Foreign Medical Graduates (FMGs) have a different path to practicing medicine in the United States than those who were trained in-country. This path is different because it is an attempt at discerning quality education at foreign medical schools. It isn’t that foreign medical schools aren’t as good as American medical schools, but not all medical schools adhere to U.S. standards or higher. The different path FMGs must travel ensures that all physicians practicing in the U.S. have met or exceeded U.S. standards.

The ECFMG

The Educational Commission for Foreign Medical Graduates (ECFMG) is the certifying organization that confirms FMGs are ready to take part in a U.S. residency that is accredited. In order to practice medicine autonomously, FMGs will have to complete a three-year (or more) residency in the U.S. no matter what type of training they received abroad.

The ECFMG makes sure that your medical school is on its World Directory of approved medical schools. It also serves in assisting FMGs with visa applications and licensing examinations. It is a FMG’s first line of support in becoming a practicing physician in the U.S.

USMLE

The United States Medical Licensing Examination (USMLE) is broken into three parts. Step 1 and Step 2 (CK) cover clinical knowledge, and Step 2 (CS) covers clinical skills. Finally, step 3 is the final exam that covers knowledge and skill combined. In order to get ECFMG certification, FMGs must pass steps 1 and 2. In order to qualify to take Step 3, an FMG must have ECFMG certification.

Visas

The J-1 visa is the most common visa used by FMGs to get into residency programs. The ECFMG sponsors physicians with this visa. A FMG must have passed step 1 and 2 of the USMLE in order to apply along with having ECFMG certification. An official letter must be held from a Graduate Medical Education or training program, and the Ministry of Health at the last country of permanent residence must provide a statement of need.

Once the requirements are met for a J-1 visa, the FMG is free to complete a residency program once he or she is Matched. Then, he or she must return to the home country for 2 years before being eligible to return. This ensures that low-income countries do not suffer “brain drain” where physicians leave to obtain premium knowledge but never bring that knowledge and expertise back home.

There are exceptions to the 2 year at-home requirement if there is probably danger or persecution that the FMG will face if returning home. It can also be dropped if it would cause a hardship to a spouse or children. Lastly, there are exceptions available for those who an Interested Governmental Agency has taken interest (i.e. Department of Health and Human Services).

The Match

The National Resident Matching Program (NRMP) is how most residency candidates are matched to a residency program, and the application for the Match is called the Electronic Residency Application Service (ERAS). In order to get into the ERAS program, you must get a token from the ECFMG.

Once you have applied through ERAS, the Match process begins. This includes you evaluating all of the residency programs you are interested in and getting interviews to bolster your chances of matching into a residency program. You make a rank order list with all of your top picks (strategically chosen to increase you chance of acceptance in a program you like). The program directors also make a rank order list. Using algorithms meant to create best-fit matches with residencies and applicants, applicants are matched.

Physician Shortage

FMGs do not match as frequently as U.S.-trained medical graduates. This happens for many reasons, but it is a reality that FMGs face. Fortunately, the U.S. is realizing the severe physician shortage they are facing with people living longer and developing more chronic conditions. This has created a call for more residency slots to be available. This takes money, so it is a battle, but it is one where FMGs are seeing progress.

Networking is Key to Practicing in the U.S.

Throughout the struggle that FMGs have getting into a residency and then practicing medicine, there is one thing that helps, and that is networking. The biggest challenge for FMGs is that nobody knows them, and program directors are unfamiliar with the details of their education. That is why any U.S. experience (i.e. externships, observerships) is essential to success.

FMGs who work closely with medical facilities, especially those where the residency is, have local letters of recommendation. Medical providers have first-hand knowledge of their ability, and program directors can speak to people who know that the FMG is comfortable and good at working in the U.S. healthcare system. Without networking, there is less of a chance of being recognized during the Match, which is potentially the most important part of the path to practice for Foreign Medical Graduates.

Foreign medical graduates (FMGs) sometimes struggle to get into residency programs, and U.S.-trained graduates are often chosen over these equal but foreign individuals. The reasons for choosing U.S.-trained medical graduates vary, but there is one very good reason to include more FMGs into U.S. medical residencies and the healthcare field, and that is that they bring more cultural competence to healthcare.

          In the United States, there is a dominate culture that is Christian and Caucasian. While this culture greatly influences our government and healthcare systems, America has always been a “melting pot” consisting of natives and immigrants with religious freedom and a multitude of skin colors. In fact, the dominant culture in the U.S. came from migrant populations, but their conquering history created a long-lasting power struggle between different races.

In modern medicine, lawmakers and medical educators strive to make the healthcare culture more diverse and inclusive. People realize that there are disparities in healthcare outcomes caused by a lack of cultural competence, and they work diligently to equalize the results. No person should receive better care based on their race or religion, nor should they be forced to take part in care that goes against their personal values. This is where foreign medical graduates are able to bring more cultural competence to healthcare.

            If it doesn’t make sense how simply being from a different country could bring cultural confidence, consider the United States law enforcement or government system. In these systems, the minority races they serve feel underrepresented and therefore feel as though they have no voice. As these societal systems become more diverse, you see a decrease in disparities and more comfort with the impositions that result from these systems. It is not that a police officer should not have white skin. It is simply that having a diverse force implies that there is no bias. It is not that government should include every race, but making sure it includes multiple races without discrimination is essential to show equality among all races.

In U.S. medicine, there are surprising cultural healthcare disparities. According to one study, over 10 percent of African American, Asian Americans, and Latinos feel they would receive better care if they were a different race. That’s compared to 1% of Caucasians. This does not take into account actual results, but the simple feeling of disparity is enough to affect health outcomes. If disparities are real or imagined, they have a negative impact.

One of the most obvious places in medicine where shortfalls occur because of lack of cultural competence is in language. There are so many different languages that it is nearly impossible to include each in the primary care setting. Including more FMGs in the healthcare system provides more opportunity for bilingualism (or multilingualism), and patients who do not speak English are willing to travel or participate in remote care in order to speak their native tongue. The inability to reach people who share cultures and languages is a shortfall that is difficult to overcome without more diversity. Not only that, but the more people are exposed to different languages, the more they are able to communicate authentically despite language barriers. It is a sort of immersion therapy where people become more aware of non-verbal communication in order to improve environments. It also helps to remove biases associated with not knowing English, which has no impact on intelligence or worth.

Another advantage of including more FMGs in the healthcare provider mix is that they have awareness of other cultures. It is difficult to understand some cultures even when cultural competence is included in medical training. The values of one culture may directly contradict the values inherent in U.S. medicine. In these situations, physicians may feel they are violating their own moral code in order to satisfy a patient’s cultural needs. Having other physicians who are familiar with different cultural attitudes and goals for healthcare results in better outcomes. Patient-centered care is not possible without cultural competence.

One last reason more FMGs brings more cultural competence is that it reinforces the ideas already presented in cultural competence training many doctors receive today. It is easy to say you understand cultural competence and are ready to practice it every day in the healthcare setting.  It is much more difficult to put those words into action. Having more FMGs in the healthcare field gives all medical providers the ability to practice cultural competence among their colleagues. This makes cultural competence with patients more natural and maybe even instantaneous.

The world is diverse, but the U.S. healthcare system is lacking somewhat in its diversity. This impacts healthcare outcomes whether it is because of bias and discrimination or perceived bias and discrimination. Having more FMGs in the healthcare field will improve healthcare outcomes and make patients feel like they are equal to all others in the eyes of their providers.

When looking at the rules of the Educational Commission for Foreign Medical Graduates (ECFMG), it can get pretty confusing. The commission sets educational and technical standards for the medical education of foreign-trained medical graduates, but it also attempts to set ethical standards in order to avoid the acceptance of fraudulent applicants. Actions that undermine this process are called “irregular behavior,” and they can result in the permanent loss of certification or potential certification.

The specific definition of irregular behavior as defined by the ECFMG is:

“Irregular behavior includes all actions or attempted actions on the part of applicants, examinees, potential applicants, others when solicited by an applicant and/or examinee, or any other person that would or could subvert the examination, certification or other processes, programs, or services of ECFMG, including, but not limited to, the ECFMG Exchange Visitor Sponsorship Program, ECFMG International Credentials Services (EICS), the Electronic Portfolio of International Credentials (EPIC), and Electronic Residency Application Service (ERAS) Support Services at ECFMG. Such actions or attempted actions are considered irregular behavior, regardless of when the irregular behavior occurs, and regardless of whether the individual is certified by ECFMG.”

Basically, if it has anything to do with an FMG being allowed to practice medicine in the United States, and it is subversive, it is “irregular behavior.”

What are examples of irregular behavior?

