usmle step 1 Educational Commission for Foreign Medical Graduates (ECFMG)
By Live Dr - Mon Dec 01, 12:51 am
GUIDE TO EFFICIENT EXAM PREPARATION 24
words, go with your “first hunch.” However, studies show that if you change
your answer, you are twice as likely to change it from an incorrect answer to a
correct one than vice versa. So if you have a strong “second hunch,” go for it!
Fourth-Quarter Effect (Avoiding Burnout)
Pacing and endurance are important. Practice helps develop both. Fewer and
fewer examinees are leaving the examination session early. Use any extra time
you might have at the end of each block to return to marked questions or to
recheck your answers; you cannot add the extra time to any remaining blocks of
questions or to your break time. Do not be too casual in your review or you may
overlook serious mistakes. Remember your goals, and keep in mind the effort
you have devoted to studying compared with the small additional effort you will
need to maintain focus and concentration throughout the examination. Never
give up. If you begin to feel frustrated, try taking a 30-second breather.
CLI N ICAL VIGNETTE STRATEGIES
In recent years, the USMLE Step 1 has become increasingly clinically oriented.
Students polled from 2003 exams report that nearly 80% of the questions were
presented as clinical vignettes. This change mirrors the trend in medical education
toward introducing students to clinical problem solving during the basic
science years. The increasing clinical emphasis on Step 1 may be challenging
to those students who attend schools with a more traditional curriculum.
What Is a Clinical Vignette?
A clinical vignette is a short (usually paragraph-long) description of a patient, including
demographics, presenting symptoms, signs, and other information concerning
the patient. Sometimes this paragraph is followed by a brief listing of important
physical findings and/or laboratory results. The task of assimilating all
this information and answering the associated question in the span of one
minute can be intimidating. Be prepared to read fast and think on your feet. Remember
that the question is often indirectly asking something you already know.
Remember that the Step 1 vignettes usually describe diseases or disorders in
their most classic presentation. Look for buzzwords or cardinal signs (e.g., malar
rash for SLE or nuchal rigidity for meningitis) in the narrative history. Be aware,
however, that the question may contain classic signs and symptoms instead of
mere buzzwords. Sometimes the data from labs and the physical exam will help
you confirm or reject possible diagnoses, thereby helping you rule answer
choices in or out. In some cases, they will be a dead giveaway for the diagnosis.
Your first hunch is not always
Do not terminate the block
too early. Carefully review
your answers if possible.
Be prepared to read fast and
think on your feet!
Step 1 vignettes usually
describe diseases or disorders
in their most classic
GUIDE TO E FFIC IENT EXAM PREPARATION
Making a diagnosis from the history and data is often not the final answer. Not
infrequently, the diagnosis is divulged at the end of the vignette, after you have
just struggled through the narrative to come up with a diagnosis of your own.
The question might then ask about a related aspect of the diagnosed disease.
One strategy that many students suggest is to skim the questions and answer
choices before reading a vignette, especially if the vignette is lengthy. This focuses
your attention on the relevant information and reduces the time spent
on that vignette. Sometimes you may not need much of the information in
the vignette to answer the question.
National Board of Medical Examiners (NBME)
Department of Licensing Examination Services
3750 Market Street
Philadelphia, PA 19104-3102
Fax: (215) 590-9457
Educational Commission for Foreign Medical Graduates (ECFMG)
3624 Market Street, Fourth Floor
Philadelphia, PA 19104-2685
Toll free within North America: (800) 500-8249
Fax: (215) 386-9196
Federation of State Medical Boards (FSMB)
P.O. Box 619850
Dallas, TX 75261-9850
Fax: (817) 868-4099
3750 Market Street
Philadelphia, PA 19104-3190
Sometimes making a
diagnosis is not necessary at
GUIDE TO E FFICIENT EXAM PREPARATION 26
1. Bidese, Catherine M., U.S. Medical Licensure Statistics and Current
Licensure Requirements 1995, Chicago, American Medical Association,
2. National Board of Medical Examiners, 2002 USMLE Bulletin of Information,
3. National Board of Medical Examiners, Bulletin of Information and
Description of National Board Examinations, 1991, Philadelphia,
4. Federation of State Medical Boards and National Board of Medical
Examiners, USMLE: 1993 Step 1 General Instructions, Content Outline,
and Sample Items, Philadelphia, 1992.
5. Pohl, Charles A., Robeson, Mary R., Hojat, Mohammadreza, and
Veloski, J. Jon, “Sooner or Later? USMLE Step 1 Performance and
Test Administration Date at the End of the Second Year,” Academic
Medicine, 2002, Vol. 77, No. 10, pp. S17-S19.
