The Misguided Importance of the USMLE Score

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.

6 Prejudices All Medical Graduates Must Avoid

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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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 Closure News

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 16th. 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.

It starts with an ECFMG identification number.

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.

Handling Doubters after a Successful Match

March 15th 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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!

Health Security and the Foreign Medical Graduate:

Foreign Medical Graduates (FMGs) face skepticism from Americans and healthcare professionals, but that is changing quickly. While many FMGs come to the United States to obtain a quality residency and return to their home country, many stay in the U.S. to continue practicing medicine as a career. This has many switching from skepticism to thankfulness as FMGs fill gaps in the accessibility of healthcare.

By the year 2050, 20 percent of the U.S. population will be made up of adults 65 year’s old and older. That is an increase from 12 percent in the year 2000. Currently, there is a physician shortage of over 30,000. This number will increase to over 100,000 in the next 30 years.

Elderly patients cost the healthcare more than younger populations because of chronic metabolic and geriatric disorders such as type II diabetes, heart disease, and dementia. They need physicians for continued care in order to manage their health. Telemedicine does a lot toward improving healthcare accessibility, but there is still a growing need for physicians in order to meet face-to-face and tele medical needs.

The physician shortage will not be eliminated by nurses or advanced-practice nurses. It will only be somewhat lessened. With the growing shortage of physicians will come an equally burdensome shortage of nursing and ancillary staff. This leaves the mystery of why FMGs are met with skepticism instead of appreciation.

Similarly to residency program directors, the general public does not know if the education FMGs receive abroad is equal to what would have been received within the United States. Of course, FMGs know that they are thoroughly checked out via the ECFMG certification process, but that is hardly common knowledge.

It is important therefore for the American public to understand how FMGs are vetted. It is also important for FMGs to be able to communicate the vetting process, so patients can have faith that they are getting quality care. Americans need to rely on FMGs in order to get access to quality care, so confirmation of quality education will go a long way to building trusting relationships between FMGs and their patients.

How are Foreign Medical Graduates vetted?

Educational Commission for Foreign Medical Graduates (ECFMG):

We already mentioned ECFMG certification, but it is integral to the vetting process of FMGS. It is essentially a Dean’s Office for international medical graduates. It is the ECFMG’s job to make sure that education received abroad meets the standards of the American Healthcare System. It also ensures that a resident has the communication skills necessary to treat English-speaking patients.

ECFMG certification requirements

  • Medical Schools must be listed on World Directory of Medical Schools
  • United States Medical Licensing Examination (USMLE)
    • Step 1 and 2: clinical knowledge
    • Step 2: clinical skills
      • English proficiency requirement
    • Diploma and credential verification

By the time FMGs have been certified by the ECFMG, it is established that they have had sufficient education and can perform well in a clinical setting.

  1. Visa:

It can be very difficult to get a visa to enter and stay in the United States, and travel bans increase the challenges faced by FMGs. However, U.S. Citizens should rest assured that FMGs are not only trained adequately, but they are not criminals and are welcomed by the U.S. government. The hurdles to getting FMGs in the U.S. are controversial, but they can be a positive item too.

USMLE Step 3:

This last stage in USMLE testing is a final assessment of a physician’s ability to practice medicine alone in the United States. It determines their ability to be independently responsible for patients and is a final step in medical licensure.

Residency:

Every state requires at least one year in an accredited residency program. This means that before the FMG is released to practice medicine, he must practice it under the supervision of other physicians. The FMG has to do basically everything every other doctor does, but they also have to prove it.

Health Security and the Foreign Medical Graduate

In order for the United States citizens to have security in their healthcare system, they are going to have to embrace international medical students rather than question their abilities. That does not mean eliminating the vetting process, but it does mean streamlining it.

Americans need to remember that FMGs bring diversity and unique medical knowledge to the healthcare system. They also represent one solution to alleviate some of the physician shortage present and growing in the U.S.