Examples of fraudulent behavior typically involve fraudulent documents such as falsified diplomas, transcripts, or information on the ECFMG application. It can also be providing information about exams or bringing notes to an exam when they are prohibited. The USMLE has more information about irregular behavior here.

What are the consequences of irregular behavior?

The consequences for irregular behavior are severe and permanent. You can be removed from the certification process permanently or even have your certification revoked. There will be a “permanent annotation” in your ECFMG file, and you are basically removed from the U.S. medical community. In some cases, the consequences are shorter, but they still cause a delay in ECFMG certification.

What happens when you are accused of irregular behavior?

If a complaint is filed, the ECFMG first evaluates the complaint to see if it is worth investigating. If it is reasonable to investigate, the ECFMG refers the case to the Medical Education Credentials Committee. The alleged person will be notified in writing of the alleged irregular behavior. They will also be allowed the chance to provide a written explanation or appear in-person to explain before the committee. If found “guilty” of irregular behavior, the accused will have the opportunity to appeal.

What to do if you are accused of irregular behavior?

Irregular behavior is a serious accusation that can have career-ending consequences, at least if you plan on practicing medicine in the United States. That is why you must act quickly and thoroughly to defend yourself.

The first thing you should do is identify the event in question. Write down any details that you can remember, so you don’t forget what happened should the case be drawn out for any length of time. If you have any evidence to support your case, collect it and preserve it, so you can present it when the time comes. Ask for character references from peers and colleagues to provide evidence that you are not the type of person that would engage in the accused behavior.

Lastly, consult with an attorney that is familiar with irregular behavior cases. He or she will be able to make recommendations about further documents that you should present and how you should handle yourself during your presentation/defense. Not all irregular behavior consequences are permanent, but they can cause significant delays in your medical career and serious black marks on your record. It is worth it to spend the extra time and money to ensure you are found to be NOT engaging in irregular behavior.

The Intentions are Noble

The intentions of the ECFMG are to ensure that quality health care is delivered by all medical providers in the U.S. healthcare system. In order to do that, they must have accurate information and transparency about the entire medical education applicants have received. Without this information, the U.S. cannot guarantee quality healthcare in the country, and lives could be harmed or lost.

Typically, it’s nothing to worry about.

If you are fully transparent and honest on all of your applications, you probably don’t have anything to worry about. However, mistakes happen, and you could potentially be accused of irregular behavior while remaining completely innocent. Mistakes can be forgiven, and the ECFMG is not looking to eliminate people from the certification process. This is why it is important to ensure that you plead your case if you are accused. In many cases, people are punished for intentional acts because they were trying to cheat the system. However, if you are unjustly accused, you should fight back and make sure that you don’t suffer career delays due to a mistake or misunderstanding.

Step 2 of the USMLE exam has two components, clinical knowledge (CK) and clinical skills (CS), and language is an important part of CS. That is because you will have 15-minute “encounters” with patients and be expected to communicate with those patients while being observed. The fluency used will have to be much more than a functional grasp of English in order to fully understand, diagnose, and establish a relationship with the patient. Encounters may be face-to-face or over the telephone, in which case pronunciation and fluency are even more critical.

The scoring of USMLE Step 2 CS is further broken up into Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP) and Integrated Clinical Encounter (ICE). This means that not only must a physician be able to speak clearly and professionally, he or she must also be emotionally supportive and speak at a level that is understandable to the patient.

True English fluency is difficult for those who haven’t spent enough time conversing with those for whom English is their native tongue. Like most languages, there are nuances to learn that can only be appreciated when immersed in the language. The most-dedicated medical student can memorize all the medical terms in the text books, but he or she won’t be able to communicate with a patient without understanding common vernacular.

There are many methods to learning English, and often, living in an English-speaking country for a while is the best one. However, there are other ways to speed up the process that are valid and make learning American lingo an easier quest.

10 Non-traditional Ways to Learn Common American English

1. Watch television

The TV is an excellent way to listen to common English, and if your language skills are very rough, subtitles can help with comprehension and pronunciation. Stick to entertainment television, not the news, or you won’t get the lower-level diction required for fluency.

2. Watch YouTube

If you watch television, you’ll definitely get some exposure to slang, but YouTube allows you to see real people doing ordinary things. Watch children’s videos, how-to videos, and viral videos to get a variety of voices and dialects.

3. Read magazines

Don’t restrict yourself to books when you are reading, as magazines offer fun language opportunities and a different format that enhances the variety of your language knowledge. It’s all about variety, and the more variety you get in your language use, the more complete your language fluency will be.

4. Listen to music

Music is a fun way to learn any language, and it is a great way to work on pronunciation. This makes any drive time more productive because you can sing to the music in the car.

5. Go out for coffee

Many foreigners have a tendency to hang out with people from their home country or other foreigners because of the shared situation. As a result, they diminish their exposure to native speakers. Going to a coffee shop, even with fellow foreigners, will expose you to ambient native language.

6. Sit in lobbies

Like going to a coffee shop, sitting in lobbies is an excellent way to eavesdrop and hear normal conversations. This will help with your listening skills and also teach social norms. One-on-one conversation is difficult to observe unless you are in a public place like this.

7. Ask questions

If you don’t understand, make sure to ask. It may seem cumbersome at first, but asking questions will catapult your learning. It also helps people to understand that you are trying to speak fluently.

8. Socialize with Americans

Foreigners sometimes socially isolate themselves from Americans because they don’t speak well enough to engage in casual discussion. This isolation only furthers the problem, so get out there!

9. Don’t be shy

Plenty of people who speak English perfectly are shy, and changing that is nearly impossible. However, that doesn’t mean you cannot force yourself to communicate more. Chit chat with the person at the cash register, and say hello to people passing by. You may make some mistakes, but surviving those mistakes will make you more confident.

10. Practice

Practice all of the time. Give up your own native language for a day. Immerse yourself in everything that will give you more practice. If language is your hurdle for USMLE Step 2, conquer it.

Learning proper English is difficult, but learning common English with all of its idiosyncrasies and colloquialisms can take some time. The only way you can ensure that you have enough fluency to effectively communicate with patients is to use it often. As you can see from these tips, it is all about exposure and usage, and the more you surround yourself with the English language, the more natural it will feel to hear and speak it. When you get to the clinical skills portion of your USMLE exam, language will no longer be a problem.

Most people would agree that one test score does not declare the success of a physician, but for medical graduates applying for residency, it can mean a successful Match. The average number of residency applications per applicant has increased from 79 to 91, and according to the Association of American Medical Colleges (AAMC), residency programs may receive 1,000 applications for only a handful of residency slots. They have to sift through these candidates somehow, so test scores receive an elevated importance.

Sifting Through Scores

Instead of looking at each candidate as a whole, residency programs cull program applicants by eliminating those with low test scores and only considering those with scores well above passing. The result is that quality applicants may be removed from applicant pools based on a number instead of more important skills that can be understood through experience and in-person interviews.

A Necessary Evil

This year, the Invitational Conference on USMLE Scoring (InCUS) convened and discussed ways to improve the USMLE. One of the recommendations they created was to make USMLE Step 1 pass/fail. Another idea was further examination of the reliability of USMLE scores in predicting residency success. Lastly, the conference sought to find ways to address racial disparities in test scores, as white students statistically have higher test scores than any other demographic.

Ultimately, there was no solution that eliminated the value of a real test score. In order to handle the number of applications, program directors have to eliminate candidates by some quantifiable measurement regardless of talented physicians who score poorly on the USMLE exam.

Negative Impacts of USMLE Now

There are other negative impacts of the USMLE besides removing otherwise talented physicians from applicant pools. The biggest one is mental health. USMLE test takers suffer insurmountable stress because of the importance placed on test scores during the Match process. If you are currently getting ready for the Match, you have already suffered this predicament. The score predicts your future success, and placing that importance on ONE TEST creates a level of stress that is difficult to pile on the stress of the Match process and the future of a medical career.

This is the type of stress that causes medical students, residents, and physicians to burnout, which is why there are efforts to change the test to possibly pass-fail or something that would reduce mental health issues and increase equitable acceptance into residency programs.

Accepting the Way It Is…For Now

Right now, medical students don’t have a choice when it comes to the importance placed on USMLE scores. If you score poorly, you can retake the test up to six times. This may not reduce stress, and it takes time to wait for another test to be available, but at least one bad test score does not have to equate to the end of your medical endeavors.

The only other thing you can do is make sure that a lackluster score on the USMLE test is met with exemplary training, volunteer experiences, and excellent interviewing skills. If your scores qualify you to get into a program, you’re going to have to shine the get an interview. A little pre-planning by volunteering or being an intern at locations that are top picks for your residency applications can also help you to stand out above the rest.