6. Case, Susan M., and Swanson, David B., “Validity of NBME Part I
and Part II Scores for Selection of Residents in Orthopaedic Surgery,
Dermatology, and Preventive Medicine,” Academic Medicine, February
Supplement 1993, Vol. 68, No. 2, pp. S51-S56.
7. Holtman, Matthew C., Swanson, David B., Ripkey, Douglas R., and
Case, Susan M., “Using Basic Science Subject Tests to Identify Students
at Risk for Failing Step 1,” Academic Medicine, 2001, Vol. 76,
No. 10, pp. S48-S51.
8. Basco, William T., Jr., Way, David P., Gilbert, Gregory E., and Hudson,
Andy, “Undergraduate Institutional MCAT Scores as Predictors
of USMLE Step 1 Performance,” Academic Medicine, 2002, Vol. 77,
No. 10, pp. S13-S16.
9. “Report on 1995 Examinations,” National Board Examiner, Winter
1997, Vol. 44, No. 1, pp. 1-4.
10. O’Donnell, M. J., Obenshain, S. Scott, and Erdmann, James B., “I:
Background Essential to the Proper Use of Results of Step 1 and Step
2 of the USMLE,” Academic Medicine, October 1993, Vol. 68, No.
10, pp. 734-739.
11. Robinson, Adam, What Smart Students Know, New York, Crown
12. Thadani, Raj A., Swanson, David B., and Galbraith, Robert M., “A
Preliminary Analysis of Different Approaches to Preparing for the
USMLE Step 1,” Academic Medicine, 2000, Vol. 75, No. 10, pp.
First Aid for the
First Aid for the
First Aid for the
First Aid for the
Student with a
S E C T I O N I S U P P L EMENT
SPECIAL SITUATIONS 28
FIRST AI D FOR THE INTERNATIONAL MEDICAL GRADUATE
“International medical graduate” (IMG) is the term now used to describe any
student or graduate of a non-U.S., non-Canadian, non-Puerto Rican medical
school, regardless of whether he or she is a U.S. citizen. The old term “foreign
medical graduate” (FMG) was replaced because it was misleading when applied
to U.S. citizens attending medical schools outside the United States.
The IMG’s Steps to Licensure in the United States
If you are an IMG, you must go through the following steps (not necessarily
in this order) to become licensed to practice in the United States. You must
complete these steps even if you are already a practicing physician and have
completed a residency program in your own country.
Complete the basic sciences program of your medical school (equivalent
to the first two years of U.S. medical school).
Take the USMLE Step 1. You can do this while still in school or after
graduating, but in either case your medical school must certify that you
completed the basic sciences part of your school’s curriculum before taking
the USMLE Step 1.
Complete the clinical clerkship program of your medical school (equivalent
to the third and fourth years of U.S. medical school).
Take the USMLE Step 2 Clinical Knowledge (CK) exam. If you are still
in medical school, you must have completed two years of school.
Take the Step 2 Clinical Skills (CS) exam.
Graduate with your medical degree.
Then, send the ECFMG a copy of your degree and transcript, which they
will verify with your medical school.
Obtain an ECFMG certificate. To do this, candidates must accomplish
Graduate from a medical school that is listed in the International Medical
Education Directory (IMED). The list can be accessed at
Pass Step 1, the Step 2 CK, and the Step 2 CS within a seven-year period.
Have their medical credentials verified by the ECFMG.
The standard certificate is usually sent two weeks after all the above requirements
have been fulfilled. You must have a valid certificate before
entering an accredited residency program, although you may begin the application
process before you receive your certification.
Apply for residency positions in your field of interest, either directly or
through the Electronic Residency Application Service (ERAS) and the National
Residency Matching Program (“the Match”). To be entered into the
Match, you need to have passed all the examinations necessary for ECFMG
certification (i.e., Step 1, the Step 2 CK, and the Step 2 CS) by the rank order
list deadline (February 22, 2006, for the 2006 Match). If you do not pass
these exams by the deadline, you will be withdrawn from the Match.
More detailed information can
be found in the 2006 edition of
the ECFMG Information
Booklet, available at
Applicants may apply online
for the USMLE Step 2 CK or
Step 2 CS or request an
extension of the USMLE
eligibility period at
Obtain a visa that will allow you to enter and work in the United States if
you are not already a U.S. citizen or a green-card holder (permanent resident).
If required for IMGs by the state in which your residency is located, obtain
an educational/training/limited medical license. Your residency program
may assist you with this application. Note that medical licensing is
the prerogative of each individual state, not of the federal government, and
that states vary with respect to their laws about licensing (although all 50
states recognize the USMLE).
In order to begin your residency program, make sure your scores are valid.
Once you have the ECFMG certification, take the USMLE Step 3 during
your residency, and then obtain a full medical license. Once you have a license
in any state, you are permitted to practice in federal institutions
such as VA hospitals and Indian Health Service facilities in any state. This
can open the door to “moonlighting” opportunities and possibilities for an
H1B visa application. For details on individual state rules, write to the licensing
board in the state in question or contact the FSMB.
