Medical Education in the U.S.

Unlike India, medical education in the United States generally follows completion of a bachelor's degree in any other field. The U.S. universities do not have medical degrees at undergraduate level like India has in the form of MBBS and BDS. Admission to entry level medical programs in the U.S. is very competitive. Less than half of U.S. citizen applicants are accepted to medical school, and typically less than 3 percent of international applicants are accepted. In 2007 only 155 of the 16,221 students who entered medical school were foreign nationals, and most of them were individuals who had completed their undergraduate education in the United States. Because medical schools, particularly public medical schools, are funded largely by taxes raised in the states where they are located, admissions preference is usually given to residents of that state. Some state-supported schools will consider only U.S. citizens and permanent residents for admission. Therefore it is strongly advised to Indian students to apply for U.S. medical education only after completing their MBBS.

First Professional Degree                                             Medical school usually lasts four years and students graduate with the Doctor of Medicine (M.D.) degree, which is equivalent to MBBS in terms of classroom teaching and experience with observation and clinical work. Admission requirements include an undergraduate degree in almost any discipline as long as the student's course load includes the required minimum number of prerequisite courses in the biological sciences, chemistry, mathematics, behavioral and social sciences and humanities. Additional requirements include an excellent undergraduate academic record; fluency in English; extracurricular activities such as work experience and volunteer commitments; and a satisfactory score on the Medical College Admission Test (MCAT), a standardized entrance examination administered around the world on computer.

Students interested in studying toward an M.D. degree should carefully consider the level of difficulty of entrance requirements, length of time involved (four years of undergraduate study plus another four years of medical school), and recognition of a U.S. medical degree and licensing qualifications in their home country to determine if medical study is appropriate for them. The Association of American Medical Colleges (http://www.aamc.org) publishes an annual guide to medical schools that includes useful information and statistics on admission requirements.

Postgraduate Training                                                   Many foreign nationals who receive their first degree in medicine (MBBS for India) in their home country choose to continue their graduate medical education in the United States. To be eligible to practice medicine in the United States, all physicians, regardless of whether they were educated in the United States or outside the United States, must:

• receive the first professional medical degree from a medical school accredited by the Liaison Committee on Medical Education;
  
• complete a period of residency or graduate medical education;
  
• pass state licensure examinations.

Obtaining ECFMG Certification                                       U.S. graduate training for physicians generally involves completing a prescribed period of clinical training in a chosen medical specialty, usually called a "residency". The Accreditation Council for Graduate Medical Education (ACGME) accredits such programs. While entry to residencies is quite competitive, international physicians have far better chances to pursue U.S. study at this level than at the first professional level.

To obtain residency positions or other training involving patient contact, graduates of medical schools outside the United States must pass a certification program administered by the Educational Commission for Foreign Medical Graduates (ECFMG). This certification program is designed to assure both the U.S. public and directors of residency programs that applicants from foreign medical schools have qualifications comparable to U.S. medical school graduates. All graduates of medical schools outside the United States and Canada (including U.S. citizens who have graduated from medical schools not accredited by the Liaison Committee on Medical Education) must meet ECFMG certification requirements.

For ECFMG certification, you will have to:

• Submit documents showing graduation from a medical school listed at the time of graduation in the then current edition of the World Directory of Medical Colleges.
  
• Submit documents showing completion of all educational requirements to practice medicine in the country where your medical education was completed. Physicians who are nationals of the country where they were educated must also have a license to practice medicine in that country.
  
• Pass both the basic medical science (Step 1) and clinical science (Step 2) sections of the U.S. Medical Licensing Examination (USMLE). These are computer-based examinations administered at testing centers worldwide.
  
• Achieve an acceptable score on the Test of English as a Foreign Language (TOEFL), which is a computer-based English language proficiency test administered at testing centers worldwide.

In addition to ECFMG certification, some states require that foreign medical graduates pass a third medical licensing examination, the USMLE Step 3, prior to taking part in a residency. This test is administered only in the United States.

Locating a Residency

ECFMG certification does not guarantee placement in a residency program. Indeed, in some years, only small percentages of international medical graduates who gained ECFMG certification have been placed in residency positions.

International medical graduates applying for residencies must have ECFMG certification before beginning a residency, but they may initiate correspondence with a program before they receive certification.