Especially for FMGs, USMLE scores are very important because FMGs are considered a little bit of an unknown due to different education systems. The Educational Commission for Foreign Medical Graduates (ECFMG) has done its best to ensure that only quality medical graduates are accepted by U.S. medical residencies, but it is not infallible. Program directors may have biases against foreign applicants, so high USMLE scores ensure that you won’t be automatically dismissed for a U.S. medical graduate who has known medical training.

Preserving Mental Health

Hopefully, the future of USMLE testing will result in the best applicants being accepted for quality residency programs and promoting the best results for the healthcare system. Until then, we work with what we’ve got, which means USMLE scores are very important.

USMLE Step 1 and 2 should be completed before applying for residency programs through the Match. If you want to shine a little more, consider taking step 3 as soon as possible. This will give further confidence to residency program directors that you’re a good fit for their program.

Other than that, you can preserve your mental health with proper diet, exercise, and sleep regulation to ensure that your body and mind are in as good of shape as possible to handle the demands of the exams.

It May be Misguided, But it is Important

Suggesting that the USMLE exams should be pass/fail does not diminish the importance of these exams. The ability to pass this three-step test does determine to a certain extent whether or not you have learned the skills required to practice medicine competently in the United States. Until the format is changed to one that more accurately represents medical knowledge and skill, your score will remain an important part of the Match process.

Having a certain attitude about a group of people grounded on assumptions and preconceived notions of reality based in fiction has a negative impact on the quality of care given by medical professionals. Foreign Medical Graduates (FMGs) are very familiar with receiving prejudice. They face it during their residency match, during training, and by patients and colleagues. They are criticized because they are unknown, and these prejudices affect their medical training experience. However, FMGs are not immune to having their own prejudices. Each physician, no matter where he or she went to medical school, must make a concerted effort to avoid common prejudices toward patients. In this way, you can ensure you are giving equitable care to all human beings.

6 Prejudices All Medical Graduates Must Avoid

1. Weight Prejudice

An August 2019 article from Medical News Today notes that physicians may be prone to unfairly judging patients based on their weight. It told of a study where medical students used obesity simulation suits to appear like a diabetic patient with a body mass index of over 30. Researchers performed an Anti-Fat Attitudes Test (AFAT) to measure prejudice. The test was a 5-point Likert scale to rate statements about obesity. The statements blamed people for being fat, denied genetic variables, and linked obesity to laziness. Students reported that the suit enabled normal stereotyping of obese individuals. Females were stereotyped more than males, and previous research has shown that these attitudes make physicians less likely to pursue alternative treatments to weight loss. This could greatly reduce efficacy of treatments for obesity where depression or other health conditions were the root causes of obesity.

2. Sexuality Prejudice

According to Flórez-Salamanca et al., there are negative health outcomes for homosexual people due to feelings of discomfort, communication problems, and the inability to develop a positive alliance between a provider and patient (2014). These authors also pointed out that homosexual people received unequal and lesser quality care. They recommend identifying these prejudices as a first step in eliminating them. Logically, it can be assumed that this would apply to all non-heterosexual preferences.

3. Age Prejudice

Geriatric medical practice comes with its own set of challenges, and the elderly may have multiple morbidities that require complex treatment in an environment of poor understanding and compliance. However, not every elderly person has the same level of ailments, and those in the community may function as well as young adults. In either case, it is important to have compassion for those suffering from cognitive decline while also acknowledging that age does not automatically equate to cognitive decline. One of the very apparent results of this is under-treatment of geriatric patients because of an acceptance that their decline is inescapable.

4. Cultural Prejudice

Foreign medical graduates come from different cultures and may face cultural prejudices every day, but they cannot extend those to their patients without risk of compromising care. The goals of medical outcomes for people from different cultures may differ from patient to patient, and this must be acknowledged by physicians in order for those outcomes to be positive. Additionally, the customs and etiquette of different cultures must be understood in order to properly communicate and come to a treatment that will be effective and the patient will understand.

5. Education Prejudice

Education prejudice may cause a physician to dumb down language to a level that is insulting to a well-read patient. It may also be insulting to use elevated language in a way that offends the person with lesser vocabulary. Both of these situations can be frustrating and cause prejudice. A physician may feel that a person will not be inclined to comply with treatment if they view them as “lazy enough” or “dumb enough” to have not pursued education. Instead, physicians should try to see all people in a manner that requires “effective” communication instead of viewing it as substandard or elevated.

6. Poverty Prejudice

Lastly, medical graduates may feel prejudice toward people who come from impoverished backgrounds, and they may not elevate treatment options like they would for a patient with private insurance who seems affluent. Sometimes, these treatment options need to be removed from the table since insurance nor the patient may be able to cover them, but they should still be considered as options until financial barriers are confirmed by the patient. Patients with less resources are no less worthy of care, and physicians must make sure they do not practice medicine with this prejudice clouding their judgement.

Prejudice Isn’t Always Known

Many physicians get involved in medicine simply because they want to help people, and these altruistic purposes do not coincide with prejudice. However, prejudice may be unknown and stem from environments where one was raised or exposures one has had to particular communities. The first step in eliminating their impact on medical outcomes is to identify them, and these six prejudices are common even among the most well-intentioned physicians.

Hahnemann University Hospital, a Drexel University College of Medicine affiliated hospital, has filed for bankruptcy and is closing. Despite large protests including the appearance of Bernie Sanders, candidate for U.S. President and Senator for Vermont, the hospital has started its long list of closures. Today (July 17), the hospital stopped admitting patients who are already in the emergency department. Technically, the hospital is scheduled to remain open until September 6, but the emergency room is scheduled for complete shutdown by August 16^th. Those deadlines seem to creep closer to the present as Philadelphia Academic Health Systems, the hospital’s parent company, continues with its bankruptcy proceedings.

What Caused this Hospital to Struggle Financially?

Basically, low-income patients with Medicaid and people with Medicare were a large cause for the struggle because these insurance companies are contracted to pay less than private insurance companies. Private insurance companies are supposed to pay more to make up for the revenue gap for government-provided coverage. However, inner-city hospitals have a large number of low-income people seeking treatment at their hospitals, and according to an article by Steven Church, they can detract those with private insurance because they don’t appear to be the better option. Interestingly, rural hospitals have the opposite problem because there is not a large enough population to turn a large profit.

What will happen to Hahnemann’s patients?

Hahnemann University Hospital sees 56,000 people in its ER annually. It is an important source of medical care in the Philadelphia community. Despite its monthly financial losses of millions of dollars a month, the hospital was not supposed to close so quickly. At the end of June, the city and the Pennsylvania Health Department ordered that the hospital not shut down until it had submitted formal notice of its closure, but Hahnemann started diverting patients that week. There is a minimum amount of time regulations allowed for a hospital to shut down any operations, which is 90 days, but Hahnemann has disregarded these regulations. The shutdown is set to continue in stages, and the other medical facilities in the area will have to take on Hahnemann’s patients.

What will happen to Hahnemann employees?

In short, they will have to find new jobs. Hahnemann started laying off workers this spring due to financial woes, and they will continue displace workers who will have to find jobs elsewhere.

What will happen to Hahnemann medical residents?

Well, if getting into a residency program through the Match wasn’t stressful enough, what is worse is losing that residency program. There are 571 residents, fellows and medical students that will be displaced by the Hahnemann closure. They can look for other residencies, but the programs have to sign off on the transfer of their funding, so they are stuck right now. Residencies are highly competitive, and being in limbo may force some residents to lose potential slots.

The Association of American Medical Colleges (AAMC) tracks open residency positions at Find a Resident, and if there are unfilled residency positions available, Hahnemann residents will have the option of filling them if selected. Residency programs with the resources to handle more slots than they are currently allocated can apply for additional positions through the Accreditation Council for Graduate Medical Education (ACGME). However, it is not known exactly how Hahnemann medical residents will be handled. Most worrisome is the fact that there are 59 visa-holding residents who could be forced to leave without an alternative residency positions.

On a positive note, it looks like residents have been a top priority during this closure. The residency program may be sold to Tower Health for the price of $7.5 million, but it may not be large enough to take all of the residents. The ACGME has located 1,000 available positions, so this may not be a problem. Residents should not have too much trouble finding another program, but they are still being displaced, which adds to the stress inherent during residency.

A Tragedy on All Sides

It is rare to see a teaching hospital of this size close, and it is a great tragedy for the people of Philadelpha, PA as well as the nation. Losing a hospital means lessened access to healthcare services, and in this case, it will impact low-income populations disproportionately. This is one of the reasons there has been so much public outcry over corporate greed at the expense of the population. Hopefully it is not a sign of things to come, but news reports state many other hospitals in Philadelphia are struggling financially, so taking on an increased number of Medicaid and Medicare patients is not likely to help the situation.

