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I. 2004-2005: "Essential Facts for International Medical Graduates"
published by the Massachusetts Medical Society in cooperation with the ECFMG
obtain a copy by calling 800-322-2303 ext 7413 or email eriley@mms.org
II. Applying for a Residency in the USA - What You Need To Know
compiled by Dr. Graham McMahon MRCPI
I graduated from the Royal College of Surgeons in Ireland in 1997, and moved to Boston after matching at the Brigham & Women's Hospital in 1999. 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.
There are a number of essential components to getting a residency
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
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.
8. Attend for your interviews
9. Rank your favourite programs
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. Sign and return your contract
13. Initiate the licensing application for the state that you matched with (requires your ECFMG certificate and a copy of the signed contract with the hospital)
14. Once the state medical license is secure, you can apply for the visa.
15. Organise accommodation, flights, cargo etc.
A review of the necessary ingredients:
1. The USMLEs
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 four blocks of about 300 questions. You're given about three hours for each block of questions, and take two blocks on each day. 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.
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 two-day, four x 3-hour question sessions, 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.
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 there to take it. Also, only a few states - most notable Connecticut and New York 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.
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 & 2
3. - passed the clinical skills assessment
4. - passed a TOEFL English examination
5. - paid ECFMG
Once achieved, the ECFMG will issue you with a certificate saying that you have fulfilled the requirements for entry into training in the USA.
Important! 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 is where I got caught out and this delayed my visa application).
Separate from the USMLE's, but required for ECFMG certification, is the clinical skills assessment (CSA). This expensive ($1200) examination is held in Philadelphia throughout the year, and nowhere else (as of Sept 2000). It brings examinees face-to-face with simulated 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.
The English examination is not run by ECFMG any longer. You will be required to take a TOEFL (teaching of English as a foreign language) examination. It is run in most countries by the Educational Testing Service. Click here for more information on the TOEFL examination.
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 standardised 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
(* the program prints a bar-coded page that is sent on paper with these documents)
Foreign medical graduates send their disk and the paper items marked * above to the ECFMG who act as your "dean's office". They 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.
4. 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 specialties participate only in the "Early Match". See the NRMP site for more information. As an international applicant, you must register as an 'independent applicant'.
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, 2001 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 two 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
5. State Medical Licenses
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
6. 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.
6A. 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. J-1 visas are issued by the U.S. consulate in the country to which the resident will return and are generally sponsored by the ECFMG Exchange Visitor Program.
Your governmental health office must sign a document indicating the need in your home country for physicians trained in your prospective specialty. U.S. consulates sometimes refuse to issue J-1 visas when they believe the applicant does not intend to return. Since J-1 visa applications are filed after the match when the resident has already secured a position, inability of the applicant to obtain a visa may pose a problem for residency programs.
An exchange visitor holding a J-1 visa cannot remain in the U.S. beyond the seven year limit to pursue other types of training or for practice, or for academic activities unless he/she qualifies for a waiver to the foreign residency requirement.
There are now four statutory justifications for such a waiver. Three have been available for several years;
(1) a finding by the INS of exceptional hardship for a spouse or child who is a U.S. permanent resident or citizen;
(2) a finding by the INS that the alien would face persecution on returning home;
(3) support of a waiver from a U.S. government agency based on the alien accepting a position that could not be filled by a U.S. citizen.
Typically, the latter have been issued by the U.S. Veterans Administration or less often, the Appalachian Regional Commission (for work on American Indian reservations).
Some countries, notably Canada, refuse to submit the documentation needed by its nationals to obtain a J-1 visa. Thus, it is becoming very difficult for Canadian nationals to obtain U.S. training through the J-1 visa mechanism. Some have likened the J-visa to the HIV virus - once infected with it, you're never cured!
6B. 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;
(2) must have passed USMLE Steps 1, 2 AND 3 (Or NBME/FLEX combinations) AND
(3) must hold a license to practice in a U.S. state or territory before application.
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.
Fortunately, many of you reading this will avoid the problems that I had to go through in securing my H1B visa, as now (Nov 2000) 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. Visas are now easier to change, and green cards may be easier to receive.
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 liaise closely with your employing hospital in this regard and may wish to retain an immigration attorney to handle the process.
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 one week or so to secure a state medical license and submit your H-1B visa application.
Some good visa sites for physicians are as follows:
Carl Shusterman's Immigration site
Udall's Immigration site
7. 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 Specialty that interests you, you must do all your training from PGY-1 (post-graduate year one) to specialty 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.
Good luck!
Graham McMahon
Useful Sites when Applying for Residency
ECFMG Educational Commission for Foreign Medical Graduates
USMLE United States Medical Licensing Examinations
ERAS Electronic Residency Application System
ERAS ADTS ERAS Automated Document Tracking System
NRMP The National Residency Matching Program
American Association of Medical Colleges Coordinate ERAS and NRMP.
FSMB Federation of State Medical Boards - where to apply for your state medical license
American Board of Internal Medicine
American College of Physician's Online Residency Database
U.S. News & World Report Listing of Best Hospitals Comprehensive ranking of US hospitals by speciality and state
Residency Page lists many residency programs that have web pages.
Immigration sites
Shusterman's Immigration site
Udall's Immigration site
VisaLaw.com Providing updated information on immigration
Immigration information page Details information on different visa types
American Immigration Lawyer's association webpage
US Immigration and Naturalization Service Homepage (INS)
Immigration support network
HI-B Frequently asked questions answered here
Immigration Support Network Good FAQ section with independent advice.
Medicine and me
My own home page and listing of Irish medical links
RCSI My medical school
Beaumont Hospital My first teaching hospital
Brigham & Women's Hospital where I am currently working
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