When corresponding with residency programs, graduates should obtain information on such issues as salary, length of appointment, elements of the program, hours of duty and responsibilities, and provision of health and professional liability insurance.

Application must be made to individual programs, and, in addition, applicants must generally participate in the National Resident Matching Program (NRMP) or one of several other computerized application programs in which residency programs in particular specialties participate. An increasing number of medical specialties are requiring use of the Electronic Residency Application System (ERAS), administered for international medical graduates by ECFMG.

To take part in the NRMP, physicians must pass all ECFMG examinations by January 1 of the year in which they plan to enter the residency. The NRMP allows each applicant to submit a list of their preferred residencies, which are then matched with the preferences submitted by residency programs.

ECFMG-certified foreign physicians who are matched with residency positions usually are eligible to receive sponsorship from the ECFMG for exchange visitor (J-1) visas. The period for which J-1 status is valid varies with the medical specialty chosen, with each specialty board determining the appropriate length of time for graduate clinical training in that specialty. After completion of the stipulated training period, exchange visitor physicians must leave the United States. They are not eligible to petition to apply to return to the United States in immigrant, temporary worker, or trainee status, or as an intra-company transferee, until they have resided in their home country, or country of last permanent residence, for two years.

Alternatives Not Requiring ECFMG Certification

Graduate Academic Education
Foreign medical graduates can apply directly to graduate academic programs in medically related fields that do not involve patient care. Such programs do not require ECFMG certification. Application procedures are similar to those for graduate programs in non-medical fields. A few examples of medically related fields of study include radiology, immunology, molecular biology, genetics, neuroscience, pathology, and physiology. Foreign medical graduates may also apply for research grants in the health sciences. Hospitals, universities, and independent research centers are possible sites for research.

Short-term Opportunities
Medical centers, hospitals, and medical associations frequently offer conferences or short-term courses, lasting from a few days to a few weeks to, occasionally, several months. Such opportunities are open to foreign medical graduates without ECFMG certification as long as they do not involve direct patient contact. Some medical centers, particularly larger research and teaching institutions, may also be able to arrange individual training for international physicians on request. Such exchanges, again, cannot involve direct patient contact but they can provide valuable opportunities for consultation, observation, and comparison of facilities. There are specific offices, called by a variety of names, including International Services, at some medical centers that arrange such visits. Visits may also be arranged directly with U.S. colleagues.

ECFMG International Fellowships in Medical Education     This program brings selected international medical school faculty members to teach and study in a U.S. medical school for between six months and one year. Eligible areas of study include educational methodology, curriculum design, evaluation systems, medical school governance, and the development of basic and clinical science departments. ECFMG generally arranges a match with a U.S. medical school. All applications must include the endorsement of the candidate's home country medical school. Fellowships are not intended to support a formal curriculum leading to a degree.

The GRE route to Residency!

Due to the difficulties involved in obtaining H1/J1 visa through the USMLE/Residency route, the GRE/MPH has rapidly become an alternate route to enter the United States for many International Medical Graduates (IMGs), who eventually shift to the clinical areas! There are several advantages of taking this route. Some of them are:

• The student visa (F1) is a lot easier to get for programs like Master of Public Health (MPH). You can apply on the basis of your MBBS/MD, get accepted, get the I-20 and then get the visa and fly to the U.S.
• Once you are in the U.S. on an F1, it becomes much easier to move around and get the much sought after clinical experience and research "from a U.S. medical school". Most programs give preference to these candidates. The Drexel University Psychiatry Residency program for example, says "preference is given to candidates who have clinical or research experience in the United States or in the United Kingdom, though this is not a requirement".
• These experiences give you an opportunity to get the U.S. LORs, which is simply not possible otherwise.
• You need not worry about business/visitor visa to appear for Step 2 CS, Step 3 and residency interviews. You simply go to the nearby Prometric center in the U.S. and appear for the CS/Step 3. Similarly you just take a leave of 2 days and take a 3-4 hour flight to appear for the residency interview. Much simpler than flying all the way from India!
• And all the effort that you are going to be puting in earning an MPH or other non-clinical degree is not going to be for nothing. Many residency programs do give enough weightage to these degree programs. The University of Missouri, Columbia website, for example, mentions one of the many IMG requirements as "Completed an advanced degree program (M.P.H., PhD) with a record of multiple publications in peer-reviewed medical journals."
• Considering all these factors, sometimes it makes much more sense to appear for GRE rather than the USMLE!

