The Path to Practice for Foreign Medical Graduates

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 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.


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.


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 Bring Cultural Competence to Healthcare

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.

Irregular Behavior According to the ECFMG

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.

Learning Common English for USMLE Step 2 CS

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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

  1. 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!

  1. 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.

  1. 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.

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.


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!