With that said, FMGs must remember that they have been thoroughly vetted, and they are fully equipped to practice in the U.S. They also must be able to communicate that to patients.

Hopefully, as the world continues with globalization efforts and communities become more diverse, FMGs will be looked at similarly to any other trained physician. FMGs are not a questionable entity with a questionable background. They have been scrutinized in many ways more than the American Medical Graduate.

Journeys in Medicine makes FMGs feel connected.

It is easy a foreign medical graduate (FMG) to feel isolated and even discriminated against, especially during the Match. The Educational Commission for Foreign Medical Graduates (ECFMG) is an organization committed to alleviating some of these feelings, but the world’s university systems are simply not set up in a way that completely remedies the added dilemmas FMGs face.

Thankfully, the ECFMG is constantly working on making conditions favorable for FMGs, and one of the ways they have recently accomplished part of this goal is by creating a blog. Journeys in Medicine is a blog that focuses on the true stories of foreign physicians and their experiences in the United States and in home countries through the Exchange Visitor Program.

The stories in the blogs are not terrible stories of failure or complaints about the stress of being an FMG. They are instead inspirational stories that confirm the importance of FMGs in the U.S. and abroad. They are also incredible tales about the amazing resources available for FMGs, and how to keep a positive attitude and perspective about training and education.

Sometimes, all it takes to remain motivated during studies as an FMG is to feel connected and like you are part of a community. Journeys in Medicine helps one to accomplish this goal by giving authentic accounts of experiences rather than analogies or fictitious tales of what should be. The stories are the real deal, and they are a reminder of the reasons FMGs should keep striving to do their best.

5 Reasons to Read Journeys in Medicine as an FMG

Anecdotal Evidence: The purpose of the stories in this blog are to encourage participation in the U.S. healthcare system. Sure, it is a difficult road, but the road is filled with heartfelt success stories. Often, the anecdotal evidence FMGs receive is negative and focused on discrimination and failures due to things out of one’s control such as Visa issues. This blog gives a person hope through real life success stories, which can encourage the FMG to keep trying no matter what obstacles get in the way.

Sense of Community: Reading Journeys in Medicine is a reminder that FMGs are part of the medical community. The stories remind FMGs of this by noting the accomplishments and importance of FMG contributions. It is not only the FMG that reaps rewards from their education while in the U.S. The patients in the healthcare system also benefit from the unique knowledge FMGs may possess. Sometimes, FMGs can forget that they are an asset to a nation that struggles with a physician shortage and lack of diversity.

Connections: In many cases, Journeys in Medicine gives FMGs connection to doctors who have shared similar experiences. One they have read a blog post, an FMG is free to try contacting that physician for more information or help with their own struggles. Admittedly, the blog does not have a discussion forum or contact information. However, the names of the physicians are included in the stories, so an FMG could look up the doctors in a physician’s directory.

Resources: Many of the blog posts in Journeys in Medicine give clear information about resources that aided the visiting physician and allowed them to have a positive learning experience. Being able to follow the trail of resources used to get to a certain endpoint can be instrumental in another FMGs successful finding of their own resources. It also confirms for an FMG who is feeling lost that there are resources available to put them on the path to success.

Authenticity: Lastly, Journeys in Medicine is an authentic account of real life experiences, so the reader is not getting a story about how things are SUPPOSED to be but how it actually is. Too often, FMGs are presented with promotional material that paints a false picture of reality. That does not mean that reality is not as good, but it does mean that the information in the promotional material may be inaccurate. Reading actual stories from people who have been visiting from abroad gives credence to the account.

The news is filled with stories about the challenges FMGs face, and the news is also filled with stories that question the abilities of FMGs. Much of this has to do with politics, but there is another story that is starting to emerge, and that is the story of how important FMGs are to an overburdened healthcare system. Not only do FMGs fill the gap in healthcare accessibility by creating more providers in the U.S. healthcare system, but FMGs gain a valuable education about state-of-the-art medical practice that they may not be able to receive in the U.S.