The OPT advantage

If you are enrolled in a Masters or Doctoral program in any university in the U.S., you are eligible for a 29 month long Optional Practical Training (OPT), that allows you to stay in the U.S. without much difficulties. All you have to do is fill in a simple form at the university once you are done with your master's, pay the required fees and you are good to go. Once it is approved by the USCIS, you get an Employment Authorization Document (EAD) with which you can stay and move around anywhere in the U.S. for a good two-and-a-half years without worrying about your status.

The IMGs who are looking forward to a Residency Match should always save this entire period towards that end. Once you reach the stage of applying for residency through ERAS, you simply put your visa status as EAD.

And when you find a good match, you can right away start your residency on OPT. Some programs even prefer that IMGs come through this route. The Drexel University Psychiatry Residency program for example says "typically we sponsor H visas only if the applicant already has an H visa with enough years remaining on it to complete the residency program or if the candidate has an F visa with an OPT extension that can be used until the H visa cap opens up in October of the candidate’s PGY-1 year."

Once you are a resident, you have a full two-and-a-half years to prove to your Program Director (PD) that you deserve an H1 visa sponsorship. This also gives you enough time to complete your USMLE step 3, to strengthen your case.

There is another distinct, but not readily apparent advantage of starting your residency on OPT and then opting for H1. Once your H1 petition is approved you will be required to get it stamped on your passport, by appearing for an interview at a U.S. consulate in Canada, Mexico, UK or India. At this interview you would be very easily able to show enough proof that you are already employed in a hospital and so you rightly deserve this visa. This proof would be in the form of your pay-stubs from the residency program, your residency certificates, a letter from your PD, a few pictures of you working with your team of researchers etc. This would in most cases be sufficient to get the approval from the consular officer. He or she is not going to turn away an IMG who is already contributing towards the betterment of the U.S. Health Care system!

However there is one big disadvantage as well, of taking the GRE route to residency. One of the clauses in the OPT petition says that the student will utilize his/her OPT in working in areas closely related to MS/PhD program. For example MPH candidates on OPT are expected to work towards improving the Public Health system in the U.S. and not to do advanced research and residency in Internal medicine or Cardio! In this kind of a scenario, you may have to use all your persuasive skills to convince your PD that the residency is not a violation of any of the OPT clauses. You could provide them with proper documentation from the USCIS website to somehow link the residency to what you are supposed to do on the OPT status.

One more issue that IMGs may be asking is weather they can start their residency on F1 itself and later transfer to H1 status. Well, the answer is no. You cannot do that for the simple reason that F1 students are permitted to work only for 20 hours per week, on campus while the semester is on. Whereas a  residency is a full-time commitment that requires 40 or more hours per week. Even the transitional or preliminary year cannot be done a a student visa status.

Planning for Residency via GRE

Once you have decided to take the GRE route to residency, you will have to plan on how to maximize the overall long-term benefits of investing your time, money and energy in earning a degree that is not your final goal. But since it does require your efforts, it should benefit you even if your eyes are set on something else. The first issue, of course, is to select a field. Is it going to be Public Health? or Neurological Science? or Biomedical? Well there are close to 30 fields in Medical. Health and Biomedical areas in which you can earn a master's degree in the U.S. The point here to emphasize is which one will augment and supplement your residency application the most, for which you are taking all this trouble in the first place. For a moment consider that you are keen on a Neurology residency. Think about what will impress the PD of Neurology more-An MPH or a Masters in Neurological Science. 

After you have zeroed in on the major, the next step is to find a suitable university that offers a master's in that major. Your target should be to get into universities that are well known in the medical residency circuits like John Hopkins, Case Western, Tufts, Washington University etc. Of course, there are others like Harvard, Stanford etc., but they are too difficult to get into for majority of the IMGs. The university's name  should catch the attention of Residency PDs running through hundreds of applications in a short span of time. Names do matter while applying for medical residency programs!

Another important factor that IMGs should consider in shortlisting the university is to apply to only those universities that have full-fledged Medical Schools.