For foreign medical graduates, this is one poor example of the dynamics of the United States Health Care System. Whether one agrees with the privatization of healthcare or prefers a universal system, it cannot be said that capitalism produced a good result for the public in this case.

What is EFMG?

The Educational Commission for Foreign Medical Graduates (ECFMG) is the organization that certifies foreign medical graduates for U.S. residencies that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). It is essentially like a Dean’s Office for all medical schools outside of the United States. The ECFMG certifies that the education you received abroad meets or exceeds the standards of the United States Medical Education System. Their stamp of approval means you are free to continue with the USMLE exams and onward into the Match to apply for residencies. ECFMG certification is not an approval into any residency program, but it makes you eligible.

How to get an ECFMG identification number

The first thing you will need to move forward with ECFMG certification is a USMLE/ECFMG identification number (web application here).  The information in the application must be legal and current, or you will not be assigned a number.

An ECFMG identification number will be used on all of your future USMLE and ECFMG application forms. For more information about ECFMG number details, see the ECFMG website.

How Much Does It Cost?

An application for certification from ECFMG cost $135. For USMLE step 1 and 2 (Clinical Knowledge, the fee is $940 each. Step 2 (Clinical Skills) cost $1,580. Rescheduling the exam or changing the testing region can add fees. For a schedule of all fees through ECFMG, check out this link.

What are the USMLE exams?

In order to get certified by the ECFMG, you have to pass the United States Medical Licensing Examination (USMLE). Step 1 and Step 2 CK are considered the medical science part of testing, and this requirement can be replaced with a passing ECFMG examination, Visa Qualifying Examination, Foreign Medical Graduate Examination in the Medical Sciences, or part 1 and 2 exams of the National Board of Medical Examiners. The clinical skills portion of the USMLE is also required and can be replaced by passing both the ECFMG Clinical Skills Assessment and an acceptable English language proficiency test.

Is there a time limit?

The ECFMG requires USMLE exams to be finished within a 7-year period. The period starts on the exam of the first exam passed. You cannot get an ECFMG certification if you do not complete all of the exams within this time period.

Developing a Lifestyle for Success

Beginning the ECFMG certification process is arduous, but this process preps a medical graduate for the process of the Match and then residency. Rather than thinking about the extra work involved in becoming a medical resident, it is better to plow through the paperwork and make sure everything is done properly. This is part of developing a lifestyle for success that will get you to your end goal of becoming a practicing physician in the United States of America.

A Healthy Lifestyle is a Successful Lifestyle

The USMLE exams are tough, but so is the Match process. All the while, you need to keep your medical knowledge and skills updated by participating in clinical externships and anything that can add medical experience to your curriculum vitae. If that weren’t enough, it’s never too late to work on your interviewing skills. For the foreign medical graduate, it can be tough to get into a medical residency, so they must keep their health in top shape.

This means eating right, getting enough sleep, and exercising. A person who stays up all night studying will not retain information better than the person who stopped studying and got a good night’s sleep. Getting enough water, health food, and exercise also has performance benefits. You want a clear mind when you go through this whole process.

Planning is a Recipe for Success

There are many dates, fees, and plans that must be made in order to successfully get to the Match and land the residency of your dreams. It is important to keep track of all the dates because missing one can set you back an entire year. That may not be a lot in the whole scheme of things, but it will seem like a long time while you are waiting.

The Foreign Medical Graduate Bias

Unfortunately, the foreign medical graduate bias is not a myth, but thankfully, it is more often an implicit bias than something people outwardly feel and support. The world is more globalized than ever, but old habits and thoughts will persists through the generations. What this means for the foreign medical graduate is that you must now live the life of the physician you one day will be. In order to show residency directors with hidden biases that you are an excellent candidate for a residency despite your FMG status, you will have to make sure you meet all the requirements, but you will also have to present yourself in a way that is likeable, intelligent, and organized. It all starts with an ECFMG identification number, and you will begin your path to residency.

March 15^th has come and gone, and the Match is over. Congratulations! You are now a first-year resident. You are also still an International Medical Graduate (IMG), and you might still face some criticism because of it. Don’t let this alter your excitement about your program. After a successful Match, every resident should be proud of their accomplishments.

You may have heard that people don’t care where you went to medical school. This is true, but only after you’ve established yourself. This means you may get asked and face unwanted opinions until about your second year as a resident.

Why Does IMG Criticism Persist?

The biggest problem medical professionals and the public have with international schools is that they are unfamiliar.  For the average American, The Medical School for International Health at Ben-Gurion University of the Negev could just as easily be a fraud as it could be a reputable medical school.

Additionally, fraudulent and substandard medical schools have made it to news headlines. Certain medical schools in the Caribbean have been criticized for overcrowding, high drop-out rates, and low Match rates. People don’t remember good stories. They remember the bad, and any bad press builds a bad reputation. Regardless of the truth, people associate foreign education with substandard education.

Of course, this is not the truth, and you wouldn’t be Matched if you didn’t receive a good education. So, what can you do about this persistent doubt people, even colleagues, have about your educational background?

What to do when they doubt your education:

1. Be Proud.

You know what you had to do to get your medical degree. You know why you chose your medical school. Not only that, but you know what it took to get certified by the ECFMG. None of these things are easy, and you should be proud of what it took to get where you are today.

Furthermore, you must be sure of yourself in order to practice medicine well. If you are seeing patients and doubting your education, then you won’t be able to correctly make life-saving decisions.

Lastly, you are now a resident, but that does not mean you won’t burn out. You still have crazy schedules, stressful situations, and not much time for personal life. If you add guilt over your education, it may be too much. Be proud of your accomplishments because you should be proud, and that pride will give you the boost you need to practice good medicine.

2. State Facts.

If you must, defend yourself. The ECFMG won’t certify a person that was education in a substandard institution. Also, all IMGs take the same USMLE exam as non-IMGs. The criteria are the same for all medical students. Explain to people how you took the same tests and went through the same Match process, and open their eyes.

Many opinions about foreign education are not well thought out. It’s more of a prejudice than a real opinion. It’s like thinking all Germans like beer and all Chinese like math. Nobody logically believes that this overgeneralization can be true, but people will think they believe things until presented with facts.

Even your peers and colleagues may unintentionally harbor prejudices against your training abroad. Simply reminding them that you had to face the same hurdles as other residents can be a good reminder to them, so they don’t forget and fall back on their prejudice. Just remember, don’t get defensive. As the saying goes, the best defense is a good offense. Be prepared with facts, but don’t get offended.

3. Ignore it.

If you can muster the internal fortitude to ignore criticism, go ahead! This too shall pass, and eventually you will either show people your ability, or eventually people will stop caring where you went to medical school. You are a physician, and once you get through residency, most everyone will accept that you are trained well.

Ignoring criticism about your education is only an option, and if you must say something, that is fine. Opt for ignoring criticism when it will not help the situation or when you fear you may get argumentative.

4. Engage.

Don’t hide from people, so they don’t find out that you went to an international medical school. Engage with people. Throw it in their face. The more they have to work with you, the more you will validate your education. Not only will this help others to appreciate your education, but it will help you to build pride in yourself.

5. Make Connections.

Make sure you take care of your mental health by making connections. Join a social media group, or network with friends, so you can have a forum for discussing things like this. It is difficult to find time for things like this during residency, but you must. If you face a lot of criticism, it may get into your head. There’s nothing like like-minded friends to get you back on your feet.

Congratulations!

You have Matched, and your training and experience are awesome, which is why you Matched. Unfortunately, you will face a bit more judgement about your education abroad, but dealing with it appropriately will help you through this. Be proud! You deserve to be here!

When it comes to your interview for a US medical residency program, it’s important to be prepared. Not only do you want to have a good idea of what to expect in terms of the interview day schedule–as we discussed in the previous post–but it can also be helpful to know what might be coming when you go into the formal interviews themselves. Although the specific interview questions can vary between programs (and between individual interviewers within a single program), there are certain questions that you’re probably going to be asked. Read on for a list of the most common questions and some ideas on how you might approach them in your US medical residency interview.

Common Interview Questions for Foreign Medical Graduates

As a foreign medical graduate, here are a few of the US medical residency interview questions that you are most likely to be asked:

• Can you tell me a little bit about yourself?

This is the standard opening question for a US medical residency interview, and it can help set the stage for your whole conversation. When you’re responding, your goal is to be informative, but succinct. You should provide a brief personal and educational background (where you grew up and went to medical school), as well as a short description of how you got interested in medicine, but you don’t need to go into too much detail. After, all, you don’t want to start giving answers to questions that might be asked later in the interview and end up repeating yourself.