Complete your residency and then take the appropriate specialty board exams
in order to become board certified (e.g., in internal medicine or
surgery). If you already have a specialty certification in your home country
(e.g., in surgery or cardiology), some specialty boards may grant you six
months’ or one year’s credit toward your total residency time.
Currently, many residency programs are accepting applications through
ERAS. For more information, see First Aid for the Match or contact:
P.O. Box 11746
Philadelphia, PA 19101-0746
Fax: (215) 222-5641
The USMLE and the IMG
The USMLE is a series of standardized exams that give IMGs a level playing
field. It is the same exam series taken by U.S. graduates even though it is administered
by the ECFMG rather than by the NBME. This means that passing
marks for IMGs for Step 1, the Step 2 CK, and the Step 2 CS are determined
by a statistical process that is based on the scores of U.S. medical
students. For example, to pass Step 1, you will probably have to score higher
than the bottom 8-10% of U.S. and Canadian graduates.
Timing of the USMLE
For an IMG, the timing of a complete application is critical. It is extremely
important that you send in your application early if you are to garner the maximum
number of interview calls. A rough guide would be to complete all
exam requirements by August of the year in which you wish to apply. This
SPECIAL SITUATIONS 30
would translate into sending both your score sheets and your ECFMG certificate
with your application.
In terms of USMLE exam order, arguments can be made for taking the Step 1
or the Step 2 CK exam first. For example, you may consider taking the Step 2
CK exam first if you have just graduated from medical school and the clinical
topics are still fresh in your mind. However, keep in mind that there is a large
overlap between Step 1 and Step 2 CK topics in areas such as pharmacology,
pathophysiology, and biostatistics. You might therefore consider taking the Step
1 and Step 2 CK exams close together to take advantage of this overlap in your
USMLE Step 1 and the IMG
What Is the USMLE Step 1? It is a computerized test of the basic medical
sciences that consists of 350 multiple-choice questions divided into seven
Content. Step 1 includes test items in the following content areas:
Interdisciplinary topics such as nutrition, genetics, and aging
Significance of the Test. Step 1 is required for the ECFMG certificate as well
as for registration for the Step 2 CS. Since most U.S. graduates apply to residency
with their Step 1 scores only, it may be the only objective tool available
with which to compare IMGs with U.S. graduates.
Official Web Sites. www.usmle.org and www.ecfmg.org/usmle.
Eligibility. Both students and graduates from medical schools that are listed
in IMED are eligible to take the test. Students must have completed at least
two years of medical school by the beginning of the eligibility period selected.
Eligibility Period. A three-month period of your choice.
Fee. The fee for Step 1 is $685 plus an international test delivery surcharge (if
you choose a testing region other than the United States or Canada).
Retaking the Exam. In the event that you failed the test, you can reapply and
select an eligibility period that begins at least 60 days after the last attempt.
You cannot take the same Step more than three times in any 12-month period.
You cannot retake the exam if you passed. The minimum score to pass
the exam is 75 on a two-digit scale. To pass, you must answer roughly 60-65%
of the questions correctly.
Statistics. In 2004, only 67% of ECFMG candidates passed Step 1 on their
first attempt, compared with 93% of U.S. and Canadian medical students and
graduates. Of note, 1994-1995 data showed that USFMGs (U.S. citizens attending
non-U.S. medical schools) performed 0.4 SD lower than IMGs (non-
U.S. citizens attending non-U.S. medical schools). Although their overall
scores were lower, USFMGs performed better than IMGs on behavioral sciences.
In general, students from non-U.S. medical schools perform worst in
behavioral science and biochemistry (1.9 and 1.5 SDs below U.S. students)
and comparatively better in gross anatomy and pathology (0.7 and 0.9 SD below
U.S. students). Although derived from data collected in 1994-1995, these
data may help you focus your studying efforts.
Tips. Although few if any students feel totally prepared to take Step 1, IMGs
in particular require serious study and preparation to reach their full potential
on this exam. It is also imperative that IMGs do their best on Step 1, as a poor
score on Step 1 is a distinct disadvantage in applying for most residencies. Remember
that if you pass Step 1, you cannot retake it in an attempt to improve
your score. Your goal should thus be to beat the mean, because you can then
confidently assert that you have done better than average for U.S. students.
Good Step 1 scores will also lend credibility to your residency application and
help you get into highly competitive specialties such as radiology, orthopedics,
Commercial Review Courses. Do commercial review courses help improve
your scores? Reports vary, and such courses can be expensive. Many IMGs decide
to try the USMLE on their own and then consider a review course only if
they fail. Just keep in mind that many states require that you pass the USMLE
within three attempts. (For more information on review courses, see Section IV.)
