UK - US Postgraduate Medical Link
A Guide for UK Medical School Graduates Considering Postgraduate Clinical Training in the USA

About me  

Can I do postgraduate clinical training in the USA?

How do I get started?

What exactly are the USMLEs and how do I get ECFMG certification?

How do I apply to Residency programs?

How do I apply for a US non-immigrant visa?

What can I expect when I move to the USA?

References

A quick guide to US medical internship - NEW!

 

Are you a medical  student  or  recent  medicine  graduate  from  the  UK  and considering undertaking part of your clinical medical training in the USA?  This resource  is  intended  as  a  guide  for  such  medics  who  are  seeking  further information on continuing their postgraduate training in the USA, but are unsure whether this is feasible in terms of being licensed in the US, securing a training post, or obtaining a visa, and require guidance on how to negotiate the complex process.

 

About me

I completed undergraduate medical training at Imperial College School of Medicine, London, in 2005.  During my final year I became interested in continuing training overseas, and arranged clinical electives in Massachusetts and Rhode Island USA.  I was highly impressed by the structure and outcomes of the internal medicine residency training programs that I saw, and hugely motivated by the residents I met, who seemed to have an endless appetite for finding a ‘better way’ to take care of their patient and incorporate their substantial evidence-based knowledge into exceptional medical care.   Re-enthused in medicine by my elective experiences, I returned to the UK and sat the USMLEs STEP 1 and STEP 2 CK during my final year.  I graduated, and began work as an F1 trainee at Chelsea and Westminster Hospital, and found my busy post to be both challenging and rewarding.  However, I was acutely aware that the one hour’s formal teaching time per week was far below that which my American peers would be receiving, and that although learning to carrying a census of 30+ patients was a huge hands-on learning curve, especially as many of my patients were complex and very unwell, being thrown in the clinical deep end was not on its own sufficient to make me a good doctor.  I was anxious to receive evidence-based teaching on current best clinical management, ample opportunities with procedures such as central lines, and work in a structured medical environment that would fully develop my novice clinical judgment.  In addition, it was clear during my F1 year that there would be rougher waters ahead in terms of the structure of medical training in the UK, and morale on the wards was already being tested by frequent changes in management and training policies. 

Therefore, with the first two USMLE exams already behind me, I began to look into internal medicine residency programs in the US and try to work out their training requirements and application procedures.  Deciding where I wanted to apply and submitting ERAS applications was as much a leap into the unknown as the day I turned up for STEP 1; there was no-one else that I knew from the London medical schools doing this at that time, and I had little reliable information on whether I was applying to the right sort of programs and whether I had any chance of getting interviews.    I was invited to interview at 7 programs in January 2006, including Boston University Medical Center, which became my first choice program.  In fact, I received a much warmer reception at all of the programs I interviewed with that I had expected, and program directors seemed to view my British training as an asset rather than a drawback – those warnings of “the American system looks only looks after its own graduates” turned out to be completely unfounded.  I matched at BU, completed three years of internal medicine residency training and am now a Chief Medical Resident 2009-2010.  I will be entering Cardiology Fellowship at Cleveland Clinic next year.  I hope that this resource will allow other British medics considering a similar career path to make informed and valid decisions, and fulfill their postgraduate training aspirations. 

 

Can I do postgraduate clinical training in the USA?

 So long as you are in good standing with your British medical school +/- postgraduate training posts, are eligible for a US non-immigrant visa and are prepared to put in the extra time and money necessary to see you through the process, the answer is likely to be ‘yes’.   I was aiming for an Internal Medicine Residency program to enable me to progress to my chosen medical sub-specialty (Cardiology), and so I have less authority to speak on other specialties, but I will outline their training paths.   US medical graduates are required to complete 3 to 7 years of post-graduate training as accredited by the ACGME (Accreditation Council for Graduate Medical Education).  The ACGME has established general requirements for all residencies as well as specific requirements for each medical specialty, and serves as the regulatory body that accredits individual training programs nationwide. Each residency graduate must then meet certification requirements to enter into clinical practice which are established by the relevant specialty board; they usually involve the completion of residency plus passing a comprehensive specialty examination known as ‘The Boards’ (somewhat analogous to Membership exams in the UK).  The ECFMG (Educational Commission for Foreign Medical Graduates) is responsible for assessing whether international medical graduates (IMGs) reach the standards required for entry into an ACGME training program, and facilitate sponsorship of J-1 training visas.  The ECFMG defines an IMG as a physician who received his/her basic medical degree or qualification from a medical school located outside of the United States and Canada.  To be eligible for ECFMG certification, your medical school and year of graduation must be listed in the International Medical Education Directory of the Foundation for Advancement of International Medical Education and Research – this directory can be accessed through the ECFMG website at www.ecfmg.org.  

Common training paths for various specialties:

Internal Medicine:  3 year Residency + optional  1-5 year Subspecialty Fellowship training (incl General Internal Medicine, Geriatrics, Cardiology, GI, Pulmonary and Critical Care, Endocrine, Rheumatology, Infectious Diseases, Hematology-Oncology).  Many Internal Medicine Residency programs offer 2 tracks, one Categorical or Traditional track, and one Primary Care track preparing residents who are likely to focus their careers on outpatient medicine and so providing training for the specific challenges of the Primary Care Physician role.

Family Practice: 3 year Residency (covering Internal Medicine with emphasis on Primary Care, Pediatrics, OBGYN) + additional subspecialization Fellowships

Emergency Medicine:   Transitional or Preliminary year + 3 to 4 year EM training

Pediatrics:   3 year Residency + optional Subspecialty Fellowship Training

OBGYN:   4 year Residency

Pathology:   4 to 5 year Residency

Surgery:   5 year General Surgery Residency + 3 year Subspecialty Fellowship / 1 year Gen Surg internship + 4 year Residency in Orthopedics, ENT, Urology or Neurosurgery

Anesthesiology, Dermatology, Neurology, Nuclear Medicine, Ophthalmology, Physical and Rehabilitation Medicine, Psychiatry, Radiology, Radiation Oncology:   Transition or Preliminary year + 3 year Residency in any of the aforementioned specialties.

This is a general outline of training, and different programs vary in their length and requirements; for your specific career plans check with the AMA FRIEDA website, programs in which you are interested and the relevant specialty board.  Most specialties are now applied for through the ERAS system: https://services.aamc.org/eras/erasstats/par/ lists the Programs currently receiving applications via ERAS.  Notable exceptions at present are Ophthalmology and Neurosurgery.  Most specialties also participate in the Match as organized by the NRMP, although separate Residency matches operate for Urology (consult www.auanet.org) Child Neurology, Neurotology, Ophthalmology and Plastic Surgery (www.sfmatch.org).   Another fantastic resource regarding the Residency application process is the book “First Aid for the Match” by Tao Le et al, published by McGraw Hill (ISBN 0-07-140929-7).  It has a particularly useful section detailing the match statistics and application requirements of each of the various Residency specialties.

With the early medical specialization – straight out of medical school – in the US training system, there is a marked spectrum in the competitiveness of the various specialties.  Quantifying this comparative competitiveness is difficult, but it is worth mentioning that certain specialties are extremely tough to enter even for US graduates, and applicants for areas such as Dermatology, Ophthalmology, ENT, Urology and Orthopedics require especially high USMLE scores, very strong applications, and will be expected to apply coast-to-coast and interview at upwards of 20 programs to succeed into matching into their chosen field.   In contrast, the high numbers of Internal Medicine housestaff required for medicine departments across the country mean there are medicine positions that go unfilled each year, and hence there is a preponderance of IMGs working in internal medicine in the US.  In 2008, of the 4,858 internal medicine spots available, only 2,660 were filled by US medical school Seniors[1].   Of course within internal medicine, there is again a wide spectrum of program standards, from those with top-notch reputations, facilities, training opportunities and subsequent fellowship matches, to less academic programs in less desirable regions of the country with IMGs forming the majority of the housestaff.  My experience is that the best and the worst internal medicine programs are very receptive to IMG applications – at the best programs because they value the strengths of especially European-trained doctors and are keen to incorporate diverse skills-sets into their Program, and at the less reputable programs they rely heavily on a foreign-trained workforce to complete their staffing requirements.