• Why do you want to do your medical residency in the United States?

This is a question that only foreign medical graduates get asked, and your answer can help you stand out from the other candidates. Your interviewer will probably be genuinely interested in what brought you to this decision, so you should be ready for it.When faced with this question, it is important to be honest because there is no “right” answer. The most important thing is to offer a thoughtful, well-reasoned response that tells the interviewer a little more about you and your goals. If possible, try to tell an illustrative story that highlights the factors that played into your decision. .

• What do you envision yourself doing after completing your residency?

As you answer this question, it is especially important to remember to avoid a “canned” response: make sure you aren’t just listing the professional goals from your personal statement. The interview gives you the opportunity to expand on what you wrote and offer a more personal perspective. Whether you dream of advancing your career in the United States or hope to eventually return to the country where you completed medical school (or another country altogether), you want to show your interviewer that you have clear goals and a high level of motivation to achieve them.

• Why are you interested in this particular specialty area?

With this question, you have two objectives: to show that you are well-informed about your chosen specialty area and to demonstrate your genuine passion for the field. It offers an excellent opportunity to expand on some of the specialty-related experiences that you listed on your CV, such as student electives and graduate externships. In the interview, you have the chance to explain to your interviewer how meaningful these experiences were to you personally and how they shaped your professional goals for the future.

• What is your favorite book/movie/TV show?

When you get a question like this, you might feel pressured to reference an American show that you think your interviewer has heard of–and if that’s the truth, no problem. However, if you love an obscure TV show that only airs in your home country, don’t be afraid to talk about it! With these types of questions, interviewers are looking to hear about your interests outside of your academic and professional life, so your sincerity is more important than the specific book/movie/TV show you choose. Plus, your interest in foreign media could help demonstrate a way in which you could contribute diversity to the program!

Getting Ready for Your Interview

As you prepare for your interview, you may want to do a trial-run with a friend or colleague, and they can ask you some of the questions listed above. However, as you practice, you want to make sure that your answers don’t sound scripted. Even if you’re expecting one of these common questions, you still want your real interview to be a conversation, not a performance. This is especially important for foreign medical graduates from non-English-speaking countries, since interviewers may be evaluating your language skills, and you don’t want your interviewer to think you simply memorized a well-written speech. Therefore, remember to engage with your interviewer and be genuine with your responses–don’t just recite what you planned out in advance.

FMG Portal is here to help foreign medical graduates at every step of the US medical residency application and preparation process. Contact us today for more information!

The interview process for a US medical residency program offers a variety of valuable opportunities for foreign medical graduates who are hoping to match in the spring. Not only do interviews allow you to show why you are a good fit for the program, but they also give you the chance to learn more about different programs and decide how you might rank your options on your ROL in the winter. Usually, the interview process lasts for one or two days, and every event on the itinerary counts. In order to make the most of these these events, it can be helpful to know what to expect. Read on to learn more about the structure of the interview days and how you can make the most of each event.

Interview Day Events to Expect

Every residency program has a unique itinerary for its interview day(s), but there are some general similarities that you can count on. As a candidate, knowing what to expect from each event–and how you can get the most out of it–can help you successfully navigate the interview day(s):

• Orientation / welcome presentation. The official start to most interview days is a welcome presentation by an administrative leader, during which you and the other hopeful candidates are given an overview of the program. You’ll typically hear about the daily expectations for residents, the educational structure of the program, and any research opportunities that may be offered. The presentation also usually covers logistical details related to salary, benefits, services, and lifestyle (like housing and transportation). It can be helpful to take notes during this session, but most of the information will probably be available in information packets provided by the program. Instead of frantically trying to copy every word, keep a pen handy to jot down the side notes and anecdotes that you won’t be able to find in the official paperwork.

• Formal interviews. Of course, the formal interviews are at the heart of the interview days. Depending on the program, you might find yourself interviewing with faculty members, current residents, or both. The number of interviews also varies between programs, but you can typically expect anywhere from two to six formal interviews. As we discussed in an earlier post, there are key do’s and don’ts that can help you through the interview. As you prepare, you may also want to set up a practice run with friends, colleagues, mentors, or other candidates from your medical school.  

• Tour of the facility. The extent and scope of the tour can vary significantly depending on the size of the facility, but it always gives you the chance to get a feel for the general atmosphere of the institution and the surrounding area. It can be challenging to take notes as you walk during the tour, and you probably won’t notice as much if you’re focused on your notebook. Instead, focus on observing observing your surroundings and write down what you remember later.

• Informal meals and social events. Often, aspiring residents will have the chance to sit down to an informal meal with current residents and/or staff. It could be a breakfast in the hospital cafeteria, dinner at a nearby restaurant, or even drinks after all the interviews are complete. These events can be fun, but you should also remember that they are still part of the interview process, so you don’t want to make a poor impression. Instead, try to get to know the residents and staff, find out what it’s like to live in the area, and take the chance to ask about informal topics like apartment options and nearby recreational opportunities.

• Opportunities for resident shadowing. Although not included on the itinerary for all US medical residency programs, there are some programs that give you the chance to shadow residents during rounds or resident reports. This can help you get an idea of the workplace atmosphere and the daily life of residents in the facility. However, if you’re considering several different specialty areas when you are constructing your ROLs later in the winter, it’s important to remember that a few hours of shadowing may not provide enough information for you to develop a comprehensive understanding of the differences between specialites. For that, you may want to consider a longer graduate externship program. On the interview days, you should focus on the atmosphere in the facility and the general experiences of the residents so you can decide if it is the kind of place where you would enjoy working.

• Exit interviews or closing presentation. Formal exit interviews are less common, but there are some programs where you will briefly meet with an administrative official before the conclusion of the interview days. There are also programs where a one-on-one exit interview is replaced by a general closing presentation from a hospital administrator. Either way, this closing event isn’t the time to try to cram in details about your previous experiences or plans for the future. Rather, an exit interview or closing event gives you the chance to make one final, positive impression–so remember to be friendly, indicate your sincere interest in the program, and smile!

If you’re a foreign medical graduate looking to get matched to a US medical residency program, FMG Portal is here to help you at every step of the process. Contact us today to learn more about everything we offer!

Now that you’ve finished your initial application, completed your interviews, and finalized your registration for the 2018 Match, there is only one thing left to do: prepare your Rank Order List (ROL). Earlier on the blog, we talked about the basics of ROLs — what they are, how they work, and what foreign medical graduates need to know from the start. Today, we were going to go further in-depth and talk about some of the Do’s and Don’ts for creating an ROL. That way, when the Rank Order List Entry opens on January 15, 2018 (mark your calendar!), you will have the tools you need for success.

DO’s for Creating Your Rank Order List (ROL)

When it comes to creating your rank order list, there are key things that you should make sure to do.

• DO rank programs in the order of your true preference. The ROL is the place where you get to tell the NRMP where you want to train. After spending months or even years scoping out programs and trying to get a feel for the different training options, this is your opportunity to let the NRMP know which programs you think will best support both your personal and professional goals. Even if you worry that a particular program might be a “reach” for you, you should rank it at the top if it is the place where you would most like to complete your training!

• DO include a both competitive and less-competitive schools on your ROL. While you should definitely rank your preferred programs at the top — even if they are highly competitive — you should also try to include programs with less competitive profiles on your list. That way, if you don’t end up getting matched to some of the more competitive programs, you won’t run the risk of not getting matched at all.

• DO remember to certify your ROL before the deadline. In order for the match algorithm to process your ROL, it needs to be certified within the R3 system by 9:00 pm Eastern Standard time on February 21, 2018. Also, you should note that the R3 system is notorious for running slowly in the last few days before the deadline, so if you have your ROL ready in advance, DO upload it early.

• DO remember that you can change ROLs that have already been certified. If you decide to upload your ROL early, you still have the chance to change your mind before the February 21 deadline — as long as you remember to recertify your ROL. The Match algorithm will only process the last certified ROL.

DON’Ts for Creating Your Rank Order List (ROL)

Preparing your rank order list might seem simple enough, but don’t be fooled! There are a variety of pitfalls that you can easily fall into if you’re not careful. Here are a few major DON’Ts for foreign medical graduates who are preparing their ROLs:

• DON’T rank programs where you aren’t interested in training. When creating your ROL, you may be tempted to rank all the programs where you interviewed, and that’s a great plan if you feel comfortable training in any of the programs. However, if you have misgivings about a program and are only including it because you feel desperate to get matched, you might want to think twice about adding it to your ROL. When you certify your ROL, you make a binding commitment to train at any program where you get matched, so you should only rank programs where you would feel satisfied about (and celebrate!) a match.

