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.

Three Benefits of U.S. Clinical Externships for Foreign Medical Graduates

Clinical externships allow foreign medical students to test their skills at U.S. medical institutions. In a clinical externship, a foreign medical graduate (FMG) is placed with an attending at a U.S. institution. Depending on the length of the externship, FMGs may have the chance to learn from multiple attendings in different specialties. Not only is this an excellent learning opportunity, FMGs that complete clinical externships are more likely to match with a U.S. medical residency. They have more of the tools necessary to successfully interview and match.

Meet Requirements for U.S. Medical Residencies

Many U.S. residency programs require time spent working in the U.S. This is an easy requirement for U.S. allopathic seniors, who can complete clinical studies at their medical schools or neighboring institutions. Foreign medical graduates, however, must relocate to the U.S. for an extended period of time to meet these requirements. Unfortunately, every U.S. medical residency has a different requirement for the amount of U.S. clinical experience. While a 3 month externship may be enough for one program, it’s not enough for another. FMGs should review the requirements of their preferred medical residency program to determine the length of externship that is required.

Receive Letters of Recommendation

Letters of recommendation from U.S. doctors are a great tool for foreign medical graduates during the interviewing process. The interviewing program is likely to trust known U.S. doctors more than unknown foreign doctors recommending a graduate for a program. For some schools, it is a requirement that faculty member write a letter of recommendation for a foreign medical graduate. It would not be possible for a FMG to match with this type of school unless they completed a externship with a faculty member or knew a faculty member through other means.

Learn U.S. Terminology and Common Ailments

Externships also prepare FMGs for the U.S. testing required to match with a medical residency. There is a clinical section to the exam. A foreign medical graduate who has already spent time working in a U.S. institution will not be surprised by any differences in protocol. They already learned the basics at an externship. The skills gained at the externship can immediate translate to the exam. FMGs who complete externships will also become more familiar with common U.S. ailments, which are more likely to appear on the clinical exam.

Clinical externships are not only beneficial for FMGs, but, in many cases, they are a requirement for matching with a U.S. medical residency. Selecting the right externship can make the difference between matching with a U.S. medical residency or not being able to do so.

U.S. Residences have Additional Requirements for FMGs

Unlike U.S. allopathic medical school seniors, foreign medical graduates (FMGs) must meet additional requirements to be considered for U.S. medical residencies.  These additional requirements may be one reason that FMGs are not placed in the NRMP Match Program at as high of rate as U.S. allopathic seniors. To be fully prepared for the NRMP process, foreign medical graduates can educate themselves on typical U.S. medical residency requirements. The University of Washington’s internal medicine application site provides an example of the additional requirements that FMGs face when trying to match with a U.S. residency.

If applying to the University of Washington medical program, FMGs have to meet these requirements (in addition to the typical personal statement, transcripts and letters of recommendation).

Must be a permanent resident of selected states OR sponsored by faculty

Because most foreign medical graduates are not permanent residents of Washington, Montana, Wyoming, Alaska or Idaho, most applicants will have to meet the second requirement, faculty sponsorship. The faculty member must write a letter explaining how he or she knows the foreign medical graduate and what qualifications the FMG possesses. Foreign medical school graduates may be able to find a link to a University of Washington faculty member through their medical school. Another option for FMGs is to try to obtain a clinical clerkship or internship with a University of Washington faculty member. This can be a difficult requirement to meet and it is only the first of three.

Must have 2 weeks of clinical clerkship at an LCME-accredited medical school OR four months of residency at an ACGME-accredited program

The University of Washington also specifies that these clerkships and residencies must be at a Puerto Rican, Canadian or U.S. location. Foreign medical graduates that have only worked in their native countries will not meet this requirement. To be able to apply for residency at the University of Washington, FMGs will need to obtain one of these clerkships or residencies. For the LCME clerkship option, there are 155 qualifying schools. For the ACGME residency option, FMGs can select from schools listed on the ACGME list.

Must apply through the ECFMG ERAS Program

The online ERAS application program certifies that FMGs meet the same clinical standards as U.S. allopathic seniors. There are three exams that FMGs must pass in order to apply through this program. It is likely that foreign medical graduates will have to visit the U.S. for at least one of these exams. Therefore, it is imperative to have enough time to meet these requirements before the application and interviewing process for NRMP begins.

Many U.S. medical residencies, including the University of Washington, have additional requirements for foreign medical graduates. FMGs should examine what requirements are needed long before the fall application and interview process. Some requirements, like a 4 month residency or 2 week clerkship, require travel and take weeks or months to complete. By researching these additional requirements early, FMGs can be prepared for the NRMP matching process.

NRMP Matches 52.4% of Foreign Medical Students to U.S. Residencies in 2017

The National Resident Matching Program, or NRMP, announced the largest number of medical residency applicants and placements in 2017. The program places medical school students and graduates in residencies using a Nobel-prize winning algorithm. To be included in the program, medical school students submit applications and interview with programs starting in the fall and continuing through early winter. The program directors and applicants then rank their order of preference. The algorithm matches applicants to residency programs. This successful program continued in 2017 with over 35,000 medical school student and graduate applicants.

In 2017, these medical school students and graduates competed for over 31,000 positions. 94% of U.S. allopathic seniors were successfully matched. This is a consistent number from year to year. However, the placement rate for non-U.S. citizen international medical school graduates and students (also known as FMGs) is much lower, only 52.4%.  Over 7,000 FMGs applied in 2017 and less than 4,000 were placed. NRMP notes that this is the highest match rate since 2005, so 52.4% is better than average.

The lower match rate of international medical students suggests that these students may need additional support to successfully match with U.S. residency programs. Comparing the experiences of U.S. seniors and foreign medical students might illuminate some difference that account for the lower match rate. U.S. allopathic seniors follow a standard process for medical residency matching. They know when to take their USMLE (United States Medical Licensing Examination). In many cases, their medical school can support and guide them through the process. For foreign medical students, their medical school might not be able to provide the support and guidance needed to obtain a residency in the United States. The medical school’s process might be set up for medical residency in the local area.

U.S. students might also have an advantage during interviews. Resumes are written and interviews are conducted in their native language. Additionally, many U.S. school provide workshops on resume writing and interviewing. Foreign medical students may not have access to this support.

Hand-on clinical experience might also help U.S. students rise through the ranks. Many medical schools including clinical experience as part of the curriculum. These schools partner with U.S. hospitals and clinics for training. Foreign medical students may have clinical training in their native country. However, interviewing residencies may be more comfortable accepting students with training at known U.S. institutions.

It seems as though foreign medical students are at a disadvantage when it comes to medical residency placement. However, additional support can enable international medical students and graduates to be successfully matched to a U.S. residency. Hands-on clinical experience in the U.S., resume advice, and interview preparation are likely to increase the chances that a FMG will be matched with his or her preferred medical residency.