Postgraduate training in the United States: joining a residency programme as a foreign medical graduate
Authors: Cyril Mauffrey
Publication date: 22 Apr 2006
Current competition for training posts means that it may make sense to hone your skills across the pond, says Cyril Mauffrey
Educational Commission for Foreign Medical Graduates—www.ecfmg.org
Selecting programmes and specialties
American Medical Association—www.ama-assn.org/ama/pub/category/2997.html
www.ama-assn.org/vapp/freida/srch/ is a mine of information on each available programme
Useful forums where you can chat about various topics
Competition for training posts is intense. Motivated doctors have long looked overseas for training opportunities, and the most popular destination for UK graduates has been Australia. An alternative you might not have considered is the United States.
Any graduate wanting to practise medicine in the United States needs a certificate from the Educational Commission for Foreign Medical Graduates (ECFMG). To be eligible for this, international medical graduates must meet the examination and medical education credential requirements given below.
These include passing step 1 and step 2 of the United States Medical Licensing Examination (USMLE). Step 2 has two separately administered components—clinical knowledge and clinical skills. American graduates must also pass these exams so bear in mind that you're competing with them.
Step 1 can be taken in most countries, costs around $800 (£457; €667), and consists of seven hours' multiple choice questions, which test your knowledge in basic sciences.
Step 2 clinical knowledge is similar to step 1. It costs the same and can be taken in most countries. It is an hour longer and tests knowledge of clinical disciplines.
Step 2 clinical skills is different. It tests three components—history taking skills, physical examination aptitudes, and communication ability—by assessing command of the English language as well as the ability to communicate with patients.
Step 3 emphasizes selected tasks like severity of patient problems and managing therapy. Clinical problems involve mainstream, high impact diseases and less common but important clinical problems. It is assumed that basic science and clinical fundamentals have been assessed in Steps 1 and 2.
Medical education credential requirements
Your medical school and graduation year must be listed in the International Medical Education Directory.
You can apply to residency programmes after passing step 1, and most programmes ask you to have step 2 clincial knowledge and clinical skills before interviewing you. Applications are processed electronically through the electronic residency application service. You can apply to as many specialties as you like and an unlimited number of programmes, bearing in mind that costs increase with each additional programme or specialty applied for. In addition to your application form, programmes request up to four letters of recommendation, a personal statement, a dean's letter, and medical school transcripts.
Competition and selection criteria vary widely between programmes and specialties. Most surgical specialties are highly competitive, and internal medicine and family medicine are the least competitive. Programmes are divided into those that are university based, community based, affiliated to university, or community based.
Your graduation year from medical school is incredibly important but few will tell you this. It is very unlikely that you'll find a residency position if you graduated more than five years before applying, especially for surgical specialties.
USMLE scores allow programme directors to compare you with American graduates and are crucial, especially step 1. As a rough guide, for internal medicine or family practice, a passing score can be enough, for general surgery your score should be around 85 to 90, and for the most competitive specialties, scores above 95 are often required.
Letters of recommendation are key. Getting one from an American physician or a renowned specialist is ideal. This is where US experience comes in handy.
Once the interview is over and your bank account drained, you will have to wait patiently for the selection process, known as Match, which takes place in March. If you're successful, congratulations. There are a few things you ought to know.
Them and us
Working hours during residency are just under double the hours we work in the NHS. Residents work an average of eighty hours a week.  A typical day starts at 5 30 am and finishes at around 6 pm unless you are on call. Salaries are low, ranging from $35 000 for an intern to $50 000 for a chief resident. Depending on where you are living, this just about covers expenses.
There are two types of visa—J1 and H1. The former is sponsored by ECFMG and allows you to stay in the United States for the duration of your residency, after which you must return to your home country for at least two years before being eligible to come back to the States. The H1 visa is directly sponsored by the programme itself and to be eligible you must have successfully passed the USMLE step 3 before the beginning of your residency. The advantage is that H1 allows you to work in the United States after the end of your residency.
Going to the United States for residency is challenging and rewarding, and with the recent changes in junior doctors' training in the United Kingdom is well worth considering. Specialist board examinations in the United States are recognised by most countries. The United States of America maintains high standards of education and care thanks to the impressive dedication of their faculty members to junior doctors' training. ■
Cyril Mauffrey specialist registrar in trauma and orthopaedics Robert Jones and Agnes Hunt Hospital, Oswestry firstname.lastname@example.org