USMLE Step 2 CK and the IMG
What Is the Step 2 CK? It is a computerized test of the clinical sciences consisting
of 370 multiple-choice questions divided into eight blocks. It can be
taken at Prometric centers in the United States and several other countries.
Content. The Step 2 CK includes test items in the following content areas:
Obstetrics and gynecology
Other areas relevant to the provision of care under supervision
SPECIAL SITUATIONS 32
Significance of the Test. The Step 2 CK is required for the ECFMG certificate.
It reflects the level of clinical knowledge of the applicant. It tests clinical
subjects, primarily internal medicine. Other areas that are tested are surgery,
obstetrics and gynecology, pediatrics, orthopedics, psychiatry, ENT, ophthalmology,
and medical ethics.
Official Web Sites. www.usmle.org and www.ecfmg.org/usmle.
Eligibility. Students and graduates from medical schools that are listed in
IMED are eligible to take the Step 2 CK. Students must have completed at
least two years of medical school. This means that students must have completed
the basic medical science component of the medical school curriculum
by the beginning of the eligibility period selected.
Eligibility Period. A three-month period of your choice.
Fee. The fee for the Step 2 CK is $685 plus an international test delivery surcharge
(if you choose a testing region other than the United States or
Retaking the Exam. In the event that you fail the Step 2 CK, you can reapply
and select an eligibility period that begins at least 60 days after the last attempt.
You cannot take the same Step more than three times in any 12-month
period. You cannot retake the exam if you passed.
Statistics. In 2003-2004, 75% of ECFMG candidates passed Step 2 on their
first attempt, compared with 92% of U.S. and Canadian candidates.
Tips. It’s better to take the Step 2 CK after you have completed your internal
medicine rotation because most of the questions give clinical scenarios and
ask you to make medical diagnoses and clinical decisions. In addition, because
this is a clinical sciences exam, cultural and geographic considerations
play a greater role than is the case with Step 1. For example, if your medical
education gave you ample exposure to malaria, brucellosis, and malnutrition
but little to alcohol withdrawal, child abuse, and cholesterol screening, you
must work to familiarize yourself with topics that are more heavily emphasized
in U.S. medicine. You must also have a basic understanding of the legal
and social aspects of U.S. medicine, because you will be asked questions
about communicating with and advising patients.
USMLE Step 2 CS and the IMG
What Is the Step 2 CS? The Step 2 CS is a test of clinical and communication
skills administered as a one-day, eight-hour exam. It includes 10 to 12 encounters
with standardized patients (15 minutes each, with 10 minutes to
write a note after each encounter). Test results are valid indefinitely.
Content. The Step 2 CS tests the ability to communicate in English as
well as interpersonal skills, data-gathering skills, the ability to perform a
physical exam, and the ability to formulate a brief note, a differential diagnosis,
and a list of diagnostic tests. The areas that are covered in the exam
are as follows:
Obstetrics and gynecology
Significance of the Test. The Step 2 CS is required for the ECFMG certificate.
It has eliminated the Test of English as a Foreign Language (TOEFL) as
a requirement for ECFMG certification.
Official Web Site. www.ecfmg.org/usmle/step2cs.
Eligibility. Students must have completed at least two years of medical school
in order to take the test. That means students must have completed the basic
medical science component of the medical school curriculum at the time they
apply for the exam.
Fee. The fee for the Step 2 CS is $1200.
Scheduling. You must schedule the Step 2 CS within four months of the
date indicated on your notification of registration. You must take the exam
within 12 months of the date indicated on your notification of registration.
Retaking the Exam. There is no limit to the number of attempts you can
make to pass the Step 2 CS. However, you cannot retake the exam within 60
days of a failed attempt, and you cannot take it more than three times in a 12-
Test Site Locations. The Step 2 CS is currently administered at the following
Los Angeles, CA
For more information about the Step 2 CS exam, please refer to First Aid for
the Step 2 CS.
USMLE Step 3 and the IMG
What Is the USMLE Step 3? It is a two-day computerized test in clinical
medicine consisting of 480 multiple-choice questions and nine computerbased
case simulations (CCS). The exam aims at testing your knowledge and
SPECIAL SITUATIONS 34
its application to patient care and clinical decision making (i.e., this exam tests
if you can safely practice medicine independently and without supervision).
Significance of the Test. Taking Step 3 before residency is critical if an IMG
is seeking an H1B visa and is a bonus that can be added to the residency application.
Step 3 is also required to obtain a full medical license in the United
States and can be taken during residency for this purpose.
Official Web Site. www.usmle.org.
Fee. The fee for Step 3 is $590 (the total application fee can vary among states).