Before committing to the time-consuming and expensive process of USMLE examinations, Residency applications and interviews it is valid to ask “What sort of chance do I have of getting a good training post in the US that will enhance my career more than remaining in the UK?”  The bottom line is that the total number of Residency spots offered in the US exceeds the number of medical students graduating in the US each year by around 30%.  It is IMGs who fill this staffing gap.  The ECFMG reports that for the 2005-2006 academic year, approximately 6,900 international medical graduates entered U.S. PGY 1 positions![2]   As alluded to above, IMGs show a different specialty distribution than graduating US students; more train and practice in internal medicine and family medicine than the highly competitive specialties of Dermatology, Ophthalmology, ENT, Urology and Orthopedics.  From my experience with internal medicine and in talking with program directors and reviewing the published statistics, with a bit of hard work your chances of matching in medicine are very high.  The 2008 “42%” Match rate is not necessarily an accurate reflection of your chances or the following reasons.  Most of those IMGs who fail to score highly in the USMLEs or don’t match for Residency have been penalized for not understanding the system, its expectations, and how to appropriately pitch themselves.  In reading this guide, I hope you will be coming some way towards rectifying these handicaps for UK graduates.  Also bear in mind that you also have the good fortune of fluency in the English language and a progressive medical training within a system and patient population very equivalent to those which will be encountered in the US, which is not the case for a large proportion of IMGs.  A further factor that negatively skews the Match rate is that applicants who are not US Seniors are not obliged to obtain their residency position through the NRMP Match; as described in a later section, IMGs are permitted to withdraw from the Match if a program at which they interview offers them a “pre-Match” contract.  This is reflected by the 2,135 IMGs - 19.2% of all IMGs who applied – who withdrew from the NRMP in 2008[1].  We don not know how many of these IMGs accepted a Pre-Match contract, but it contrasts sharply with the 349 (2.2%) US seniors who withdrew.  However, it is concerning that from the data presented below, that the Match rate of international applicants appears to be heading in the wrong direction; I am unsure why this should be the case, as the proportion withdrawing has remained consistent in the 19-25% range over the past five years.

NRMP data on Match rates[3]:

Applicant type

2002

 

2005

2006

2007

2008

US allopathic medical school seniors

14,336

 

14,719

15,008

15,206

15,242

%US medical school seniors matched

94

 

93.7

93.7

93.4

94.2

US citizen IMGs

2,029

 

2.091

2,435

2,694

2,969

% US citizens matched

54

 

54.7

50.6

50.0

51.9

Non-US-citizen IMGs

4,556

 

8,554

6,442

6,992

7,335

% non-US citizens matched

51

 

55.6

48.9

45.5

42.4

For even more detailed stats, consult the NRMP PDF “2008 NRMP Main Residency Match: Match Results by State and Specialty” for a breakdown of match results by state and specialty.   For example, in Massachusetts this year there were 433 Internal Medicine positions of which 431 were filled; 336 went to US Seniors, 10 to US citizen IMGs and 65 to non-US citizen IMGs (the remainder went to prior US graduates, osteopathic medical school graduates or 5th pathway applicants)[4].

One further thought; this resource is written with medical students or junior doctors pursing residency training, perhaps followed by fellowship, in mind.  It is worth pointing out that in order to be accredited by the US Board in your specialty, and therefore have the option of working as an attending (consultant) in the US in the future, you must have completed all of the required training from intern year onwards in the US.   Hence, there is a sizeable cohort of foreign-trained doctors who have worked for several years as junior doctors in their home countries, but then move to the US and have to backtrack to intern year again in order to ultimately become US board certified in their career of choice.   There certainly are a few British doctors who have completed their junior years in the UK and came to the US later in their career to undertake specialized training in a certain procedure or condition, or work in world-renowned research labs, but such scenarios are outside my area of experience and information on such training would require direct communication with individual clinical centers.

[1]  Advance Data Tables 2008 Main Residency Match www.nrmp.org/data/advancedatatables2008.pdf

[3] Advance Data Tables 2008 Main Residency Match www.nrmp.org/data/advancedatatables2008.pdf

[4] 2008 NRMP Main Residency Match: Match Results by State and Specialty www.nrmp.org/data/resultsbystate2008.pdf

 

 

How do I get started?

 

Once you have decided that clinical training in the USA is for you, or even if you are wanting to start taking steps in the direction of residency application whilst you consider other options, it is helpful to have a timeline for the process in mind.  Although the full journey from UK medical school to US residency program may appear daunting at first, the good news is that it all comes around in small steps, and as long as you are aware of how to seek your next step and when it needs to be completed by, the process should not be too painful.  I would encourage embarking on this process as soon as possible – ideally during the latter half of medical school.   People have since asked me “when’s the best time to sit the USMLEs?” and although I do not feel there is one correct answer to that, I would suggest that you consider the following points.   As outlined below, USMLE STEP 1 covers the basic sciences of medicine, although with a strong clinical slant.  Most med school courses will have covered the necessary material by their 3rd year (some teach Pathology at a later point than the other basic sciences).  Hence STEP 1 can be taken at this stage (USMLE guidelines state that you need to have completed the basic sciences program of your medical school, equivalent to the first 2 years of US medical school[1]).  Conversely, I found it very useful to take STEP 1 in the winter of final year, as the intense revision of basic science gave me an excellent grounding on which to build the following months of Finals revision.  The same would stand for junior doctors about to undertake the MRCP part I exam or intercollegiate MRCS part A; although there are some areas covered in much more detail by the USMLEs than would be required for the British exams (e.g. some of the biochemistry, microbiology and embryology) a detailed revision of basic science for STEP 1 is likely to boost your membership exam performance. 

If you are still in medical school, do not neglect your overseas elective as valuable resource in your campaign to secure a US residency position.   Research US medical school websites as to the elective rotations offered for visiting students, and determine which schools accept applications from foreign medical students.  As will be mentioned later, establishing contacts at a well-esteemed US medical school, even if it is not a University whose residency program you ultimately apply for, is very useful, and a strong letter of recommendation from an attending (consultant) at a US teaching hospital will be a huge boost to your residency application.  I undertook two 4-week electives in the US during my final year; one in Boston and one in Providence.  This experience was invaluable in formulating my decision to train in the US, helping me to understand the context of some of the material covered in the USMLEs, shaping my expectations for applying to residency, and making contacts with doctors who helped me to succeed in my residency applications.  For those who have already graduated, it is worth trying to arrange a clinical observership in an American hospital for the same list of reasons.  Many residency programs actually stipulate that they require some form of US clinical experience from international applicants.

As a final pieces of advice, although it may technically be possible to complete the USMLEs during medical school, apply for residency program in the autumn of final year, and Match into a program to start in June of final year (although this may cut it quite close for getting your medical degree credentialed by ECFMG), I would strongly advise staying to complete the F1 year and so achieve eligibility for a full GMC license.  To leave the UK before gaining full license would be extremely risky as it may be difficult to fit back into the British training scheme when you return.  For most applicants this will mean that you complete two intern years, one as an F1 in the UK and one the first year of US residency, but I found that I needed this to get up to speed on US healthcare, policies and guidelines, and cultural expectations.   Of course, with all the changes to the UK’s training scheme following Modernising Medical Careers, it remains to be seen how those of us who carried out our junior doctor training overseas will successfully integrate back into the UK structure.  Steps I have taken to try to prepare for my return after specialty training include talking to senior physicians in my intended specialty who are involved in interviewing for consultant posts to ask them how they would regard a candidate with an American training, speaking to the JCHMT regarding training requirements and getting my first year of residency program accredited as an overseas F2 year.   Bear in mind that a particular hurdle to be overcome when transferring between UK and US training schemes is that the UK medical year runs from August 1st, whereas the US cycle starts July 1st, often with a preceding week of orientation for new residents at the end of June.  A final consideration when embarking on US training is financial.  The costs include exam fees for STEP 1, STEP 2 CK and STEP 2 CS which are (as of  March 2008) $695+$160, $695+$180, $1,200 plus travel expenses respectively;  fees for residency application and the Match ($75 for the ‘token’ to begin application, $50 to the ECFMG to release UMSLE transcript, upwards of $60 to ERAS depending on number of programs applied to, $40 to register with the NRMP for the Match); the cost of travel and accommodation to interview at prospective residency programs; the cost of visa application (for J-1 visa $200 annually plus $100 one-time fee, plus expenses to travel back to the UK annually to be interviewed at the US Embassy); and relocation costs.  I won’t total it up; it’ll depress me as much as it would depress prospective applicants, but my personal experience is that the sacrifices have been more that worth it in terms of the medical knowledge and enjoyment of my career that I have gained in return.  Be aware that the salaries for US residents and fellows are currently lower than those earned by UK trainees at similar levels (see FRIEDA website for salaries of individual programs), although the cost of living is lower in the US and hence the lower salary goes further.

[1] USMLE Bulletin of Information at www.usmle.org

 

 

What exactly are the USMLEs and how do I get ECFMG certification?