Journeys in Medicine highlights the positive aspects of visiting physicians from those physicians’ perspectives, and it is a must-read for FMGs who need a little connection and pick-me-up during residency matching and training.

American International Integrated Observership Programs

It is a difficult road for any international medical graduate (IMG) trying to practice medicine in a country different from the one where they graduated from medical school. Each country’s requirements for medical school are different, and pre-requisites for those medical schools vary greatly. As a result, other countries do not know what they are getting when they take on a foreign medical graduate. Although their education may be superior, there is no way of telling whether it was superior or greatly inferior.

Whether inferior or superior, education abroad combines many strengths and challenges. Being multi-lingual and multi-cultural is a definite advantage when it comes to bedside manner and diversity in care. However, language barriers, standards of care, and the overall practice of medicine may differ greatly from one country to another. There are also different exposure rates to the treatment of various regional illnesses. For example, experience in the care of dengue fever patients varies across different countries. While one country may have a large incidence of the illness, another country may have little to none. It is difficult to determine what medical graduates have had adequate training in all illnesses.

There are no “apples-to-apples” comparisons of international medical school programs, but this does not mean foreign medical graduates are inferior. Instead, it means that they have to prove their academic and clinical know-how in an effort to provide a comparison to those who need it.  The EFMG does a good job of serving as a Dean’s Office for foreign medical graduates, but residency applicants still need to have experience in the United States in order to confirm that their clinical skills and training fit the practice of medicine in this country.

The American Medical Association (AMA) registers American International Integrated Observership Programs (MedicalObs) to help foreign medical graduates become accustomed to medical practice in the United States. These observerships last for one to three months, and they allow FMGs to get a taste of American medicine and do a little networking along the way.

Program Elements

Observation: The first thing the program does for FMGs is gives them the opportunity to observe doctors in a hospital setting. This gives FMGs a greater understanding about the workflows of American hospitals, the types of patients they may encounter, and the relationships between physicians and other staff. Nurses are critical to the care of patients, and the doctor-nurse relationship is a huge facilitator of care. FMGs must understand this in order to perform successfully during residency training.

Evaluation: FMGs who are enrolled in observerships will also get reviews from the program director. This is critical feedback by professionals in the medical field, and it can be instrumental in helping guide an FMG into a successful residency Match.

Letter of Recommendation: The evaluating director will also provide a letter of recommendation. Letters from American medical leaders are critical for residency applications, as they prove that you have worked successfully in American healthcare settings.

Certification: The certification from an observership is a great credential because it shows that you are focused on integrating your culture with the American culture of healthcare rather than letting it be a barrier.

Mock Interviews: The interview process can be very intense for FMGs who have all the same struggles of American residency applicants and the added difficulty of language and cultural differences. Mock interviews are the best way to hone answers to interview questions, and they help to build confidence.

Review of Application: Acting alone in the residency application process is a mistake for FMGs, and personal statements made with the review from a qualified and experienced healthcare professional can ensure that personal statements contain the elements needed for program directors to see the candidate as a success.

Speech: For FMGs with strong accents, it can be difficult to practice medicine. Not only will staff and patients have difficulty understanding thick accents, but some patients may not be able to trust a physician whom they cannot understand. Accent reduction courses are available through observerships to combat this problem.

There are many other benefits to American International Integrated Observership Programs. Membership to the alumni network can be a good tool to help find connections with other physicians. Local community groups and events where FMGs participate in events helps to integrate future residents with community members.

In many cases, the challenges FMGs have in finding a good residency Match are unfair, as there are many good and in some cases better medical schools outside of the United States than within. However, residency program directors have no way of knowing what an FMG’s specific circumstance was, and they must be presented with evidence not only that training was sufficient but also that the applicant is ready to transition into the culture of the American healthcare industry. Observerships make it easier for residency program directors to see the quality of FMG applicants.