Eligibility. Most states require that applicants have completed one, two, or
three years of postgraduate training (residency) before they apply for Step 3
and permanent state licensure. The exceptions are the 13 states mentioned below,
which allow IMGs to take Step 3 at the beginning of or even before residency.
So if you don’t fulfill the prerequisites to taking Step 3 in your state of
choice, simply use the name of one of the 13 states in your Step 3 application.
You can take the exam in any state you choose regardless of the state that you
mentioned on your application. Once you pass Step 3, it will be recognized by
all states. Basic eligibility requirements for the USMLE Step 3 are as follows:
Obtaining an MD or DO degree (or its equivalent) by the application
Obtaining an ECFMG certificate if you are a graduate of a foreign medical
school or are successfully completing a “fifth pathway” program (at a
date no later than the application deadline).
Meeting the requirements imposed by the individual state licensing authority
to which you are applying to take Step 3. Please refer to www.
fsmb.org for more information.
The following states do not have postgraduate training as an eligibility requirement
to apply for Step 3:
* Requires that IMGs obtain a “valid indefinite” ECFMG certificate.
The Step 3 exam is not available outside the United States. Applications can
be found online at www.fsmb.org and must be submitted to the FSMB.
Residencies and the IMG
It is becoming increasingly difficult for IMGs to obtain residencies in the
United States given the rising concern about an oversupply of physicians in
the United States. Official bodies such as the Council on Graduate Medical
Education (COGME) have recommended that the total number of residency
slots be reduced. Furthermore, changes in immigration law are likely to make
it much harder for noncitizens or legal residents of the United States to remain
in the country after completing a residency.
In the residency Match, the number of U.S.-citizen IMG applications has
been stable for the last few years, while the percentage accepted has slowly increased.
For non-U.S.-citizen IMGs, applications fell from 7977 in 1999 to
5554 in 2005, while the percentage accepted significantly increased (see
Table 4). This decrease in the total number of IMGs applying for the Match
may be attributed to several factors:
A decrease in the Step 2 CS passing rate to 80%.
Increased difficulty obtaining U.S. visas.
Increased expenses associated with the USMLE exams, ERAS, and travel
to the United States.
An increase in the number of IMGs who are withdrawing from the Match
to sign a separate “pre-Match” contract with programs.
More information about residency programs can be obtained at www.amaassn.
Visa Options for the IMG
If you are living outside the United States, you will need to apply for a visa
that will allow you lawful entry into the United States in order to take the Step
TA B L E 4 . IMGs in the Match.
APPLICANTS 2003 2004 2005
U.S.-citizen IMGs 1987 2015 2091
% U.S. citizens accepted 55 55 55
Non-U.S.-citizen IMGs 5029 5671 5554
% non-U.S. citizens accepted 56 52 56
U.S. graduates (non-IMGs) 14,332 14,609 14,719
% U.S. graduates accepted 93 93 94
SPECIAL SITUATIONS 36
2 CS and/or do your interviews for residency. A B1 or B2 visitor visa may be
issued by the U.S. consulate in your country. Citizens of some countries may
have to undergo an additional security check that could take up to six
months. Upon your entry into the United States, either the B1 or, more commonly,
the B2 will be issued on your I-94. Both visas allow you a limited period
within which to stay in the United States (two to six months) in order to
take the exam. If the given period is not sufficient, you may apply for an extension
before the expiration of your I-94.
Documents that are recommended to facilitate this process include the following:
The Step 2 CS admission permit and a letter from the ECFMG (which
explains why the applicant must enter the United States)
Your medical diploma
Transcripts from your medical school
Your USMLE score sheets
A sponsor letter or affidavit of support stating that you (if you are sponsoring
yourself) or your sponsor will bear the expense of your trip and that
you have sufficient funds to meet that expense
An alien status affidavit
Individuals from certain countries may be allowed to enter the United States
for up to 90 days without a visa under the Visa Waiver Program. See http://
As an IMG, you need a visa to work or train in the United States unless you are
a U.S. citizen or a permanent resident (i.e., hold a green card). Two types of
visas enable you to accept a residency appointment in the United States: Jl and
H1B. Most sponsoring residency programs (SRPs) prefer a Jl visa. Above all,
this is because SRPs are authorized by the Department of Homeland Security
(DHS) to issue a Form DS-2019 directly to an IMG. By contrast, SRPs must
complete considerable paperwork, including an application to the Immigration
and Labor Department, to apply to the DHS for an H1B visa on behalf of
The J1 Visa
Also known as the Exchange Visitor Program, the J1 visa was introduced to
give IMGs in diverse specialties the chance to use their training experience in
the United States to improve conditions in their home countries. As mentioned
above, the DHS authorizes most SRPs to issue Form DS-2019 in the
same manner that I-20s are issued to regular international students in the
To enable an SRP to issue a DS-2019, you must obtain a certificate from the
ECFMG indicating that you are eligible to participate in a residency program
in the United States. First, however, you must ask the Ministry of Health in
your country to issue a statement indicating that your country needs physi-
cians with the skills you propose to acquire from a U.S. residency program.