The United States Medical Licensing Exams are taken by medical students across the USA in order to prove attainment of nationwide standards of medical knowledge and skills, and are currently arranged into four parts (STEP 1, STEP 2 Clinical Knowledge, STEP 2 Clinical Skills and STEP 3).  STEPs 1 and 2 are administered by the ECFMG and are required prior to embarking on residency training, whereas Step 3 is administered by the FSMG and is only required prior to residency if you are intending to apply for a H1B visa; otherwise it is normally taken by first- or second- year residents.   You will need to have your STEP 1 score prior to submitting residency applications; for many program directors this score is used to sift out applicants to interview from the thousands of submissions received, so a high score will be key for your residency campaign.  When setting your goals, it would be wise to aim for a minimum of attaining the mean score of American medical students – proving yourself to be above the average US student is a valid starting point.  If you are intending to apply to competitive programs, it may be helpful to know that many have STEP 1 score thresholds below which they do not consider applicants for interview.  The highest threshold I have heard of is 85, so it is fair to say that scoring in the 90s should give you the pick of Programs in terms of academic expectations.  Bear in mind that for program directors reviewing a British IMG’s application, terms such as ‘Finals’, ‘Honours’ and ‘MRCP’ carry little meaning – its all about graduating ‘magna cum laude’ and AOA membership over here.  Hence their appreciation of your academic ability is likely to start and end with your STEP 1 score.  As in so many areas of this process, its not that programs are necessarily biased against IMGs – often quite the opposite – but more that they have difficulty in interpreting unknown quantities. 

The exams are now administered in a computer based format, and STEPs 1 and 2 consist simply of a full day of multiple choice questions each.  For IMGs, applications and results for STEP are conducted through the ECFMG.  For STEP 1 and STEP 2 CK it is possible to sit the examinations in the United Kingdom.  Review the application criteria at www.usmle.org; briefly STEP 1 requires completion of the basic sciences curriculum of your medical school course, and to enter for STEP 2 you must be at least in the final year of your medical degree course.  STEP 3 is usually taken during residency, although there are specific states that do not require US postgraduate training to enter for STEP 3 before moving to the US (enabling some IMGs to apply for an H-1B visa). 

STEP 1 assesses whether medical syudents or graduates understand and can apply important concepts of the sciences basic to the practice of medicine.  It is a computer-based exam that is offered at Prometric testing centers in the US and other countries.

STEP 2 assesses whether medical school students or graduates can apply medical knowledge, skills and understanding of clinical science essential for provision of patient care under supervision; also offered at Prometric testing centers.  It is delivered in 2 parts:

-         STEP 2 Clinical Knowledge - constructed according to an integrated content outline that organizes clinical science material along two dimensions: physician task and disease category.

-          STEP 2 Clinical Skills - uses standardized patients (people trained to portray real patients). The cases cover common and important situations that a physician is likely to encounter in clinics, doctors’ offices, emergency departments, and hospital settings in the United States.  This exam is offered at five clinical centers within the US (located in Atlanta, Philadelphia, Chicago, LA and Houston).

 

STEP 3 assesses whether medical school graduates can apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine.

More detailed syllabuses are provided at www.usmle.org within PDFs called “Content Description and General Information”.  The “Bulletin of Information” contains all you need to know about the administration of and application procedures for the exams.  STEP 1 covers seven core topics – Anatomy, Biochemistry, Physiology, Pathology, Behavioral Sciences, Pharmacology and Microbiology.  STEP 2 examines medical student level knowledge of Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, Psychiatry and Preventative Medicine.  Almost all of the STEP 2 questions are case-based; a large proportion of STEP 1’s are clinically based too.  The USMLE website also contains sample questions for the computer based exams; in addition a CD containing sample questions will be mailed to you from the ECFMG on receipt of your application.  There is also the option of paying a fee to take a practice the computer based exams at the Prometric center, ahead of the actual test.  Thomson Prometric, a division of The Thomson Corporation, provides scheduling and test centers for USMLE, and the most convenient center for me was their Cloak Lane, London location, although there are also centers in Cardiff, Edinburgh and Glasgow. 

To apply, follow the steps in registering for an OASIS account on the ECFMG website; the exam fees can be paid via credit card.  There is a form that must be signed by your medical school’s Registry to confirm that you are at the appropriate level of medical education for USMLE’s entry requirements and a recent photograph of yourself must be verified too; at ICSM the Registry staff were very helpful in filling out and stamping the paperwork, and mailed it on to the ECFMG in Philadelphia themselves.  You will then receive a scheduling permit for a exam window of 3 months; on receipt of this you can call the Prometric center and arrange a date within this eligibility period (testing not available on major holidays or in the first two weeks of January).   Your score should arrive by mail about 6 weeks after the exam. 

Once you obtain a passing score, you cannot retake the test to improve upon your score.  The scores are a little confusing, as the number of questions answered correctly will be converted into two equivalent scores, one on a 3-digit scale and one on a 2-digit scale.  On the 3-digit scale, most scores fall between 140 and 260. The mean score for first-time examinees from accredited medical schools in the United States is in the range of 200 to 220, and the standard deviation is approximately 20. Your score report will include the mean and standard deviation for recent administrations of the STEP.

The 2-digit score is not a percentile, but is derived from the 3-digit score. It is used in score reporting to meet requirements of some medical licensing authorities that the passing score be reported as 75. The 2-digit score is derived so that 75 always corresponds to the minimum passing score.  Therefore a given two-digit score may represent a different level of performance if the two administrations were subject to differing pass/fail standards.  The 3-digit score is calculated using statistical methods ensuring that scores from different years are on a common scale and have the same meaning.  Currently, the passing scores as set by USMLE are 185 for STEP 1, 184 for STEP 2 CK and 187 for STEP 3 on the 3-digit scale, or 75 on the 2-digit scale. Each of these corresponds to answering 60-70% of the items correctly[1].

In terms of preparation for the USMLEs, everyone studies differently and has their own learning patterns, but I will describe what worked well for me.  I used the “First Aid for the USMLE” book series by Tao Le et al., and worked through their chapters of high-yield information, drawing on my medical school notes and textbooks as I revised each subject area.  Preparing for STEP 1 in this manner was a very helpful prelude to Finals revision.  I also subscribed to the Kaplan website’s Q-bank to work through practice questions for 3 months prior to the exam.  I made notes in the margins of my First Aid books, and tried to solidify my knowledge on “hot topics” that seemed to come up frequently in the practice questions.  On the day, some forward planning of your testing strategy is necessary to prepare for such an intense exam.  Don’t forget your scheduling permit and government-issued photo identification.  STEP 1 consists of 7x 60 minute blocks with a total of 350 questions, over 8 hours.   STEP 2 has 8 blocks with a total of 370 questions, over 9 hours.  On either exam, familiarization with the test format (FREDTM software) increases your break time as it allows you to omit the 15 minute optional tutorial.  Plan ahead how you are going to schedule a short rest and a lunch break.  Some questions will contain figures or color illustrations; I understand that this year media clips are expected to be included too.  I took Kaplan’s advice re test technique; read the text of the question, pausing briefly after each piece of information presented to synthesize the data and think “what’s going on here?”  By the time you reach the actual question being asked, you will already have an opinion about the correct differential, therapy or intervention.  This helps to avoid your being mislead by “distracter” options on the multiple choice answer list and is more time efficient in eliminating some reading back through the question to work out the answer. 

The CS exam will involve a trip to the States, but should not provide much of a challenge to a British-trained medic, so long as you know what to expect.  Introducing yourself clearly, demonstrating courtesy towards the patient, hand washing at the beginning and end of the examination and trying to elicit that “hidden agenda” are all big point-scorers here.  The main piece of advice I have is that you will be pushed for time to ask enough of a history and perform the breadth of exam expected, plus communicating to the patient their potential diagnoses and plan and answering any questions all within 15 minutes (to be repeated for twelve standardized patients).  There are then an additional 10 minutes to record your history and exam findings, generate a differential and answer written questions on the management plan.  It is worth at least thinking through, if not role-playing with a friend or colleague, the common presenting complaints and how you plan to focus in on the relevant history questions and physical exam elements for each scenario within the allotted time.  E.g. a patient complaining of dizziness will require sufficient focused questioning to distinguish between the major differentials for this symptom, then examination including a cardiac exam with auscultation of carotids, a concise neurological exam highlighting cranial nerve and cerebella/proprioceptive deficits, perhaps otoscopy and a brief Dix-Hallpike maneuver and hopefully an opportunity to stand the patient up and take a few steps!   But don’t panic, missing a few elements here and there is not going to fail you – as in most UK exams, it is major communication deficits and discourtesy to the patient, or else emotionally “falling apart” in the exam room that are likely to cause a candidate problems.

Please refer to the extremely helpful “2008 Bulletin of Information” at usmle.org for further details on any of the above exams.

Once these exams are under your belt and the ECFMG has received verification of your medical degree and a copy of your college transcript from your Medical School Registry, an ECFMG certificate will hopefully find its way to you – mine showed up in the mail a couple of months after passing the CS exam.  You will need to hold a Standard ECFMG Certificate without expired examination dates, before starting at an ACGME-accredited residency program (although you can apply and match to programs prior to this certificate being issued).   It is also worth being on the e-mailing list for the ECFMG Reporter whilst you are navigating through the examination and certification stages. 

[1] ‘Scores and Transcripts’ at www.usmle.org
 
 

How do I apply to Residency programs?