Difficult Residency Interview Questions

The purpose of residency interviews during the Match is to pair a medical graduate with an environment that will enhance learning and develop the skills of the physician. However, interviewers are not equipped with the time to get to know every medical student, so they must use challenging interview questions to really get to know what type of candidate a medical graduate is. For the foreign medical graduate, difficult interview questions can be particularly challenging.

The Easy Questions

Don’t worry. There will be easy questions, and medical graduates will have plenty of general questions in which they can rehearse answers. Typical “easy” questions are:

  • Why do you want to be a physician?
  • Why are you interested in this residency?
  • What are your strengths when it comes to practicing medicine?
  • What is your biggest weakness when it comes to practicing medicine?
  • What are your goals for the future?
  • Why did you choose your specialty?
  • Describe your medical school training.
  • Who has been your greatest mentor?
  • What will you do if you are not selected for this program?

These questions are easy because they can be predicted and rehearsed. Especially for foreign medical graduates who may struggle with cultural or language barriers, the easy questions are a stress reducer because they can be practiced.

These questions are also very important because they confirm your education experience and the quality of education received abroad. They also give the candidate a chance to insert some personal details that will allow him or her to stand out amongst other candidates.

Although rehearsing the easy questions is advisable, answers should not be memorized. This can make replies come out robotically and make answers seem disingenuous. When practicing the easy interview questions, it is better to use bullet points to rehearse rather than full replies in complete sentences. This will give the candidate a chance to practice delivering natural and semi-spontaneous responses. The interviewer is not seeking a prepared speech but rather a natural conversation.

The Difficult Questions

While the content and delivery of the easy questions is important to assessing your ability to communicate your skills, difficult questions are designed to see how a residency candidate handles stress. They may be bizarre questions that have nothing to do with the residency program, and how you react to them tells interviewers a lot about your ability to handle stress.

For the foreign medical graduate, the difficult questions can be extra stressful because the interviewee must understand first that it is an intentionally difficult question. This can be difficult if the contextual elements of the question are misunderstood. This may force the interviewer to ask the question in a different manner to try to get the FMG to understand the question, and if this does not work, the interview may take an awkward negative turn. Examples of difficult questions are:

  • What is your favorite color and why?
  • Have you heard any negative comments about our residency program?
  • If you were stranded on a desert island and could bring one item from home, what would it be?
  • Tell me a joke.

It is obvious that these questions have nothing to do with your skills or qualifications, but they can show a lot about what a person is able to handle.

Preparing for the Difficult Questions

It is impossible to predict what the difficult questions will be, but your response to them should be candid. Some questions are meant to evoke hard emotional responses, and how you handle your emotions matters. Remain calm, and answer the questions with as many facts as possible. Leave any feelings or emotions out of your replies whenever possible. This is a test of emotional fortitude, which is a requirement in medicine, and the only way your interviewers can judge your strength is by throwing out some unexpected lines of questioning.

When you are practicing with mock interviews, throw in some crazy lines of questioning, and practice responding in an intelligent and calm manner. If it is a funny question, don’t be afraid to give a clever or witty response. The difficult questions are a chance to show personality and uniqueness. Everyone has practiced, canned responses for the easy questions, and the difficult questions are an extra way to stand out.

Lastly, start thinking about the difficult questions as an advantage. They are really an opportunity more than an obstacle, as long as the candidate is prepared. They are an opportunity because they give the interviewee a stab at capturing the interviewers’ attention and showing how the candidate can think on his or her feet. If a candidate feels like this is where their weaknesses are, then they should practice more because the difficult questions are going to happen.

The Match is a lengthy process, and after all the exams, certifications, and residency hurdles, there is still one part of the residency application process that must be conquered to be matched, and that is the interview. Like everything else, it requires preparation, and practicing the easy and the hard questions will give the foreign medical graduate a big advantage in the interview.

