An Introduction to the ECFMG Certification Examination

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

Step 1

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

A USMLE Bulletin states:

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

Step 2: Clinical Knowledge (CK)

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

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

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

Step 2: Clinical Skills (CS)

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

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

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

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

U.S. Residences have Additional Requirements for FMGs

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

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

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

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

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

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

Must apply through the ECFMG ERAS Program

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

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