Having already decided on your intended specialty, the next step is to research what programs are available, what their relative strengths and weakness are, and where you are likely to be successful in getting a place.  Also, don’t neglect to consider which parts of the country you would rather relocate to – this may already be narrowed down by family ties, previous experiences or personal preferences, but for those who have never spent much time in the USA before it is worth noting that within such a huge country there are marked regional variations in lifestyle, attitudes and environment.  Try to think about where you would feel most at home.   Additional considerations include living costs (NYC, Boston, DC, and Chicago are much more expensive than more rural  areas where a big family house is a lot more affordable than in the UK), types of programs (University-associated versus Community) and the reputation of programs within your specialty.  Fully research the AMA FREIDA website, which is an excellent online resource, and contains application and employment information on individual programs, contact information to program directors and administrators and links to program websites.  You may also be interested in the ‘NRMP Program Results’ available online each year which lists all programs that did not fill, although interpret these with caution.  Having narrowed down appealing programs within your specialty and area of interest, how many programs should you apply to, and how do you know if a program is likely to interview you?  Most US medical students seem to apply to about 20 programs, and interview at roughly half.  Bear in mind also how many places are available at each program, because bigger programs will obviously interview more candidates and offer more spots.  There are various lists available on the web of places that are “IMG friendly”, but personally I didn’t find them helpful.  It is much more useful to research whom the current residents are – did any of them train overseas? – and try to gauge the staff’s attitude towards having an international graduate on the team.  The programs who do not accept applications from IMGs are usually very upfront about it on their website, or if you call their program administrations – examples I came across in 2005 were NYU, MGH and Beth Israel Deaconess who were not accepting IMGs other than those in very exceptional circumstances (such as medical graduates who already have extensive research experience in their labs).  I put down a few places that I thought may be out of my league, a few more moderate programs and a few safety-net places (programs of lower reputation that rely heavily on hiring IMGs to complete their workforce).  Many advisors recommend a rule of thirds: chose about 1/3 ‘dream’ programs, 1/3 ‘realistic’, and 1/3 ‘backups’.  Interestingly, it was the upper end programs that offered most of my interviews and who were most receptive to the idea of a candidate with a slightly different training pathway and additional clinical experience.  Do check out the USMLE STEP 1 score requirements for the programs you're interested in; this will give some indication of the competitiveness of individual programs. 

The majority of programs received applications throughout the Electronic Residency Application Service (ERAS), although a few programs use their own application materials – FRIEDA and program websites will alert you to this.  Applicants are reminded that it is their responsibility to ensure that they meet a program’s eligibility requirements before applying, including whether the program supports the type of visa that you would require. The ERAS service is reasonably straight-forward and is a portal for transmission of information to program offices, including applicant details, personal statements, letters of recommendation, Dean’s letters, transcripts and USMLE scores.  The ECFMG acts as the ‘Dean’s Office’ for IMGs.  Check the application deadlines for the programs in which you are interested – most will be in November/December.  Therefore you will be aiming to submit your application by early November.  A timeline for application submission may look something like this – dates are those posted for the 2007-8 round of applications:

Plan overseas elective /observership in US to gain experience and hopefully a US letter-writer – 1 to 2 years before application

Pass at least STEP 1 before deciding whether to and where to apply; plan for STEP 2 CK and CS to be completed by the time that you interview

Request information from programs and research your options – Aug/Sept

Request a token from ECFMG website ($75)

Ø  Enroll in the NRMP Match as an “Independent Applicant” (unless your specialty has its own matching system) and pay $40 – by Nov 30th

Ø  Request Letters of Recommendation – Sept/Oct

Ø  Work on CV and Personal Statement

Ø  Get a suitable photo taken         

Ø  Work through ERAS online application and pay fee ($60 for first 10 programs applied to, with scale of fees for additional programs beyond that)

Ø  Submit applications – for Internal Medicine applicants the deadline will be around end of November/beginning of December, depending on the stated deadlines of the programs to which you are applying

Ø  Schedule interviews

Ø  Interview – Nov to Jan

Ø  Write letters of thanks

Ø  Create your Rank Order List – by Feb 27th

Ø  Matched/Unmatched list is released – March 17th

Ø  (Scramble – March 18th)

Ø  Match Day! – March 20th

Ø  Write letter s of thanks to those who supported and advised you

Ø  Sign your contract, complete forms for visa application and State medical license

Ø  Interview at the US Embassy in the UK – at a minimum 5 working days before your flight to the US to allow time for visa processing

Ø  Move to the US, undergo program orientation and then start work on June 25th (the universal start date)

Tentative Dates for the 2009 Match per ECFMG website:

August 2008

Registration opens on the NRMP website

November 2008

Registration deadline

February 2009

Late registration deadline, and rank order list certification deadline

March 2009

Results of Match announced

For additional information, visit the NRMP website or contact:
NRMP, 2450 N Street NW, Washington, DC 20037-1127 USA;
Telephone: (202) 828-0566 or toll-free (in the United States) (866) 617-5838;
E-mail:
nrmp@aamc.org.

Personal statement: I found this difficult to write, as it is quite a ‘un-English’ requirement for a professional application.  It remains unclear to me how much weight program directors attach to this part of the application, and to what extent it can help or hurt your applications.  However, for the non-US applicant, I think that the personal statement offers an excellent opportunity for you to explain how you got where you are, what stands out from your British medical training, and what you are looking to gain from – and contribute to – the American system.  Beyond this, other elements that should find their way into your writing include why you chose your medical specialty, how you see your career plans for the next 10 years, particular accomplishments that you wish to emphasize, interests outside of medicine that have shaped you into the doctor you will be, at the contributions you see yourself making to your future specialty and/or residency program?  Often, applicants use the opening paragraph to recall or explain a motivating experience, moment of great clarity, or life-shaping event to lead into their thoughts on the issues above.  This is definitely an opportunity for some degree of personal insight, but the general consensus is that you should stay away from gimmicky writing, over-emotional revelations, self-congratulatory statements, or huge clichés; this is not a moment for “every patient has a story”, or “life is a journey” musings.  Proof-read carefully for misspellings and poor grammar.  Don’t be afraid to sell yourself – be assured that the Americans against whom you are competing will!  You will see examples, good and bad, on various internet sites and in “First Aid for the Match” by Tao Le et al.

Letters of recommendation: Most programs will require 3 letters.  Start thinking about your letter writers early on in the application process.  Certain efforts will help you to obtain as strong letters of recommendation as possible.  There are two major considerations in selecting letter writers; the ideal writer is eminent and well-respected in their field, and also known you well and in a positive enough light to speak strongly on your behalf.  Few of us are in a position to know three such people!  So chose a combination of those who are well-known and those who are lower key but know you very well.  In the end, it will always be in you favor to have people in your corner who think highly of you and will strongly endorse you on paper, than people who are well-known but luke-warm about your abilities.  Tactfully gauge a potential writer’s enthusiasm towards you with a question such as “Do you feel you have worked with me enough to be in a position in write a strong letter of recommendation for me please?”  For those who are more advanced in training, try to solicit writers from all stages of your medical education; e.g. pre-clinical, clinical course, and as a junior doctor.  Help your writers by providing a copy of your CV and your personal statement, and take some time to explain to them your future career plans and reasons for applying to the US system.  The letter itself should be on official letterhead, typed, and personally signed, and loaded with frequent personal references and unconditional praise.  I think it is fair to say that English writers are dryer and more reserved in their letter-writing than the Americans, so explain who will ready the letter (American program directors) and encourage them to really 'sell' you on paper.  One further thought; do not underestimate the huge asset of having a letter writer from the US.  As mentioned elsewhere, program directors are generally wary of candidates with a background of which they have no experience, and so an impressed US letter writer will go a long way towards reassuring directors that you are on a par, if not above, the US applicants with who you are competing.  Therefore use the opportunity of your overseas student elective or observership wisely. I am forever indebted to a generous Cardiologist who wrote a supportive letter of recommendation for me.  Writers can either return their letter to you for onward mailing to the ECFMG in Philadelphia, or can send them directly to the mailing room in Philadelphia themselves (ensure that the letter is accompanied by a completed ERAS ‘document submission form’, as found at http://www.ecfmg.org/eras/docform.pdf).  Make sure you provide them with the appropriate envelopes/postage/addresses for their troubles. 

Dean’s letter, now known as MSPE:  The ‘Medical Student Performance Evaluation’ is prepared for all US medical students by their Dean’s office, and includes a range of information that serves as an expanded letter of recommendation, and can be key in gaining highly sought interviews.  When approaching your medical school Dean or Chair of Undergraduate Medicine for such a letter, be sure to provide for them a copy of your examination transcript, any copies of evaluations you have, and a CV, as they are unlikely to have all this information on you to hand.  Also supply them with guidance as to the expected structure of the letter – Dean’s letters usually include something on the student’s communication skills and personality, perhaps their academic background prior to medical school, their preclinical evaluations at medical school and even more importantly information from their clinical rotation evaluations (incl quotes from doctors who supervised their undergraduate rotations).  There is often also mention of med school-related extra-circular activities, positions of leadership or service, and research experience, rounded off with a summary paragraph.  Further information on this is available in the PDF “A Guide to the Preparation of the Medical Student Performance Evaluation” on the ERAS website at http://www.aamc.org/students/eras/resources/downloads/mspeguide.pdf - it even includes a template of what your Dean is expected to write in the MSPE, so be sure to supply them with a copy of this PDF.  Submit the MSPE with the ERAS ‘document submission form’.  