• DON’T include programs where you did not interview. As you already know, the Match is a computer algorithm. It won’t recognize any programs where you did not interview as options for a match. Therefore, it’s not worth the time to include any of these programs on your ROL.

• DON’T wait until the deadline to enter your ROL into the system. Creating an ROL requires more than just writing down a list of programs — the R3 system can initially be confusing, so you should give yourself enough time to figure it out. Also, the NRMP warns that its servers tend to get overloaded in the last few days before the deadline, so it’s a good idea to give yourself extra time to make sure that you won’t have to worry about unexpected technological glitches.

• DON’T forget to save your ROL after making changes. When you add a new program to your list or change the order in the R3 system, you have to click the “save” button before you leave the system if you want to return to your ROL the way you left it. It is important to note that saving an ROL is different from certifying it. Saving your ROL allows you to develop and change your ROL as the deadline approaches, but it is only finalized and ready for processing by the match algorithm when you certify it.

• DON’T try to import an ROL on a mobile device. These days, you can use your smartphone or tablet for just about everything. Unfortunately, that doesn’t include every part of the residency matching process. In order to import an ROL in the R3 system, you need to be using a traditional laptop or desktop computer.

Whether you’re anticipating the last few months of the 2018 NRMP Match, gearing up for the 2019 Match, or looking ahead to future years, FMG Portal is here to help you every step of the way. Contact us today for more information!

In the United States and around the world, cardiovascular disease is the number one cause of death, so there is a high demand for physicians with expertise in cardiology. Last week on the blog, we went over the steps that you need to take to become a cardiologist in the United States. After earning your medical degree, you must complete a three-year residency in internal medicine, followed by a three-year cardiology fellowship. After that, you have the option of completing a subspecialty cardiology fellowship in a particular area of interest.

Two subspecialty options within the field of cardiology are interventional cardiology and metabolic cardiology. For interventional cardiology, you can complete an ACGME-accredited subspecialty fellowship program after your first cardiology fellowship. There are also opportunities for advanced studies in metabolic cardiology. Read on to learn more about these two subspecialty options and why you might want to consider completing a graduate externship in one of them before you apply for a US medical residency program.

Introduction to Interventional Cardiology

Interventional cardiology is a subfield that focuses primarily on coronary artery disease, which is the most common form of cardiovascular disease in the United States. Specialists in this subfield are trained to conduct complex diagnostic procedures and design long-term health management strategies for patients with chronic and acute coronary artery disease. As an interventional cardiologist, you would also conduct percutaneous intervention procedures and put in percutaneous ventricular assist devices. If you’re looking to truly make a difference in the lives of patients who require immediate care for complex cardiac conditions, interventional cardiology could be a great subspecialty option for you.

Introduction to Metabolic Cardiology

Metabolic cardiology is a relatively new subfield that promotes an unconventional approach to the prevention, management, and treatment of congestive heart failure. Instead of relying on traditional interventions, this approach emphasizes an integrative approach based on nutrient supplementation. According to proponents of metabolic cardiology, the underlying cause of heart disease is the lack of sufficient energy for the heart to function at an optimal level. This problem can be addressed by providing the body with nutrients that support the production of enough ATP to support heart health.

Thus, experts in metabolic cardiology seek to prevent and treat cardiovascular disease through the targeted supplementation of four key nutrients that are involved in ATP production

• D-ribose, which is required for the de novo synthesis of ATP
• Coenzyme Q10 (CoQ10), which is involved in ATP recycling and reuse

• L-Carnitine, which is also involved in ATP recycling and reuse

• Magnesium, which plays a role in more than three hundred enzymatic reactions, many of which are related to energy production

Metabolic cardiology is widely viewed all-natural, less expensive alternative to traditional treatment methods for cardiovascular disease. If you’re interested in an innovative approach to cardiology, advanced studies in metabolic cardiology could be a great opportunity for you.

Reasons to Pursue Graduate Externships in Interventional and Metabolic Cardiology

As a foreign medical graduate, you might be wondering why you would want to complete a graduate externship in interventional or metabolic cardiology. After all, you still have to get through a three-year internal medicine residency and a three-year general cardiology fellowship before you have the chance to subspecialize. However, there are actually a lot of good reasons to choose such a highly specialized area for a graduate fellowship. Here are just a few:

• In the personal statement on your residency application and in your residency interview, you need to be able to articulate clear plans and goals about your educational and professional future. When you are applying for an internal medicine residency, it’s one thing to say you want to be a cardiologist and possibly subspecialize interventional cardiology, but when you have months of clinical experience to back it up, it’s a lot more believable to an application reader.
• A graduate externship in a subspecialty area can help you build on your existing clinical and research interests. While completing a fellowship in interventional or metabolic cardiology, you may be exposed to cutting-edge research and innovative clinical techniques, which could shape your future educational and career interests. Again, these are things you could include on your personal statement and talk about during your interview.
• A graduate externship in a highly specialized area can actually help you make decisions about your future education and career. Sometimes, it can be hard to determine whether or not you want to dedicate your studies and professional life to a subspecialty area just by reading about it. In a graduate externship, you would have the chance to learn what day-to-day life as a specialist physician is like. That way, you can feel confident as you make decisions about steering your future toward a specialty area of cardiology.

FMG Portal offers graduate externships in both interventional and metabolic cardiology, among a wide range of other specialty and subspecialty areas. Contact us today to learn more about our offerings!

Cardiovascular disease is the number one cause of death around the world. According to the World Health Organization, cardiovascular disease accounts for about 31 percent of all deaths — a total of around 17.7 million people per year. In the United States, the prevalence of cardiovascular disease is similar. According to the US Centers for Disease Control and Prevention, about 1 in 4 deaths are caused by heart disease — a total of around 610,000 people per year. Moreover, about 47 percent of Americans have one of the top three risk factors for cardiovascular disease: high blood pressure, high cholesterol, and/or a history of smoking.

As a cardiologist, you would have the opportunity to dedicate your career to supporting cardiovascular health and combating cardiovascular disease. The United States can be a great place to get the training you need through residency and/or fellowship programs. Read on to learn what foreign medical graduates need to do to launch a career in cardiology.

Completing a US Medical Residency Program in Internal Medicine

After earning your medical degree, the first step toward a cardiology career is a medical residency program in internal medicine. According to the National Residency Matching Program (NRMP), internal medicine is the most common residency specialty for foreign medical graduates, and the proportion of FMGs who choose internal medicine has been on the rise in recent years, jumping 6.4 percent from 2011 to 2015.

An internal medicine residency program can provide the preparation you need for a wide range of medical careers, including cardiology. In a three-year internal medicine residency program in the United States, you will get broad training in the diagnosis and treatment of the diseases and disorders that affect all organ systems. This training will include a mix of clinical practice and classroom-based seminar. You may also have the opportunity to conduct laboratory or clinical research in an area of interest, like cardiology. At the end of your internal medicine residency program, you are eligible to take the certification exam offered by the American Board of Internal Medicine (ABIM).

Completing a Fellowship in Cardiology

After earning certification from the ABIM, you can continue toward a career in cardiology by starting a three-year cardiology fellowship. During a fellowship in cardiology, you will have the chance to study a wide range of cardiac conditions, procedures, and prevention strategies. In most programs, you will also have the chance to apply your knowledge and skills in multiple settings, including inpatient and outpatient settings. Research is also an integral aspect of many cardiology fellowship programs. Just as in your internal medicine residency program, you may have the chance to choose between research in laboratory and clinical settings, depending on your specific interests.

Subspecialty Cardiology Fellowships

If you are passionate about a particular topic within the field of cardiology, you may consider completing a one- to two-year cardiology subspecialty fellowship after you have finished your three-year general cardiology fellowship. In a subspecialty fellowship, you have the opportunity to gain focused clinical and/or research experience in a particular cardiology subfield. The ACGME-accredited subspecialty options for trained cardiologists include:

• Interventional Cardiology Fellowship. In this subspecialty fellowship, your focus would be on treating coronary artery disease, the most common cardiovascular condition in the United States. Topics of study can include diagnostic procedures, percutaneous coronary interventions, and management strategies for patients with coronary artery disease. Interventional cardiology fellowships last one or two years.

• Electrophysiology (Heart Rhythm) Fellowship. In this subspecialty fellowship, your training would focus on the diagnosis and management of disorders characterized by irregular cardiac rhythms. For this, you would gain expertise in the implantation of pacemakers and other medical devices, lead extraction, and epicardial mapping, among other procedures. Electrophysiology fellowships last one or two years.

