Financial Costs of Applying for a U.S. Medical Residency

Foreign medical graduates (and U.S. allopathic seniors alike) should be aware of the various fees associated with applying for medical school. Many of these fees are less than $100, but they can add up over time. In this article, we outline some of the expenses associated with applying for U.S. medical residencies.

ECFMG Certification

In order to be considered for the NRMP match program, foreign medical graduates must receive ECFMG certification. One of the largest expenses associated with this program is the examination fees. The ECFMG breaks down the fees as follows:

  • $75: Application for Certification
  • $895: Step 1 Examination
  • $895: Step 2 CK
  • $1550: Step 2 CS

These costs are the basic ones associated with ECFMG certification. However, there are additional costs that foreign medical graduates may incur. There are fees associated with taking the Step 1 and Step 2 CK in a country other than the U.S. The Step 2 CS must occur in the U.S., so foreign medical graduates should be aware of the travel costs associated with taking the test.

Clinical Clerkships

Many U.S. medical residencies require applicants to complete U.S. clinical clerkships. These clerkships can range from 3 months to 6 months and can rotate the foreign medical graduate among various specialties. A 1995 study estimated that these kinds of clerkships cost between $1000 and $2100 USD. Costs are likely to have increased since the study was completed. Foreign medical graduates should also be aware of the costs of relocating temporarily for the clinical clerkship. Some U.S. cities, like New York City, have an expensive standard of living.

National Resident Matching Program (NRMP)

The NRMP is a program that matches U.S. medical residencies to medical graduates. Both the graduates and the residencies rank their preferences. Then an algorithm matches the graduates to the residencies. Participation in this program costs $75, according to the NRMP. There is an additional $50 late fee if the fee is paid after November 30.

Electronic Residency Application Service (ERAS)

ERAS is a U.S. service that transmits residency applications to program directors. Many medical residencies require that applications are submitted through ERAS. To apply for up to 10 medical residencies, ERAS costs $99. Additional applications are charged per application according to the following rates:

  • 11 – 20: $12 each
  • 21 – 30: $16 each
  • 31 or more: $26 each

The costs of applying for a U.S. medical residency can quickly add up. Although the examinations and relocation/travel expenses are probably the largest costs to incur, other registration fees add up to hundreds of dollars. Knowing the costs ahead of time can help foreign medical graduates prepare for a successful U.S. medical residency application.

An Introduction to the ECFMG Certification Examination

Before foreign medical graduates can match with a U.S. residency program, they must receive certification from The Educational Commission for Foreign Medical Graduates (ECFMG). Receiving a certification demonstrates that a foreign medical graduate is ready to enter an ACGME (Accreditation Council for Graduate Medical Education) accredited residency program. To receive a certificate, foreign medical graduates must demonstrate that they completed their schooling and take Steps 1 and 2 of the United States Medical Licensing Examination (USMLE). Passing the exam is one of the most time-consuming parts of ECFMG certification because graduates must prepare, study and visit the U.S. for the clinical skills demonstration. The basic components of the exam are outlined below:

Step 1

This one day examination consists of multiple choice questions. Seven hours of testing are broken into 60 minute blocks. Graduates can expect to see up to 240 questions throughout the course of the day. This test focuses on systems and processes. Examples of commonly covered systems include the immune system, the renal and urinary system, the endocrine system and the respiratory system. 55-65% of the exam tests medical and scientific concepts. The processes section covers normal and abnormal processes, testing a graduate’s knowledge of patient care, diagnosis and management. The USMLE posts examples of the question formats to give graduates an idea of what to expect.

A USMLE Bulletin states:

Test items commonly require you to perform one or more of the following tasks: interpret graphic and tabular material, identify gross and microscopic pathologic and normal specimens, and apply basic science knowledge to clinical problems.

Step 2: Clinical Knowledge (CK)

This one day examination also consists of multiple choice questions, but it has 8 hours of testing broken into 60 minute blocks. Graduates can expect to see up to 318 questions through the course of the day. The testing focuses on similar topics as Step 1, but has a different focus. A USMLE bulletin explains how test items differ from Step 1.

Most Step 2 CK test items describe clinical situations and require that you provide one or more of the following: diagnosis, a prognosis, an indication of underlying mechanisms of disease, the next step in medical care, including preventive measures.

Although similar information is covered, Step 2 focuses on the disease categories and physician tasks, as opposed to the systems and processes covered in Step 1.

Step 2: Clinical Skills (CS)

This part of the examination consists of 12 patient encounters of 15 minutes each. Each patient encounter is conducted with an actor trained to portray real patient symptoms. Telephone patient encounters may also be included as part of the examination. Sub-components that are analyzed in this portion of the test include:

  • Integrated Clinical Encounter (ICE)
    • Includes data gathering and documentation skills assessment
  • Communication and Interpersonal Skills (CIS)
    • Includes an assessment of the graduate’s ability to create a supportive relationship with the patient
  • Spoken English Proficiency (SEP)

This is the portion of the test that typically requires foreign medical graduates to visit the United States.

Foreign medical graduates that intend to pursue ECFMG certification will have to pass all three portions of the exam listed. However, with the proper support, like clinical externships,  foreign medical graduates can pass the exams, interview with U.S. medical residencies and match with a residency.