  

 

Transcript:  Contact you Registry to request a verified and stamped version of your official assessment scores during your medical school course.  Do check it for accuracy first – I discovered that several examinations were completely missing from mine and so had to spend some time going through with the Registry the sequence of our course.  The ICSM Registry office mailed my transcript, along with the ERAS ‘document submission form’ directly to the ECFMG in Philadelphia for scanning into my application. 

USMLE scores:  USMLE scores already released can be transmitted to programs to which you are applying, with payment of a $50 fee through OASIS.  If further scores become available during the application process (e.g. you pass STEP 2 CS), these should also be automatically uploaded, so long as you’ve checked off the box in your ERAS application giving your permission for this to occur. 

Photograph: This picture will be attached to your application throughout the process, and most importantly will be used jog memories of you at programs’ final ranking meetings.  It will likely be used for the class lists at the program you match into too.  As its going to haunt you for some time, pick a good one!  It needs to be professional and represent you in a good light. 

Once your applications have been submitted through ERAS, it’s time to sit back and wait for Programs to contact you by email with offers to interview.  Most will have a reasonably broad selection of dates through the winter with many programs holding interviews several times a week from mid-November to late-January.   As the offers come arrive, try to respond promptly, but arrange your interview schedule in such a way that you can visit as many programs as possible within the time you have available to be in the US.  I was only able to be in the US for 10 days during January, and scheduled 7 interviews within this time period.  Although it worked out fine, it was rather hectic travelling between cities, and had I been travelling to a new area I would have needed more time to get a feel for the cities.   In general, it is best to leave a day for travelling between interviews; also be aware that many programs will arrange for informal applicant dinners with the current housestaff on the evening before or after an interview session.  Some programs will also suggest local accommodation – if they don’t, just ask the program administrator.  Remember to be very courteous with the administrative staff because they can really help you out in making arrangements and looking after you on the interview day!  The actual interviews vary greatly.  Some interviewers just want to get a sense of you as a person, and find out about your interests and experiences.  Questions that sometimes come up are:  Why are you interested in your chosen specialty?  What do you enjoy doing outside of medicine?  What are your strengths and weaknesses?  Why are you interested in us?  What can you offer our program?  How was your training in the UK and why are you looking to move to the US?  Others will ask you to discuss an interesting case, so have a couple pre-prepared patients in the back of your mind.  It is worth having a think about how you intend to project yourself, as many programs interview hundreds and hundreds of applicants.  To stay in their mind and make it onto their rank list, you will need to find a way of standing out amongst the other candidates (apart from your English accent).  Try to a feature of yourself that makes you appealing or interesting to programs - and really sell yourself on it, in a modest way.  It may be your extensive clinical experience, research background or a particular skill or career goal.  Do your research on the program director and your interviewers (if you are told who this will be ahead of time), to give you an awareness of their backgrounds and area of expertise.  The interview day is as much an opportunity for you to learn about them, and have all your questions answered - from the directors, other senior staff you meet, the current residents, and also from your fellow applicants about things they have heard or discovered about other programs.  Get involved on interview day – without being irritating!  The more people you meet, the more potential advocates you may have when the final ranking meeting occurs.  Do make an effort to attend any social events (e.g. at BU we now organize an informal dinner with applicants at local restaurants two evenings a week during interview season), and ask questions of the residents you meet – but you should presume that you are always being judged no matter how relaxed an affair it may seem!  It may be helpful to keep some sort of a score-sheet to record your impressions on each program as you go along.  You may consider:

·         Setting: location, community vs. university, reputation, stability, subspecialty strengths

·         Training: conferences and rounds, standard of Faculty, post-Residency plans (how well do their Residents match in Fellowship?), mentorship and support, research opportunities, team morale

·         Duties: patient population and load, resident responsibilities, call schedules and work hours, on call support, benefits, vacation/sickness/parenting leave

And don't forget to write a thank you letter to the director and/or interviewer after interviewing at programs you are keen on - mention a few things you particularly liked, or an interesting point from your conversation, and express that you hope they will keep you in mind for their rank list.  It is worth mentioning at this point what is and isn’t considered acceptable in the application process.  Although it is appropriate, and often necessary, to express to a director that you view their program favorably, neither the program nor the applicant are permitted to ask each other for commitments as to how each will be ranked, and any comments that could be viewed as commitments should be avoided. 

The Match is administered by the NRMP (National Resident Matching Program), a not-for-profit organization formed in 1952 to enable a standardized date of appointment to position in graduate medical education in the USA.  Once you have completed the interview trail, it is time to decide which places you would be happy training at, and in which order you would like to rank them.  Some people try to play games with the rank list, but if you think about it logically there is nothing to be gained from overcomplicating it.  Just rank the program you would most like to go to as number 1, and then each other program you would be prepared to work at in their following order.  Don't rank anywhere lower just because you don't think they'll rank you - you never know!  If they liked you, you will be high on their list.  And don't put down anyway where you would not be prepared to work, because if you match there, you are contractually bound to that program.  Your rank order list should be submitted to the NRMP (not ERAS!) by their deadline – Feb 27th in 2008 – and then it’s another wait until Match day (20th March 2008).  The matching process is carried out in seconds by a computer algorithm: the system attempts to place an applicant into the program ranked number 1 on their list; if they cannot be matched to this program and attempt is made to place them into their 2nd choice, and so forth until the applicant makes a tentative match or all their choices have been exhausted.  A tentative match can be made if the program has also ranked the applicant and either there is an unfilled position, or the applicant in question was ranked higher by the program that another applicant who is already tentatively matched.  When a tentatively matched applicant is removed from a program, an attempt is made to re-match them starting form the top of their list until each applicant has been matched with their most-preferred choice, or all choices submitted by the applicant have been exhausted.  When this process has been completed for all applicants, the Match is completed and all tentative matches are now final.  Therefore, it is always in the applicant’s best interest to submit their rank order list in their true order of preference, regardless of whether or not they think that they program will rank them highly.

The caveat is that only US final year medical students actually have to be allocated to Residency places via the Match.  At time of writing, it is permissible for program directors to offer pre-Match contracts to IMGs at the time of interview.  This is always worth considering, although such an offer should only be accepted if it is from a program that was already very high on your list of preference.  If it is from one of your lower choices, most people would advise that you are better off expressing your interest and thanks, but saying you are not yet ready to make a final decision because have not yet fully considered all of your options.  Then you can rank that place as you see appropriate - if they want you, they will likely still place you high on their rank list, and if you don't get matched to one of your higher choices, you should still end up getting a place at the program that was keen on you.  If you decided to accept a pre-Match contract, make sure you have a firm offer of employment, in writing, before you withdraw yourself from the NRMP Match.  One of the advantages of accepting a pre-Match contract is that it will give you a couple of months extra time in which to complete the visa application etc.

If you participate in the Match, you will be informed on a specific date in March whether you have matched.  It you are unmatched, you may then participate in ‘the Scramble’ to attempt to secure a place at a program with vacancies.  This is involves frantic calls and faxing of LORs/CVs to program offices.  Those who have matched are informed two days later of the institution at which they will be working.

 

How do I apply for a US non-immigrant visa?

I am certainly not an immigration attorney and the nuances of the US Dept of Homeland Security policy remain very much a mystery to me, but I will try to outline the common routes taken by British passport holders to be eligible to work as a doctor in a US training scheme.  Do note that these are training visas and even once you are eligible for a Full Medical License you will not be able to undertake non-training activities such as locuming (“moonlighting”) in the US or attaining employment as an Attending or non-trainee on such visas.  The two main visa options (presuming that you are not eligible for a US passport or ‘Green Card’) are the J-1 and H1B visas.   You need to be thinking about which visa you will aim for when selecting programs to apply to, as many are quite specific in which visa types they will accept.  In general, an H1B is more limiting because the hospital has to pay more to sponsor you as an H1B worker, and so the ECFMG-sponsored J-1 visa is usually preferred.  