This statement, which must bear the seal of your country’s government and
must be signed by a duly designated government official, is intended to satisfy
the U.S. Secretary of Health and Human Services (HHS) that there is such a
need. The Health Ministry in your country should send this statement to the
ECFMG (or they may allow you to mail it to the ECFMG).
How can you find out if the government of your country will issue such a
statement? In many countries, the Ministry of Health maintains a list of medical
specialties in which there is a need for further training abroad. You can
also consult seniors in your medical school. A word of caution: If you are applying
for a residency in internal medicine and internists are not in short supply
in your country, it may help to indicate an intention to pursue a subspecialty
after completing your residency training.
The text of your statement of need should read as follows:
Name of applicant for visa: ____________. There currently exists in
____________ (your country) a need for qualified medical practitioners
in the specialty of ____________. (Name of applicant for visa) has filed a
written assurance with the government of this country that he/she will return
to ____________ (your country) upon completion of training in the
United States and intends to enter the practice of medicine in the specialty
for which training is being sought.
Stamp (or seal and signature) of issuing official of named country.
To facilitate the issuing of such a statement by the Ministry of Health in your
country, you should submit a certified copy of the agreement or a contract
from your SRP in the United States. The agreement or contract must be
signed by you and the residency program official responsible for the training.
Armed with Form DS-2019, you should then go to the U.S. consulate closest
to the residential address indicated in your passport. As for other nonimmigrant
visas, you must show that you have a genuine nonimmigrant intent to return
to your home country. You must also show that all your expenses will be
When you enter the United States, bring your Form DS-2019 along with your
visa. You are usually admitted to the United States for the length of the Jl program,
designated as “D/S,” or duration of status. The duration of your program
is indicated on the DS-2019.
In the wake of the terrorist attacks of September 11, 2001, a number of new regulations
have been introduced to improve the monitoring of exchange visitors
during their time in the United States. All SRPs and students are currently required
to register with the Student and Exchange Visitor Program (SEVP) via
SPECIAL SITUATIONS 38
the Student and Exchange Visitor Information System (SEVIS). SEVIS allows
the DHS to maintain up-to-date information (e.g., enrollment status, current
address) on exchange visitors. SEVIS Form DS-2019 is used for visa applications,
admission, and change of status. Procedural details for this new legislation
are still being hammered out, so contact your SRP or check http://uscis.gov
for the most current information.
Duration of Participation. The duration of a resident’s participation in a program
of graduate medical education or training is limited to the time normally
required to complete such a program. If you would like to get an idea of
the typical training time for the various medical subspecialties, you may consult
the Directory of Medical Specialties, published by Marquis Who’s Who
for the American Board of Medical Specialties. The authority charged with
determining the duration of time required by an individual IMG is the State
Department. The maximum amount of time for participation in a training
program is ordinarily limited to seven years unless the IMG has demonstrated
to the satisfaction of the ECFMG and the State Department that his or her
home country has an exceptional need for the specialty in which he or she
will receive further training. An extension of stay may be granted in the event
that an IMG needs to repeat a year of clinical medical training or needs time
for training or education to take an exam required for board certification.
Requirements After Entry into the United States. Each year, all IMGs participating
in a residency program on a J1 visa must furnish the Attorney General
of the United States with an affidavit (Form I-644) attesting that they are
in good standing in the program of graduate medical education or training in
which they are participating and that they will return to their home countries
upon completion of the education or training for which they came to the
Restrictions Under the J1 Visa. No later than two years after the date of entry
into the United States, an IMG participating in a residency program on a J1
visa is allowed one opportunity to change his or her designated program of
graduate medical education or training if his or her director approves that
The J1 visa includes a condition called the “two-year foreign residence requirement.”
The relevant section of the Immigration and Nationality Act
Any exchange visitor physician coming to the United States on or after
January 10, 1977, for the purpose of receiving graduate medical education
or training is automatically subject to the two-year home-country physical
presence requirement of section 212(e) of the Immigration and Nationality
Act, as amended. Such physicians are not eligible to be considered for
section 212(e) waivers on the basis of “No Objection” statements issued
by their governments.
The law thus requires that a J1 visa holder, upon completion of the training
program, leave the United States and reside in his or her home country for a
period of at least two years. Currently, the American Medical Association
(AMA) is advocating that this period be extended to five years.
