09/22/2017

usmle step 1 Educational Commission for Foreign Medical Graduates (ECFMG)

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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.

Strategy

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

correct.

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

presentation.

GUIDE TO E FFIC IENT EXAM PREPARATION

25

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.

TESTING AGENCIES

National Board of Medical Examiners (NBME)

Department of Licensing Examination Services

3750 Market Street

Philadelphia, PA 19104-3102

(215) 590-9700

Fax: (215) 590-9457

E-mail: webmail@nbme.org

www.nbme.org

Educational Commission for Foreign Medical Graduates (ECFMG)

3624 Market Street, Fourth Floor

Philadelphia, PA 19104-2685

(215) 386-5900

Toll free within North America: (800) 500-8249

Fax: (215) 386-9196

E-mail: info@ecfmg.org

www.ecfmg.org

Federation of State Medical Boards (FSMB)

P.O. Box 619850

Dallas, TX 75261-9850

(817) 868-4000

Fax: (817) 868-4099

E-mail: usmle@fsmb.org

www.fsmb.org

USMLE Secretariat

3750 Market Street

Philadelphia, PA 19104-3190

(215) 590-9700

E-mail: webmail@nbme.org

www.usmle.org

Sometimes making a

diagnosis is not necessary at

all.

GUIDE TO E FFICIENT EXAM PREPARATION 26

REFERENCES

1. Bidese, Catherine M., U.S. Medical Licensure Statistics and Current

Licensure Requirements 1995, Chicago, American Medical Association,

1995.

2. National Board of Medical Examiners, 2002 USMLE Bulletin of Information,

Philadelphia, 2001.

3. National Board of Medical Examiners, Bulletin of Information and

Description of National Board Examinations, 1991, Philadelphia,

1990.

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

Publishers, 1993.

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.

S40-S42.

First Aid for the

International Medical

Graduate

First Aid for the

Osteopathic Medical

Student

First Aid for the

Podiatric Medical

Student

First Aid for the

Student with a

Disability

S E C T I O N I S U P P L EMENT

Special Situations

27

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

the following:

Graduate from a medical school that is listed in the International Medical

Education Directory (IMED). The list can be accessed at

www.ecfmg.org.

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

www.ecfmg.org/

pubshome.html.

Applicants may apply online

for the USMLE Step 2 CK or

Step 2 CS or request an

extension of the USMLE

eligibility period at

www.ecfmg.org/usmle/

index.html or

www.ecfmg.org/usmle/

step2cs/index.html.

SPECIAL SITUATIONS

29

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:

ECFMG/ERAS Program

P.O. Box 11746

Philadelphia, PA 19101-0746

(215) 386-5900

Fax: (215) 222-5641

e-mail: eras-support@ecfmg.org

www.ecfmg.org/eras

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

test preparation.

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

blocks.

Content. Step 1 includes test items in the following content areas:

Anatomy

Behavioral sciences

Biochemistry

Microbiology

Pathology

Pharmacology

Physiology

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

SPECIAL SITUATIONS

31

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,

and dermatology.

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:

Internal medicine

Obstetrics and gynecology

Pediatrics

Preventive medicine

Psychiatry

Surgery

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

Canada).

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

SPECIAL SITUATIONS

33

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:

Internal medicine

Surgery

Obstetrics and gynecology

Pediatrics

Psychiatry

Family medicine

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-

month period.

Test Site Locations. The Step 2 CS is currently administered at the following

five locations:

Philadelphia, PA

Atlanta, GA

Los Angeles, CA

Chicago, IL

Houston, TX

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

deadline.

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:

Arkansas

California

Connecticut

Florida

Louisiana

Maryland

Nebraska*

New York

South Dakota

Texas

Utah*

Washington

West Virginia

* Requires that IMGs obtain a “valid indefinite” ECFMG certificate.

SPECIAL SITUATIONS

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.

org.

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

35

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://

uscis.gov.

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

an IMG.

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

United States.

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-

SPECIAL SITUATIONS

37

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.

Dated _____________

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

paid.

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

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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

United States.

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

change.

The J1 visa includes a condition called the “two-year foreign residence requirement.”

The relevant section of the Immigration and Nationality Act

states:

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.

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39

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

circumstances:

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-

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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

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41

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-

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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

annual cap:

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

nonprofit entity;

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

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