The J-1 visa is also known as the Exchange Visitor Program, and was introduced to give IMGs the opportunity to train in the US and so improve the provision of medical care in their home country.  Hence the duration of participation on a J-1 visa is typically limited to the length of time it would normally take to complete the training program of the stated specialty/subspecialty.  The maximum duration of participation is ordinarily limited to 7 years unless the IMG satisfactorily demonstrates that their home country has an exceptional need for the specialty in which he/she proposes to obtain additional training.  Requirements include that the participant register through the Student and Exchange Visitor Information System (SEVIS), which was created in the wake of the September 2001 terrorist attacks, in order to monitor exchange visitors during their stay in the US.  This involves paying a one-time fee at initial visa application, and then keeping SEVIS updated with your current address via the AR-11 form available at www.uscis.gov/ar-11.  Each year, participants must also furnish the Attorney General with an affidavit (form I-644) attesting that they are in good standing with their graduate medical education program and that they will return to their home country on completion of the training for which they came to the US.  The J-1 visa also includes a condition known as the “two-year foreign residence requirement”.  This states that upon completing the training program, the visa holder must leave the US and be resident in the home country for a period of at least 2 years.  Per Department of Homeland Security information, an IMG on a J-1 visa is ordinarily no permitted to convert from a J-1 to permanent residence until the “2 year requirement” has been fulfilled, as the purpose of the training visa is for the doctor to use their skills in their home country.  The “2 year requirement” may however be waivered, e.g. under circumstances where returning to the home country would cause “exceptional hardship” or if sponsorship is obtained by an “interested governmental agency” such as the Veterans Administration, the Appalachian Regional Commission, or the State Departments of Public Health. 

Although the H1B visa was not initially intended for the sponsorship of training doctors, since 1991 it has been possible for medical residency programs to provide H1B sponsorship.  The advantage of this visa is that there are no restrictions on converting the H1B into other forms of visa, including a green card (permanent resident status) through employer sponsorship or close relatives who are US citizens or permanent residents.  There is a strict limit on the number of H1B visas that can be issued to eligible professionals annually, and hence it is advisable to begin the H1B application process as soon as possible in the official year (beginning October) in order to maximize the chances of securing one of these visas.  For a prospective medical resident, the important points are that the applicant must have passed STEP 3 before being considered for a H1B visa, and that many residency programs are not willing to file the considerable paperwork requirement and associated costs for a H1B visa application on behalf of residents. 

As soon as you know where you've matched, get straight down to completing the visa forms - and remind the program administrators to send you the paperwork asap if they are being slow or disorganized.  Unbelievably, March to June is actually cutting it quite fine to get the application sorted out.  The checklist for initial J-1 sponsorship runs something like this:

·         Valid ECFMG certification

·         Letter of offer or copy of contract from Program

·         Application form for J-1 sponsorship

·         Form I-644, supplementary statement for graduate medical trainees

·         $200 administrative fee (annual) – can be paid through OASIS on the ECFMG website

·         SEVIS fee (one-time)

·         Statement of need for the Ministry of Health of applicant’s country of most recent legal permanent residence[1] 

The 'statement of need' confirms that your home country does need doctors with the specialty you will be training in whilst in the United States.  It also serves to confirm the physician’s commitment to return to that country upon completion of training in the USA (as required by §212(e) of the Immigration and Nationality Act as amended). It took me forever to track down the appropriate person to issue this letter in the UK, so here are her contact details: Mrs. Terri Martin, Education, Regulation and Pay, Department of Health.  Room 2E56, Quarry House, Quarry Hill, Leeds LS2 7UE.  0113 254 6654. Terri.martin@dh.gsi.gov.uk

Once the above documents have been processed (which takes several weeks), a DS-2019 will be sent from the residency program to you.  The next step is to schedule an interview at the US Embassy in Grosenover Square.  This is so much more difficult that it need be, with a premium-rate call line for scheduling the interviews, and frequent changes in the system of applying for an interview.  As of 2008, the expectation is that you call their interview hotline on 09042450100 (GBP1.2/min from BT landlines) or 1-866-382-3589 from overseas, and schedule your interview day (an all-morning or all-afternoon affair) and pay the visa application fee by credot card.  Unfortunately, they are usually booking interviews about a month ahead, and it takes 2 to 5 working days after the interview to get the visa processed, so you need to aim to be in possession of the DS-2019 and scheduling the interview at least 6 weeks before you need to fly over to start residency orientation week - and the summer is peak visa time, so even this window could be insufficient.  Take with you to the interview as many supporting documents as you can (e.g. your medical diploma, letter of welcome from the residency program, CV, names and addresses of 2 people who can verify your identity who are not relatives as required on the DS 158) as you never know what they will ask for.  The checklist of definately required items is:

  • DS 156 - complete this online and print it out with barcode
  • DS 158 - this contact info and work history form can be downloaded as a PDF, filled in and saved to be printed out again for future interviews
  • DS 2019 - which will have been sent to you by your Program
  • Proofs of payment of the visa application fee (annual) and the SEVIS fee (one-time)
  • Your UK passport - valid for at least the next year if you applying for a one-year visa
  • US visa photo - this is not the same as a UK passport photo - the photo must be 2 inches square and I have had mine taken each year by the very helpful folks at the Passport Photo Service at
    449 Oxford Street (opposite Selfridges), which is within a couple of minutes walk of the US Embassy at Grosenover Square.

Unfortunately, this process has to be repeated annually, meaning that you have to plan ahead and get at least a week off every June/July to come over and get a new visa processed!  2008 update: no cellphones/IPods/laptops etc are permitted inside the Embassy and the Security checkpoint will no longer hold these items during your interview; they will instead direct you down the road to a Pharmacy that will hold your phone etc in exchange for ten British pounds!  Despite the considerable obstacles placed before applicants, if you understand the system and have an awareness of the time course that needs to be followed, then the visa application is not as foreboding as it may appear, and once you’ve made it through your first application the subsequent rounds will be much smoother.

[1] www.ecfmg.org

 

What can I expect when I move to the USA?

My move from London to Boston was quite a whirlwind, flying directly from post-call rounds in London into the first day of program orientation in Boston; however there are a few issues that require some advance planning and some facts I wish had been pointed out to me when I was trying to make the transition!  Prior to arriving for orientation in June, your program will have been sent a stack of forms for completion, including the application for your state medical license, DEA (Drug Enforcement and Administration) number and schedule for the coming year.  The complexity of medical licensure varies between States, but so long as you do not have any medical malpractice claims or criminal convictions against you, and haven’t changed your name since graduation, it should be reasonable straight-forward.  I did have to get my medical degree certificate, ECFMG certificate and current photo notarized; I went online and found a law office in my area that offered this service for a fee.  Make sure you follow the submission deadlines; like the visa application, many new interns end up cutting it very fine in getting their licensing processed by June 25th.  Your Program will also provide you with information on the orientation week, which often includes ACLS (Adult Cardiac Life Support) teaching and accreditation.  If this is not scheduled in and you do not hold ACLS already, or if the British ALS certification is not sufficient for the hospital at which you will be working, contact the residency program to enquire where the course is run locally.  Orientation will usually also contain events to get to know your co-Residents – remember that most of them will likely be new to the are and to the hospital too – and familiarize you with the layout, call schedules and policies and procedure s of the hospital.  Program administrators will usually also be able to assist you in suggesting temporary accommodation that you can arrange prior to flying over for orientation, enabling you to do on-site apartment hunting in the first couple of weeks after arrival.  Local Realtors, residency graduates vacating their apartments, and Craig’s list at www.craigslist.org are all useful sources of properties available for rent.  Remember to complete the AR-11 form and also update the ECFMG with your new address to keep all agencies informed of your location. 

A major hurdle for me was getting a Social Security Number; the application took several weeks and in the meantime many tasks such as switching electricity and gas into my name, getting a cell phone, and applying for a credit card were not possible, although thankfully I did receive my weekly paychecks!  My employer was issued with a temporary number in order to keep me on the payroll; I had to go in person to a local Social Security office during Mon-Fri working hours to apply for an permanent number and when it cam through it did not completely solve my problems, because obviously my credit rating associated with it was non-existent.  In order to take out a cell phone contract either without a SSN, or on a SSN with no credit rating, US phone companies will require that you pay a $500 deposit for the first 12 months.  I had opened a US checking account some years ago (pre-9/11) and so I am unsure whether there are any difficulties in opening a banking account on arrival in the US these days, but I would imagine that the main problem may be securing proofs of address shortly after moving in.  If you do not have a US bank account already, it may be worth taking the necessary documentation and seeing if you are able to open one with a UK address whilst visiting the US for STEP 2 CS or program interviews, as this will ensure that you are able to receive your paychecks without delay!  It is also worth obtaining a State resident’s ID card once you have the necessary proofs of address – applications are submitted to the Dept Motor Vehicle Registration – as then you won’t have to carry around your passport and visa to get into bars and clubs.  I had yet to truly solve the credit card issue; despite having had a hefty credit allowance in the UK, I am still only eligible for a $500 credit line here.  Capital One was the only company who accepted my application when I first moved over.   On the subject of money, I will make a few comments about filing taxes.  Your annual tax return will be due every April, and although American colleagues may use one of the quick online services, if you are a J-1 visa holder you will be designated as a ‘non-resident alien’ and I have found that the online services exclude participation with this status.  Although I would not wish to formally endorse any particular accounting service, I have filed my taxes for that past 2 years with HR Block, by scheduling an appointment with one of their accountants.  Unfortunately, the ‘non-resident alien status’ (which persists throughout the length of time that you are on a J-1 visa, although alternate visa holders may be able to able to convert their status after the first 2 years) means a smaller tax rebate, or in my case this year, that you end up owing several hundred dollars in taxes.  So be prepared for that – especially in the second year of filing, because for the first year you will only have worked 6 months in the US and are likely to come away with a few hundred dollars in rebate.  In terms of airfare fares back to the UK, I consistently find American Airlines to offer the cheapest service between Boston and Heathrow.  Expect to pay around $600 at present, although this increases in the summer.  Also be aware that return trips for short lengths of time (e.g. for 3 days to interview) are about triple the price of a return ticket for a 2 week stay.  A final financial pointer is the existence of online trading sites that help you to transfer money between your accounts in two countries.  Direct wires between your US and UK accounts are possible, but are associated with substantial transfer fees at both ends and poorer exchange rates.  You may like to try sites such as www.onlinefx.co.uk, which has a GBP 15 transfer fee.