• Advanced Heart Failure Fellowship. This subspecialty fellowship would provide training in the management strategies for complex heart failure, such as transplant and implantation of artificial heart devices. You would also learn about pre- and post-operative care for patients who undergo these procedures. Advanced heart failure fellowships last for one year.

Although Interventional Cardiology, Electrophysiology, and Advanced Heart Failure are the only ACGME-accredited subspecialty options in cardiology, there are also unaccredited subspecialty fellowship options in other cardiology subfields, such as Advanced Imaging and Metabolic Cardiology. Even though these programs are unaccredited, they may still provide valuable education that can support your career success.

Pre-Residency Preparation Options for Aspiring Cardiologists

As an aspiring cardiologist with a degree from a foreign medical school, there are many things you can do to get ready for the residency application process that will launch your career in cardiology. One great way to gain clinical experience in a US medical setting is by completing a graduate externship experience. You can choose a graduate externship in general cardiology or a subspecialty area like interventional cardiology or metabolic cardiology. When writing your application for an internal medicine residency in the United States, you can draw on this experience to explain your passion for the field of cardiology and demonstrate your commitment to career success. In some cases, graduate externships can also help you make connections with potential reference writers at US institutions, which you may need to get matched in certain residency programs.
FMG Portal offers graduate externships in a wide range of medical specialty areas, including cardiology, interventional cardiology, metabolic cardiology, and internal medicine, among others. Contact us today for more information!

Over the last few weeks, we’ve been talking about the USMLE exams, which are essential for earning ECFMG certification and becoming eligible to apply for a medical residency program in the United States. In one of these posts, we introduced you to the USMLE Step 2 – CS, which tests your clinical skills. In another post, we took a more specific look at what you can expect in the two types of encounters on the USMLE Step 2 – CS: the Standardized Patient and Physical Examination and the Telephone Patient Encounter. Going into the USMLE Step 2 – CS, it is important for you to know what the examiners expect you to do — but you also need to know what NOT to do. That way, you can avoid making mistakes that cost you valuable time and/or points off your score. Read on to get tips on what NOT to do on the USMLE Step 2 – CS patient encounters.

What NOT To Do On the Standardized Patient and Physical Examination Encounters

Here are a few things that you definitely want to avoid during the in-person encounters on the USMLE Step 2:

• Do NOT perform any of the prohibited tests. The testmakers specify that you should not conduct rectal, pelvic, genitourinary, inguinal hernia, female breast, or corneal reflex examinations. Also, you should not swab the patient’s throat for a throat culture. If you think that the patient needs any of these tests, you can call for them in the diagnostic workup you propose in your Patient Note.

• Do NOT ask the patient for consent for other physical examinations. Aside from the above-mentioned prohibited tests, you can assume that you already have patient consent for all physical examinations. This includes femoral pulse exams, inguinal node exams, back exams, and axilllary exams. Asking for the patient’s consent on any of these exams will unnecessarily take up valuable time.

• Do NOT be overly forceful with the patient with the patient. You need to be gentle during the physical examination avoid being too forceful when conducting maneuvers that involve palpating or percussing. You will lose points if you apply more than the appropriate amount of pressure when conducting an abdominal examination, examining the gallbladder or liver, using an otoscope to examine the ears, examining the throat with a tongue depressor, or examining the gall bladder and liver.

• Do NOT forget about the patient’s modesty. During the exam, you must treat the patient just the way you would treat a patient in a real-life situation. Therefore, it is important to take the time to consider their personal comfort during the physical examination. For instance, if part of the exam requires a female patient’s bra to be moved or loosened, you should ask her before doing it yourself. It only takes a few seconds, and it will demonstrate your ability to remain courteous and professional, regardless of the time constraints of the exam.

What NOT To Do On the Telephone Patient Encounters

These are some things to avoid on the Telephone Patient Encounters:

• Do NOT play around with the buttons on the phone. During the Telephone Patient Encounter, all you need to do to place the call is  press the yellow speaker button. After that, touching any buttons could disconnect your call. When you are ready to end the call, press the yellow speaker button again.

• Do NOT try to call the patient back after ending the call. Once you end the call, the encounter is over. Even if you think of another question for the patient, you cannot reach them again. Trying to call the patient back will only cut into the time you have for the Patient Note, so you should just do your best with the information you have.

• Do NOT make assumptions based on your previous test experiences. This tip actually goes for both the Standardized Patient and Physical Examination Encounters and the Telephone Patient Encounters. If you are taking the USMLE Step 2 – CS for a second time, you may notice similarities between an encounter on your exam and an encounter on one you have taken before. However, you should NOT assume that the correct diagnosis or treatment strategy is the same as the one on your previous examination, as the test preparers often make slight changes between exams.

• Do NOT make assumptions about whether or not an encounter counts toward your score. You may know that some of the twelve patient encounter are unscored — that is, they are only used for test development purposes. However, it is a bad idea to try to guess which encounters are unscored. Even if a particular encounter seems to stand out as easier or harder than the others, it may not be one of the unscored encounters. You should treat each one of the encounters — including both the in-person and telephone encounters — with equal seriousness.

Following these tips can help you avoid potential pitfalls when taking the USMLE Step 2 – CS. For more help preparing for a U.S. medical residency program, contact FMG Portal today!

Over the last few weeks, we’ve been talking about the USMLE Step 1 and Step 2. As an aspiring medical resident, you have to pass both of these exams before you can move on to USMLE Step 3. Success on all three USMLE exams is a prerequisite for ECFMG certification. Therefore, if you’re a foreign medical graduate looking to get matched to a residency program in the United States, passing these exams should be one of your top priorities.

The USMLE Step 2 consists of two parts. As we discussed in two previous posts, the USMLE Step 2 – CS tests your clinical skills during real-life patient encounters. The second part of Step 2 is the Clinical Knowledge (CK) section. Like the USMLE Step 1, the USMLE Step 2 – CK is a written test that requires you to demonstrate your expertise in the field of medicine. Read on to learn more about the content of the test and the format of the questions.

The Content of the USMLE Step 2 – CK: What To Expect

Put simply, the USMLE Step 2 – CK tests your knowledge of the concepts of clinical science that the USMLE committee members have decided are the most important for medical residents to possess. The specific material can vary slightly from year to year, but the general content tends to remain the same. There are two ways that the the content of the exam can be broken down: in terms of Scientific Topics and in terms of Physician Tasks and Competencies.

Scientific Topics

When approached from the perspective of Scientific Topics, the USMLE Step 2 – CK can be broken down into three categories, each accounting for a certain proportion of the exam. The first category, General Principles of Foundational Science, typically takes up 1 to 3 percent of the exam. The second category includes Biostatistics, Epidemiology, Population Health, and Interpretation of the Medical Literature. These topics typically take up 1 to 5 percent of the exam. That means that the vast majority of the USMLE Step 2 – CK is dedicated to the third category, which encompasses body systems and tissues. This category accounts for 85 to 95 percent of the exam. The topics that fall within this category include:

• Behavioral health
• Cardiovascular system
• Circulatory system
• Endocrine system
• Gastrointestinal system
• Lymphoreticular system
• Musculoskeletal system
• Nervous system and special senses
• Pregnancy, childbirth, and the puerperium
• Renal System
• Reproductive system (male and female)
• Respiratory System
• Skin and subcutaneous tissue
• Urinary system
• Multisystem processes and disorders

Physician Tasks and Competencies

Another way to divide up the content of the USMLE Step 2 – CK is in terms of Physician Tasks and Competencies. Approaching the exam from this perspective can help you understand exactly what aspects of the Scientific Topics you will be tested on. Each of the four competencies accounts for a significant proportion of the exam.

1. Medical Knowledge / Scientific Concepts

This competency makes up 10 to 15 percent of the test. Questions that fall in this category are direct, straightforward questions about the Scientific Topics listed above.

1. Patient Care / Diagnosis

This competency makes up 40 to 50 percent of the test. Questions that fall within this category examine your ability to:

• Interpret information from a patient’s medical history and physical examination
• Interpret information from laboratory and diagnostic studies
• Make a diagnosis
• Provide a prognosis
• Determine expected patient outcomes

1. Patient Care: Management Health Maintenance / Disease Prevention

This competency makes up 30 to 35 percent of the test. The questions that fall within this category will test your knowledge of:

• Clinical intervention strategies
• Pharmacotherapy
• Mixed management
• Surveillance techniques to prevent disease recurrence

1. Professionalism

This competency takes up only a small proportion of the exam: between 3 and 7 percent. Questions within this category will assess your knowledge of:

• Professional conduct for health care providers
• System-based practice
• Patient safety
• Practice-based learning and skill development

Question Types on the USMLE Step 2 – CK

All of the questions on the USMLE Step 2 – CK are multiple choice questions. Some of the questions are single-item questions, while others are sequential item sets. For the single-item questions, you will be provided with a short vignette that ends with a question, and you will need to choose the best answer from among a set of lettered choices. For the sequential item sets, you will be given a vignette that is followed by several multiple-choice questions that assess your knowledge of different aspects.