An IMG on a J1 visa is ordinarily not allowed to change from a J1 to most
other types of visas or (in most cases) to change from J1 to permanent residence
while in the United States until he or she has fulfilled the “foreign residence
requirement.” The purpose of the foreign residence requirement is to
ensure that an IMG uses the training he or she obtained in the United States
for the benefit of his or her home country. The U.S. government may, however,
waive the two-year foreign residence requirement under the following
If you as an IMG can prove that returning to your country would result in
“exceptional hardship” to you or to members of your immediate family
who are U.S. citizens or permanent residents;
If you as an IMG can demonstrate a “well-founded fear of persecution”
due to race, religion, or political opinions if forced to return to your country;
If you obtain a “no objection” statement from your government; or
If you are sponsored by an “interested governmental agency” or a designated
state Department of Health in the United States.
Applying for a J1 Visa Waiver. IMGs who have sought a waiver on the basis
of the last alternative have found it beneficial to approach the following potentially
“interested government agencies”:
The Department of Health and Human Services. Recently, HHS has expanded
its role in reviewing J1 waiver applications. HHS’s considerations
for a waiver have classically been as follows: (1) the program or activity in
which the IMG is engaged is “of high priority and of national or international
significance in an area of interest” to HHS; (2) the IMG must be an
“integral” part of the program or activity “so that the loss of his/her services
would necessitate discontinuance of the program or a major phase of it”;
and (3) the IMG “must possess outstanding qualifications, training, and experience
well beyond the usually expected accomplishments at the graduate,
postgraduate, and residency levels and must clearly demonstrate the
capability to make original and significant contributions to the program.”
Under these criteria, HHS waivers are granted to physicians working in
high-level biomedical research.
New rules will also allow HHS to review J1 waiver applications from community
health centers, rural hospitals, and other health care providers. In
the past, the U.S. Department of Agriculture (USDA) served as the interested
federal government agency that reviewed waiver applications to allow
foreign doctors to serve in rural underserved communities outside Appalachia,
while the Appalachian Regional Commission (ARC) played that
role for Appalachian communities. The USDA is no longer handling ap-
SPECIAL SITUATIONS 40
plications for J1 waivers. HHS will now review waiver applications for primary
care practitioners and psychiatrists who have completed residency
training within one year of application to practice in designated Health
Professional Shortage Areas (HPSAs), Medically Underserved Areas and
Populations (MUA/Ps), and Mental Health Professional Shortage Areas
(MHPSAs). HHS waiver applications should be mailed to Joyce E. Jones,
Executive Secretary, Exchange Visitor Waiver Review Board, Room 639-
H, Hubert H. Humphrey Building, Department of Health and Human
Services, 200 Independence Avenue, S.W., Washington, D.C. 20201;
phone (202) 690-6174; fax (202) 690-7127.
The Department of Veterans Affairs. With more than 170 health care facilities
located in various parts of the United States, the VA is a major employer
of physicians in this country. In addition, many VA hospitals are affiliated
with university medical centers. The VA sponsors IMGs working in research,
patient care (regardless of specialty), and teaching. The waiver applicant
may engage in teaching and research in conjunction with clinical
duties. The VA’s latest guidelines (issued on June 22, 1994) provide that it
will act as an interested government agency only when the loss of an
IMG’s services would necessitate the discontinuance of a program or a major
phase of it and when recruitment efforts have failed to locate a U.S.
physician to fill the position.
The procedure for obtaining a VA sponsorship for a J1 waiver is as follows:
(1) the IMG should deal directly with the Human Resources Department
at the local VA facility; and (2) the facility must request that the VA’s chief
medical director sponsor the IMG for a waiver. The waiver request should
include the following documentation: (1) a letter from the director of the
local facility describing the program, the IMG’s immigration status, the
health care needs of the facility, and the facility’s recruitment efforts; (2)
recruitment efforts, including copies of all job advertisements run within
the preceding year; and (3) copies of the IMG’s licenses, test results, board
certifications, IAP-66 or SEVIS DS-2019 forms, and the like. The VA contact
person in Washington, D.C., should be contacted by the local medical
facility rather than by IMGs or their attorneys.
The Appalachian Regional Commission. ARC sponsors physicians in
certain places in the eastern and southern United States–namely, in Alabama,
Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina,
Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West
Virginia. Since 1992, ARC has sponsored approximately 200 primary care
IMGs annually in counties within its jurisdiction that have been designated
as HPSAs by HHS.