Whilst working in the US, it may be worth voluntarily withdrawing your name from the GMC Register if you do not intend to locum back in the UK during the coming years, in order to save the annual registration fee – the required forms can be found on the GMC website.  Depending on what stage in your training you move over to the US you may well be completing Membership exams in the UK during your US Residency, although you do not need to remain GMC registered to sit these.

In terms of lifestyle and atmosphere at work, a lot will depend on which part of the country you have settled in.  In my experience of moving from London to Boston, I have found the overall lifestyle to be richer in terms of what you can do on the same budget – eating out, transport and shopping all tend to be cheaper.  Boston is a much smaller city than London, but with its strong cultural focus there is always plenty going on.  At work, the hospital atmosphere is much less hierarchical than that which I was used to in London, and senior colleagues are extremely approachable.  It is a huge privilege to work with so many talented co-residents, and being part of a 3 year program fosters a greater sense of community and common purpose that is often the case in the UK.  The hospital I work at cares for an underprivileged and hugely diverse patient population, but the facilities and standards of care are impressive, with excellent auxiliary support (you need never take blood or place an IV again!) and Faculty.  We work hard, and although working hours can be long (80 hour weeks are the maximum permitted by ACGME) with only one day off per week, I feel that the rewards here in terms of medical knowledge, clinical skills and career satisfaction fully eclipse the challenges and sacrifices that I had to face in order to train here. 

References

You may be interested to read my article in the Student BMJ regarding postgraduate medicine training opportunities in the USA:  http://student.bmj.com/student/view-article.html?id=sbmj.b1064 

www.ecfmg.org  The Educational Commission for Foreign Medical Graduates - details on the USMLE examinations, eligibility to apply to US Residency programs and visa sponsorship.

www.usmle.org Containing official information and sample questions for the USMLEs.

http://www.aamc.org/audienceeras.htm The portal to the website through which most Residency applications are submitted.

www.ama-assn.org/go/freida  The American Medical Association's FREIDA database lists the available residency and fellowship programs, with contact details and statistics for each program listed.

www.aamc.org/audienceeras.htm  ERAS is the online system via which the vast majority of Residency programs accept applications. 

www.nrmp.org  The NRMP matches applicants to positions in all but a few specialties. 

www.sfmatch.org For the Child Neurology, Neurotology, Ophthalmology and Plastic Surgery Matches 

www.auanet.org  For the Urology match.

www.kaptest.com/med_home.jhtml?source=kap_home Link to Kaplan Medical, a test preparation company that offers USMLE prep materials in the form of books, online question banks, live lectures and recorded teaching.

http://www.uscis.gov/portal/site/uscis US Citizenship and Immigration Services, information and forms for downloading.

http://london.usembassy.gov/ or www.usembassy.org.uk For visa application information and scheduling of Embassy interviews for British residents.

www.dhs.gov For the immigration bureaus of the U.S. Department of Homeland Security.

http://www.passportphoto.co.uk/ Visa photos to US specifications at 449 Oxford Street, London.

www.craigslist.org Online listing of various items for sale and apartments for rent.

“First Aid for the Match” by Tao Le et al, published by McGraw Hill (ISBN 0-07-140929-7).

www.promteric.com To locate your nearest Prometric testing center to sit STEPs 1 and 2. 

CITY OF LONDON CENTER

Phone: 0207 248 7311
Site Code: 8021

PROMETRIC, 2ND FLOOR
PELLIPAR HOUSE, 9 CLOAK LANE
LONDON EC4R 2RU

 

 

US Medical Wards 101

Congratulations on matching into an Internal Medicine Residency position!   You will shortly be starting work in an American hospital system, and this page is intended to smooth that transition for graduates of non-American medical schools.  Especially if you have not undertaken a student clerkship in the US, you will find that there are many differences between the medical system that you are accustomed to and the way the wards work in the US.  Some international residents find it frustrating that, despite their very strong academic medical school background, they have difficulties in meeting their own and others’ expectations during their first months of residency, due to a sharp learning curve on issues such as note-keeping, ordering tests, presentations on rounds, and being an efficient intern.  Many of these issues can be addressed before you hit the wards, enabling you to concentrate on the delivery of excellent patient care and also your own medical learning from day one.

A Day in the Life of an Internal Medicine Intern:

It all starts with Pre-rounds and finishes with Sign-out, both of which may be new concepts to the international graduate….

“Pre-rounding” (the collection of vital signs and a brief check on your patients prior to the main daily rounds with your resident +/- attending) may be new to you.  The principal is that either before or after picking out your sign-out from the intern/resident who was responsible for your patients overnight, you need to check in on your patients in order to triage efficient work rounds and ensure patient safety.  Good pre-rounding sets the basis for being an efficient intern for the rest of the day.   You will check your patients’ vitals charts and note down their current and maximal temperatures (which may be written Tc and Tmax respectively); temperatures will usually be in Fahrenheit, with >100.4 being a low-grade fever and >101 being a fever.  If your patient spiked a fever overnight, you should know whether the night resident sent off cultures.  BPs and HR should be noted as a range.  Pulse ox should be noted, along with the delivery of oxygen at that time.  If the patient is diuresing, Ins and Outs and a net fluid balance, along with their change in weight, will be necessary.  And if the patient is on telemetry, quickly flick through the screen to see if there have been any alarms, and what the predominant rhythm and rate have been.  During ICU rotations there is additional information to collect, including the CVP +/- Swan-Ganz pressures, the ventilator settings, the morning ECG (or “EKG”) and the current rates of IV infusions. 

Don’t forget to ask the patient how they are doing and if there were any problems overnight; some interns like to take this opportunity to exam their patient too, although this can also be left until the ward round if there is nothing acute.  Depending on how your wards are laid out, your pre-rounds will only take about 2-3min per patient with a bit of practice.  Ask your resident exactly what they expect and how thorough they would like you to be. 

Ward rounds and presentations – having already ascertained any overnight events and the vital signs of the past 24hrs you already have much if the information you will need to be efficient on your morning rounds.  In addition, you will be expected to know the results of any tests or procedures from the past 24hrs, the most recent set of labs, and the current medication list.  Although interns carry fewer patients at one time (12 is the max) that in many other countries, the depth that you are expected to know the patient in is greater.  Remember, you are the principle physician for your patients during their admission, and in return for the privilege of making medical decisions and directing their care, you’ve got to know the details of their case!  Many hospital systems now have very helpful computer systems that print out a quick summary sheet of the patients on your census, their location, their age, most recent labs and current meds, which make things much easier.  You may also wish to make up cards on your patients, or download a “scut sheet” to organize your days’ work, although in my experience these are unnecessary and an extra burden.  A well-constructed team list with the vitals, results, and “to do” boxes for each patient is essential in organizing your day. 

On rounds, you will usually be asked to give a brief update on your patient prior to the team entering the patient room.  If this patient is already known to the team, a one-liner about their presentation and course so far (e.g. “Mrs Smith is a 65 year old diabetic who presented with cellulitis of the right lower extremity 2 days ago which has responded well to IV clindamycin”) any events overnight and her vitals, labs and any other new test results.  When you enter the room, it is usual for the intern to initiate the conversation with the patient (check with your resident if you are unsure), followed by pertinent physical exam.  The intern is then expected to formulate a plan for the day, which may be presented at the bedside or outside the room, depending on the patient scenario and team preference.  Some residents present by system (e.g. Cardiovascular, then Pulmonary, then GI etc) although I prefer to run the plan by problem list, because it better focuses the day’s tasks and the patients’ issues.  (E.g. “ 1) Cellulitis – this has responded well to IV clindamycin with no fevers in over 24hrs and negative blood cultures and I think we should switch to oral clindamycin today.  2) Glucose control – the morning fasting glucose has been consistently above 200 and so I am increasing the evening NPH dose by x units. 3) COPD – she has been doing well on her home inhaler regimen with no wheezing or decrease in PEFR and can continue unchanged. “)  At the end of the problem list are a few issues that should be addressed in all patient:

·         FEN (fluids, electrolytes and nutrition)

·         Prophylaxis – thromboembolism prophylaxis, atelectasis/pneumonia prophylaxis if indicated, PU ppx if indicated

·         Disposition – when the patient will be discharged and where to (home, skilled nursing facility, psychiatric facility etc)

·         Code status – full code, DNR/DNI (do-not-resuscitate, do-not-intubate) or any special instructions

These issues need not be belabored, and they may not be relevant in each patient, but you must at least consider them to ensure patient safety and efficient patient flow.