The way that the questions are framed can vary depending on the scientific topic or physician competency that is being assessed. Some questions ask you directly for information about a scientific concept. Others provide a story about a clinical situation that you might encounter as a physician. Still others provide a research abstract that you will need to interpret. Being prepared to see all of these question types is crucial for success on test day.
Looking for more advice on the steps you have to take to get matched to a U.S. medical residency program? Contact FMG Portal today!

All over the world, infectious diseases are on the rise. Every day on the news, you might hear a breaking story about the discovery of a novel virus that has the potential to wreak havoc across the globe. At the same time, you might be hearing about infectious diseases that have been around for centuries but are somehow making a comeback. Consider some of the most recent developments in the field of infectious diseases:

• The Zika virus has gained traction in South American countries like Brazil, and it has also been carried to other countries, like the United States. The effects of the virus are not well understood, but it has been shown to cause microcephaly in infants after their mothers have been infected.
• Between 2014 and 2016, the most recent outbreak of Ebola ravaged countries in West Africa, causing a worldwide health scare.
• Over the last two years, there have been measles outbreaks across Europe, especially in Romania, where over 3,400 cases have been reported since January 2016. Some suggest that the increase in measles, mumps, and rubella has resulted from unwarranted fears about the safety of vaccines for children.
• Scientists have recently reported that the number of new flu viruses is increasing each year. This is making it increasingly harder for scientists to develop effective vaccines.

If stories like these capture your academic interest as a physician, you may want to consider becoming an infectious disease specialist in the future. Read on to learn more about working as an infectious disease specialist and what you need to do to become one.

Working as an Infectious Disease Specialist

An infectious disease specialist is a physician who is an expert at diagnosing, treating, and preventing the spread of illnesses that are transmitted from person to person. Infectious diseases may be caused by bacteria, viruses, parasites, or fungi, and they can affect many different parts of the body. Although some infectious diseases, like the common cold, are relatively easy to diagnose and treat, most infectious disease specialists focus their work on infections that are particularly difficult to treat or have not been fully studied.

As an infectious disease specialist, your job could involve aspects of clinical practice, scientific research, and public health efforts. Depending on your interests and training, you might spend some of your time working directly with patients, providing them with vaccinations against infectious diseases and/or therapies to treat infections that they have already contracted. You might also choose to spend some of your time in the research lab, developing and conducting rigorous studies with the goal of finding new prevention and treatment strategies or identifying new strains of a deadly infection. If you are interested in public health, you could also find yourself using your medical knowledge to develop and direct large-scale efforts to address and eradicate infectious diseases in a broader community.

The Steps to Becoming an Infectious Disease Specialist

Regardless of the particular aspect of infectious disease in which you are most interested, the basic components of training for this career are the same. After you finish your training in medical school, you must complete a three-year medical residency in internal medicine. If you are specifically interested in becoming a pediatric infectious disease specialist, you will also need to complete a medical residency program in pediatrics. Although it can be tough for foreign medical graduates to get matched to U.S. medical residency programs, it is important to note that internal medicine and pediatrics are two of the specialty areas in which foreign medical graduates are most commonly matched. To increase your chances of getting matched, you might also want to consider completing a student elective or a clinical externship program in infectious diseases, internal medicine, and/or pediatrics before you apply for your residency.

After you finish your residency, you can get the expertise you need to become an infectious disease specialist by completing an ACGME-accredited fellowship program in infectious diseases. Depending on the location, these programs can last for either two or three years. In most programs, fellows divide their time between clinical training with patients and research training in a particular area of interest. Research within the field of infectious diseases tends to vary widely, and it may fall into any of the following categories:

• Basic science
• Translational science
• Clinical trials
• Epidemiology / public health
• Global health studies

Upon completion of one of these programs, you will be prepared for the Infectious Disease subspecialty certification exam offered by the American Board of Internal Medicine (ABIM). From there, you can start an exciting career as an infectious disease specialist!
FMG Portal offers valuable resources for foreign medical graduates who are looking to pursue careers in a wide range of specialty areas. Contact us today for more information about how to get matched to the U.S. medical residency program of your dreams!

As you look ahead to your medical career, one specialty area that you might want to consider is adolescent medicine. As an adolescent medicine specialist, you would provide care for pre-teens, teenagers, and young adults. The period of adolescence starts when the patient reaches puberty and ends when the patient is in their early twenties, so you would have the opportunity to work with patients during a crucial period of development. Read on to learn more about starting a career in this rewarding field.

The Educational Steps for Aspiring Adolescent Medicine Specialists

After earning your medical degree, you can expect to spend another six years in residency and fellowship programs before you can become a Board-certified adolescent medicine specialist. Specifically, you need to complete a three-year medical residency program and a three-year Adolescent Medicine Fellowship.

The first step is to complete a three-year residency program in one of the more general medical specialty areas. According to the National Resident Matching Program (NRMP), applicants for an Adolescent Medicine Fellowship must have previously completed a three-year medical residency in one of the following specialty areas:

• Pediatrics
• Medicine – Pediatrics
• Internal Medicine
• Family Medicine

That’ good news for foreign medical graduates, since internal medicine, family medicine, and pediatrics were the top three specialty areas in which foreign-trained physicians got matched in 2015, according the the NRMP.

After completing a three-year residency in one of those specialty areas, you can apply for a three-year fellowship in Adolescent Medicine. Unlike some other fellowship programs, the matching process for Adolescent Medicine Fellowship programs is facilitated by the NRMP. Therefore, after you have completed your first residency program, you would go through the ERAS process to get matched to an Adolescent Medicine Fellowship program, just like you would for any other residency program.

What to Expect From an Adolescent Medicine Fellowship Program

All Adolescent Medicine Fellowship programs last for three years. The time that you spend in the program is typically divided between clinical experience, research training, and didactic coursework. In general, the first year is spent mostly on clinical training and coursework, while the second and third years involve more academic research.

However, it is important to note that the proportion of time spent in each of these areas can vary depending on the program. Some programs are primarily intended for aspiring adolescent medicine clinicians, while others focus on training adolescent medicine specialists who spend more time on academic research that supports their practice. As you look at the different programs that are available in the United States, make sure to find out about the emphasis of each one of the programs that you are considering.

Clinical Training in an Adolescent Medicine Fellowship Program

During your clinical training, you will probably have the opportunity to gain experience in multiple settings. You may complete rotations in hospitals, outpatient care centers, behavioral health clinics, substance abuse clinics, gynecology departments, school-based health clinics, and even homeless shelters. If you are interested in public health, adolescent medicine can be a great choice, because many programs offer opportunities to work with teens and young adults from a wide variety of socioeconomic backgrounds.

Because adolescent medicine is such a broad discipline, your clinical training will equip you to treat young people with many different physical and mental health conditions. Some common topics of study include:

• Eating disorders
• Gynecology
• Substance abuse
• Nutrition
• Sports medicine
• Chronic diseases

Research Training in an Adolescent Medicine Fellowship Program

In addition to your clinical training, an Adolescent Medicine Fellowship involves academic research. In most programs, the research opportunities have implications for public health. For instance, you may conduct epidemiological research to try to understand disease frequency in certain adolescent populations, or you may conduct lab-based molecular biology research to develop sexually transmitted disease therapies that are safe for young adults. At some universities, your research can serve as the basis for a Master of Public Health (MPH) degree, which you can earn as part of the Adolescent Medicine Fellowship Program.

Starting Your Career as an Adolescent Medicine Specialist

Once you finish your fellowship program, you will be ready to take the Adolescent Medicine Certification Exam. This exam is developed jointly by the American Board of Internal Medicine (ABIM), the American Board of Family Medicine (ABFM) and the American Board of Pediatrics (ABP). The ABP administers the exam once a year to candidates who have completed an Adolescent Medicine Fellowship program. Passing this exam means that you are Board-certified in the subspecialty area of Adolescent Medicine.

Advice for Aspiring Adolescent Medicine Specialists

Even if you are still in medical school, there are steps you can take that can help you prepare for an Adolescent Medicine Fellowship program in the United States. Completing a student elective or a graduate externship in the field is a great way to learn more about the subspecialty area and increase your chances of getting matched. FMG Portal offers clinical externships for foreign medical graduates in Adolescent Medicine, as well as the three other relevant specialty areas: Internal Medicine, Family Medicine, and Pediatrics. Contact us today for more information about what we offer!