In accordance with its February 1994 revision of its J1 waiver policies,
ARC requires that waiver requests initially be submitted to the ARC contact
person in the state of intended employment. Contact information for
each state can be found on the ARC Web site (www.arc.gov). If the state
concurs, a letter from the state’s governor recommending the waiver must
be addressed to Anne B. Pope, the new federal cochair of ARC. The
waiver request should include the following: (1) a letter from the facility to
Ms. Pope stating the proposed dates of employment, the IMG’s medical
specialty, the address of the practice location, an assertion that the IMG
will practice primary care for at least 40 hours per week in the HPSA, and
details as to why the facility needs the services of the IMG; (2) a J1 Visa
Data Sheet; (3) the ARC federal cochair’s J1 Visa Waiver Policy and the J1
Visa Waiver Policy Affidavit and Agreement with the notarized signature
of the IMG; (4) a contract of at least three years’ duration; (5) evidence of
the IMG’s qualifications, including a résumé, medical diplomas and licenses,
and IAP-66 or SEVIS DS-2019 forms; and (6) evidence of unsuccessful
attempts to recruit qualified U.S. physicians within the preceding
six months. Copies of advertisements, copies of résumés received, and reasons
for rejection must also be included. ARC will not sponsor IMGs who
have been out of status for six months or longer.
Requests for ARC waivers are then processed in Washington, D.C. (ARC,
1666 Connecticut Avenue, N.W., Washington, D.C. 20009). ARC is usually
able to forward a letter confirming that a waiver has been recommended
to the requesting facility or attorney within 30 days of the request.
The Department of Agriculture. At the time of publication, the USDA is
no longer sponsoring J1 waivers. The scope of the HHS J1 waiver program
has been expanded to fill the gap.
State Departments of Public Health. There is no application form for a
state-sponsored J1 waiver. However, regulations specify that an application
must include the following documents: (1) a letter from the state Department
of Public Health identifying the physician and specifying that it
would be in the public interest to grant him or her a J1 waiver; (2) an employment
contract that is valid for a minimum of three years and that states
the name and address of the facility that will employ the physician and the
geographic areas in which he or she will practice medicine; (3) evidence
that these geographic areas are located within HPSAs; (4) a statement by
the physician agreeing to the contractual requirements; (5) copies of all
IAP-66 or SEVIS DS-2019 forms; and (6) a completed U.S. Information
Agency (USIA) Data Sheet. Applications are numbered in the order in
which they are received, since only 30 physicians per year may be granted
waivers in a particular state under the Conrad State 30 program. Individual
states may elect to participate or not to participate in this program. At
the time of publication, nonparticipating states included Idaho, Oklahoma,
and Wyoming, while Texas had suspended its J1 waiver program
pending new legislation.
The H1B Visa
Since 1991, the law has allowed medical residency programs to sponsor
foreign-born medical residents for H1B visas. There are no restrictions on
changing the H1B visa to any other kind of visa, including permanent resident
status (green card), through employer sponsorship or through close rela-
SPECIAL SITUATIONS 42
tives who are U.S. citizens or permanent residents. It is advisable for SRPs to
apply for H1B visas as soon as possible in the official year (beginning October
1) when the new quota officially opens up.
According to the Web site www.immihelp.com, as of October 17, 2000, the
following beneficiaries of approved H1B petitions are exempt from the H1B
Beneficiaries who are in J1 nonimmigrant status in order to receive graduate
medical education or training, and who have obtained a waiver of the
two-year home residency requirement;
Beneficiaries who are employed at, or who have received an offer of employment
at, an institution of higher education or a related or affiliated
Beneficiaries who are employed by, or who have received an offer of employment
from, a nonprofit research organization;
Beneficiaries who are employed by, or who have received an offer of employment
from, a governmental research organization;
Beneficiaries who are currently maintaining, or who have held within the
last six years, H1B status, and are ineligible for another full six-year stay as
an H1B; and
Beneficiaries who have been counted once toward the numerical limit
and are the beneficiary of multiple petitions.
H1B visas are intended for “professionals” in a “specialty occupation.” This
means that an IMG intending to pursue a residency program in the United
States with an H1B visa needs to clear all three USMLE Steps before becoming
eligible for the H1B. The ECFMG administers Steps 1 and 2, whereas
Step 3 is conducted by the individual states. You will need to contact the
FSMB or the medical board of the state where you intend to take Step 3 for
details (see p. 33, USMLE Step 3 and the IMG).
H1B Application. An application for an H1B visa is filed not by the IMG but
rather by his or her employment sponsor–in your case, by the SRP in the
United States. If an SRP is willing to do so, you will be told about it at the
time of your interview for the residency program.
Before filing an H1B application with the DHS, an SRP must file an application
with the U.S. Department of Labor affirming that the SRP will pay at
least the normal salary for your job that a U.S. professional would earn. After
receiving approval from the Labor Department, your SRP should be ready to
file the H1B application with the DHS. The SRP’s supporting letter is the
most important part of the H1B application package; it must describe the job
duties to make it clear that the physician is needed in a “specialty occupation”
(resident) under the prevalent legal definition of that term.
Most SRPs prefer to issue a SEVIS Form DS-2019 for a J1 visa rather than file
papers for an H1B visa because of the burden of paperwork and the attorney