On the ICU, the end-of-presentation issues are more numerous:

·         FEN – incl closer attention to electrolytes

·         VTE ppx

·         VAP (ventilator-assoc pneumonia) ppx – head of the bed elevated >30 degrees, gastric protection, daily sedation weans

·         IV access – what lines and how long have they been there

·         Dispo – ie when patient will be ready to transfer out of ICU

·         Code status

·         Health Care Proxy (HCP) status and family meetings

Progress notes, H&Ps and discharge summaries

The guidelines above for ward rounds have included all the elements of the daily progress note.  Getting into the habit of writing an efficient and useful intern progress note will reap benefits, both in organizing your thoughts, and communication care plans to other practitioners involved in the patient.  A difference between the US and other healthcare systems is that the intern is required to write a full note every day on each patient.  There is no one correct format, but most people use the “SOAP” format (subjective, objective, assessment, plan), with the objective section including the vital signs and exam, morning labs, and any new radiology studies or culture results.  In most hospitals this is still handwritten into the patient’s chart, although some hospitals are moving towards 100% electronic charts.  Don’t forget that some medical spellings differ in American-English: its edema not oedema, esophagus not oesophagus, anemia not anaemia, gynecology not gynaecology etc.

A H&P (History and Physical) serves as the admission note for the patient and may be written by hand, dictated, or typed into a computer program depending on the hospitals system.  You will always need to write one for patients you admit.  The A/P (assessment and plan) will be written in a similar, although more thorough, manner to the daily progress notes.  Don’t forget to include FEN, prophylaxis, disposition and code status!  If you are transferring a patient from your team to another (eg the ICU team to the general medicine team) you will need to write a Transfer Note that explicitly describes the care given so far, the working diagnosis, and the items which the receiving team need to follow-up on.  When accepting an internally transferred patient onto your service, an Accept Note will be expected which outlines the hospital course so far, an assessment of the patient’s issues and a plan of action.

Labs and tests – correctly ordering tests and knowing the results in a timely fashion is absolutely key to being a good intern.  How tests are ordered will depend upon your hospital’s system – make sure you get your resident to teach you the tricks of the system straight away!  Most hospitals have electronic order entry which streamlines the process, but can cause difficulties when the test you think you want isn’t listed!   As an intern it will be your responsibility to order daily labs on your patients – incl ordering in advance for your day off.  Think carefully about the frequency or appropriateness of labs you are ordering – e.g. a patient with a GI bleed may need a CBC bid or tid and an up-to-date type and screen at all times, a patient whose magnesium and phosphate were repleted yesterday will need those labs checked again today, a patient on warfarin will need a daily INR, whereas a patient with normal electrolytes being treated for a cellulitis may not need a daily chem7.  You will notice in the progress note above that the labs are recorded in a specific pattern which is rarely used outside the US:

                         Hgb                                                 Na        Cl         BUN

    WCC                                         Plt                                                               Glu

                         Hct                                                   K          CO       Cr

European graduates may not be used to checking the anion gap when a patient is acidemic and showing a low bicarb.  Learn how to calculate it [Na – (bicarb+Cl)], what it means and how to distinguish a mixed picture – it will come in handy!

Also, you will notice that many of the units of measurement are different from those you are used to.  To review a list of normal lab values, you can go to the USMLE website at http://download.usmle.org/2009step1.pdf and find page 23.  Don’t worry, you’ll soon get used to the different creatinines in the 2’s and glucoses in the 200’s! 

Medication names may sound unfamiliar to you.  In the US, there is less emphasis on using the generic name than in many other countries.  Even if you know trade names in your home country, they will likely be different in the US!   In the early days you will likely need to carry a copy of “Pharmacopedia” or a PDA application of “Hippocrates” with you on the wards to help decipher some of the drug names.  If you are unsure, always ask.  Being unfamiliar to the system is certain no excuse for making a drug error or omission. You will likely be responsible for electrolyte (“lyte”) repletion on your patients – check the expectation with your recent.  For potassium, the oral route is favored if possible with powder, tablets and liquid all potential options.  Magnesium is usually repleted IV.  In patients with any cardiac instability, the goal potassium is usually great than 4mEq/L, Mg greater than 2mEq/L.  Phosphate and calcium may also need repletion, especially in critical care patients.  Most medical teams will have an assigned Pharmacist, who may even round with the team.  Get to know them and solicit there help with prescribing!  You may also be unfamiliar with the system of Pharmacy verification of each order you place; although you may have written an electronic order it will not be immediately available to the nurse, as the Pharmacist will have to verify your prescription before it is released.   You may need to make the order STAT if it is urgently required. 

Communication is a key feature of internship.  You will likely be responsible for calling for consultations (a “consult”) from other specialty services.  Consults should be called as early in the day as possible, so that the consulting team has sufficient time to see the patient and review the case with their Attending.  Consults placed at 5pm on a Friday will not go down well!  When calling a consult, ensure that you have sufficient knowledge of the patient’s history, examination findings, labs results and other pertinent data to be able to give a full story.  Also, you must have in mind what the question is that you are asking of your consultant.  If you are unsure on any of these issues, ask your resident to sit by the phone with you when you make the call.  The consultant may give their recommendations (“recs”) verbally, on the computer system, or in the notes.  If you have called for a consult, don’t forget to follow-up in a timely manner and check the notes if necessary to see whether recs have been left during the day.  

Conferences and teaching – in order to meet ACGME teaching expectations most Residency programs design a schedule of noon conferences to deliver key curriculum items.  A few programs consolidate the 5 noon conferences into one half-day of teaching per week.  Morning report usually involves a smaller group of residents +/- interns and may be held prior to AM, or a little later in the morning.  Morning reports have significant regional variation, but the usual structure is a case presentation by a Chief resident, followed by discussion on differentials, investigation and management by the residents, with input by an Attending acting as preceptor.  One day a week the noon conference will likely be Grand Rounds, where an eminent internal or external Faculty speaker presents and area of their specialist knowledge or research.  There may also be an outpatient lecture series, or ambulatory morning reports.  Although you will be busy with your patient responsibilities, do try to attend as many teaching sessions as possible.  You are in residency to learn, after all!  Most teaching services also expect frequent Attending rounds (small group teaching delivered by the team Attending to the interns, residents and students) and the resident has a teaching responsibility towards the interns and students.  Remember, you are also a teacher, and your medical students will enjoy any teaching pearls you can pass along to them.

 Sign-outs – it’s the end of your shift… but you’re not quite done yet!  Before you leave the hospital you need to prepare an information sheet that enables the intern or resident covering your patients overnight to be fully informed of their status and any items that require follow-up.  Hospitals use various different formats, from handwritten sheets, to computer printouts.  Some base their signout on the SBAR protocol: Situation, Background, Assessment and Recommendations.  You may have lab tests or radiology studies that you are asking the night doctor to follow up – if so, you must make sure you clearly indicate what results would be abnormal and what you expect to be done in that event.  If the night doctor will be following up Hgb/Hct, make sure a transfusion threshold is stated, a type and cross is active and that you have explained the plan to the patient and consented them for blood products.   Before you leave the hospital, ensure that you have touched base with your resident, have anticipated any overnight issues and signed such information over to the night doctor, order your lab tests for the following morning, and assign your pager to the appropriate person.

Asking for help…. and where to find it – you have been given a Residency position because you are an excellent candidate and more than capable of doing the job.  However, even American medical students who have been pre-rounding, writing SOAP notes, preparing sign-outs and spelling it “edema” for the past 2 years can have a hard time making the transition from student to doctor.  By the end of your intern year all of the above will be second nature to you, but there may be times when you feel overwhelmed or underprepared for the tasks you face.  It is essential that you ask for help when you need it.  Sources of advice are your co-interns, you ward resident, your Chief residents, your ward attending, or your Program Directors.  The nurses (RNs) or other ancillary staff may also be useful sources of information.  The Chiefs are a particularly important resource as they were interns only a few years ago and know the system well.  It is their job to follow your progress through rotations, provide any necessary extra resources, and guide your ward resident if they are not providing the support that you need.  For US-oriented medical information, UpToDate (www.uptodate.com) is a very useful online resource to check current investigation and management practices – your program will likely have an institutional subscription.   Nobody expects you to be an expert instantaneously in an alien healthcare system.  But by becoming familiar with some of the system differences and asking questions when you are unclear will enable you to excel in your new institution and fulfill your high potential. 

Best wishes, Amanda Vest MBBS BSc.