The difficult questions during an interview are not necessarily graded by the quality of your answer but rather how you react to being asked such a question and then if you are able to shift your thoughts in order to answer thoughtfully. The interviewers are not expecting your answer to be as amazing as they expect from the easy questions, but they want to see that you are not easily thrown off by a little uneasiness in a situation.

ECFMG: The Starting Point for Residency Applications

In order for a foreign medical graduate (FMG), they must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). This certification assures residency programs that a candidate is qualified to enter a program based on United States medical education requirements. This is an essential part of the residency application process, and it is important because medical education requirements vary around the world.

The quality and relevance of medical education around the world has been called into question by U.S. residency programs, as program directors are unable to compare standardized U.S. medical school education with that of education in other countries. While medical knowledge is easy to determine based on standardized testing, clinical experience is not as easy to compare. That is why FMGs must attend a U.S. residency program, but programs want assurance that their educational background is sufficient to begin practicing medicine.

U.S. medical graduates are labelled ready for residency by their Dean’s Office, but those offices are not available for international students. As a result, the ECFMG has aimed to create a Dean’s –like office that standardizes the process for FMGs through certification.

In order to get certified by the ECFMG, an applicant must apply through an interactive web application (IWA). This application allows the ECFMG to confirm an applicant’s identity, contact information, and education background. This act alone is indicative of how difficult it is to confirm FMGs’ education, as the simple identification process is extensive. Simply providing current identification is not enough.

The medical school attended by the FMG must be listed in the World Directory as meeting requirements for the ECFMG examination, which is the United States Medical Licensing Examination (USMLE). Applicants who do not have a resident status in the United States must also apply for a Visa. This is only part of the process leading up to the Match, but each step must be taken in order to meet the requirements for a residency application.

USMLE

The USMLE is separated into parts, and applicants must pass Step 1 and Step 2 of the USMLE in order to be certified. The third step can be passed during residency.  Parts 1 and 2 of the exam test medical science knowledge and clinical skills. 2006 statistics show that US medical graduates scored higher on these tests than international medical graduates, but non-US international medical students scored higher than US international medical graduates except in clinical skills. Preparation is key to passing these tests, and English proficiency has been blamed for poor performance among FMGs. These tests are administered throughout the year, but you must be certified by the ECFMG before the start of your residency program.

Visa

FMGs are typically not residents of the US, but they may have established some form of legal resident status prior to applying to be certified by the ECFMG. If not, the ECFMG is able to sponsor applicants for a J-1 Visa.

ECFMG services

While the ECFMG is responsible for certifying that candidates are qualified for American residency programs, they also provide many services to FMGs. For example, they will help an FMG apply for residency programs through the Electronic Residency Application Service. They will also help applicants create verified career portfolios. They are basically the go-to organization for FMGs who need to get ready for the Match.

The ECFMG was established in 1956, and its goal was to improve the U.S. education system by standardizing the evaluation process of FMGs. In other words, it recognized the need for diversity in the medical community and welcomed the opportunity to help FMGs advance their career in the U.S. healthcare system. It is important to remember that the differences in education received abroad versus in the U.S. are not labelled as inadequate. Instead, it is simply different, and it cannot be accurately compared without some sort of a mediating process. The ECFMG provides that mediation.

That is not to say that there is not extensive preparation involved in getting certified by the ECFMG. Applicants are advised to pay attention to the timeline of deadlines and opportunities for FMGs to get certified and further their journey on the path to the Match. It is a complicated process that can quickly fail if an FMG does not complete certain tasks at certain times. Test scores are also important, and study plans should be set up and carried out months prior to the testing.

Navigating the pathway to the Match can be very confusing, and although the ECMG helps applicants get to the Match through certification, it can be helpful to employ other agencies to navigate the system and make sure steps are taken at the right time. The key to success is preparation and the utilization of resources such as FMGPortal. Obtaining a U.S. residency is an attainable goal as long as an FMG is motivated and obtains the help needed to get from the beginning of the process with the ECFMG to the end of the process with the Match.