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Medical Education in the US

 

Introduction

 

United States offers various avenues for pursuing the medical profession. Some of the various opportunities are:

 

1.       Practicing Doctor or (MD)

2.       MS/PhD

3.       Master of Biotechnology (MBT)

4.       Clinical Laboratory Scientist (CLS)

5.       Physician Assistant (PA)

 

This document explores all the above options and details the steps required to get a license/certificate for working in those fields. Some conclusions are presented at the end of the document.

 

1.†††††††† Practicing Doctor (MD)

 

Agencies associated with the examination process and getting a practice license are as listed below:

 

 

 

1.1†††††† Examination Process

 

The examination process involves taking the USMLE exams, registering with ECFMG and with the Medical Board of California. Detailed information about them is given below.

 

 

ECFMG (Educational Commission for Foreign Medical Graduates) www.ecfmg.org

 

Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG) assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States ECFMG certification is a MUST to enter residency programs in the US. ECFMG certification involves taking the USMLE exams. Before taking any of the USMLE steps, one needs to register with ECFMG. The following documents are required for the same:

 

  1. 2 copies of MBBS diploma
  2. 2 copies of final MBBS transcript
  3. 2 face photographs
  4. Forms and Certification Statement (in ECFMG application packet)

 

Note that the above documents MUST be of size 8.5 inches X 11 inches. In India, documents are printed on A-4 paper, which is bigger than this. One can get the above documents on bigger sized paper and then do reduced photocopies of the same.

 

The above registration can take anywhere between 1-2 months. So one to be take into account this time gap too.

 

USMLE Steps 1, Step 2 CK and Step 2 CS are required for ECFMG certification. Once one has completed these, one can apply for the certification. The certification takes about 2 weeks to process.

 

The ECFMG certification requires you to list residency rotations for the MBBS done in India. In some cases the rotation numbers might need to be fudged. For example, for applying for a PG in Psychiatry, one requires 4 weeks of rotation. Most Indian colleges have only 2 weeks. So you need to fake the 4-week rotation period to make sure your application is NOT REJECTED. Similarly one needs to check the rotation cycle required for other PG braches too.

 

ECFMG has a mailing list to which one should subscribe to get certification news updates and changes.

 

 

USMLE (United States Medical Licensing Examination)††††††††††††††††††††††† www.usmle.org

USMLE examination is a 3-step examination for entering into medical residency programs in the US. Various steps of the USMLE are

 

  1. Step 1:

Can be taken anywhere in the world. This can be taken after Step 2 CK. But since Step 2 CK uses material studied in Step 1, it is always advisable to take Step 1 before Step 2.

Step 1 has about 350 multiple-choice questions, divided into seven 60 min. blocks, administered in one 8-hr testing session. So itís important to be prepared for a full day of testing.

Preparation time: 6-9 months of study

††††††††††††††††††††††††††††††††††† 3-4 months of study

††††††††††††††††††††††††††††††††††† 1-month review

††††††††††††††††††††††††††††††††††† 1-month restudy

††††††††††††††††††††††††††††††††††† 1-month review

††††††††††††††††††††††††††††††††††† 1-month test taking

 

Application fee: $675

 

  1. Step 2 CK

Step 2 has approx 370 multiple-choice questions, divided into 8 60 min. blocks, administered in one 9-hr testing session.

Preparation time: 4-5 months

Application fee: $675

 

  1. Step 2 CS

Step 2 CS has 10-12 patient cases with 15 min for your patient encounter and 10 min to record the post-encounter note.

Can be taken only in the US. There are very few (4-5) centers for taking this exam. Often one might need to fly to a different city to take this exam.

Preparation time: 1 month

Pre-requisite: Step 1

Application fee: $1200

 

  1. Step 3

Step 3 has approx 480 multiple-choice questions, divided into blocks of 35-50 items with 45-60 min to complete each block. There are about 9 computer-based case simulations and each has 25 min for completion. Step 3 is administered in two 8-hr testing sessions.

Case simulations have to be taken in order and one cannot change answers later.

 

Pre-requisites: for Step 3 are Step 2 CK and Step 2 CS.

Application for Step 3 must be submitted by Sept 1 of the year in which in the exam is to be taken.

Application fee: $610

 

Step 3 is not a requirement for ECFMG certification, but is helpful when applying for residency programs. It can be taken after submitting the application and one can mention that one is taking Step 3 exam soon.

 

For each testing block for all tests, you can review and change your answers within the block time limit.

 

Notes:

Some of the subjects in these exams like Behavioral Sciences, Statistics, Psychiatry and Public Health are not covered in Indian curricula. So these may require extra preparation and effort.

 

Once you pass a Step, you CANNOT retake it until 7 years. So it is VERY IMPORTANT to get a good percentage in the first time you pass. Good passing percentage is something like 90 percentile. You are allowed to fail 5 times. You can choose to forgo a test date and take an extension by paying about around $75. If you wish to forgo the retake also, then you need to reapply with the full application fees. For retakes, the retake date will be at least 60 days after the initial test date. So one MUST plan accordingly for the

 

For Step 1, Step 2 CK you need to specify a 3-month period during which you wish to take the exam. You are allowed to select any available date from that period. The exam request needs to be submitted at least 1-2 months before the 3-month period. For the retake, the 3-month period must be contiguous to the previous 3-month period (during which you didnít take the exam). If specifying a non-contiguous period, then you need to reapply again. Every application takes about 1 month to process. For Step 3, your 3-month period starts the day your application is approved. USMLE step tests are NOT ADMINISTERED in the first 2 weeks of Jan.

 

Study material for tests can be obtained from Kaplan (www.kaplan.com). Kaplan also offers live classroom teaching in Los Angeles and has multiple study centers in Bay Area. One can switch Kaplan centers as per change in residential address or convenience.

 

It takes about 4 weeks for the scores (Step 1/Step 2CK) to come. Step 2 CS scores can take up to 3 months. Until you have all scores, you cannot apply for ECFMG certification.

 

 

FSMB (Federation of State Medical Boards)†††††† www.fsmb.org

This agency offers the USMLE Step 3 examination.

 

Medical Board of California††† www.medbd.ca.gov

 

For applying for residency in California, one needs to get an Application Status Letter from the Medical board of California. This letters requires the following

 

1.       Completed Forms

2.       Certified and Sealed Transcripts and Medical Degree Copies. The certified copies must have the original signature of the dean or registrar of the medical school; be affixed with the official school seal; and include a statement attesting that the copy is a true and correct copy of the original.

3.       2 Fingerprinting (LiveScan) cards.

4.       ECFMG certification

5.       Photograph

 

Once the initial documents (1 & 2) have been submitted, the board will get back to you in 3 months. So itís best to start this process early. Once all documents have been submitted, it will take about 3-4 months to get the Application Status letter.

 

The Application Status Letter packet can be obtained by writing to the Medical Board of California.

 

 

1.2.††††† Application Process

 

The application process involves short-listing the colleges and specialty programs that one wishes to apply to, interviewing with them to get a feel of whether they like you and might admit you, and then finally applying to those colleges via the residency match process. Information about each of these steps is outlined below. Application process also involves getting up to 3 recommendation letters from your MBBS College.

 

 

FREIDA Online††††††††† www.ama-assn.org/go/freida

FREIDA Online is a database with over 7,800 graduate medical education programs. Besides searching for specialty and subspecialty programs, you can also search for training institutions, medical schools, aggregate training statistics by specialty, and career plans of recent graduates. 

 

Residency Visa Requirements

In order to work as a resident in a residency program, one needs a valid US visa. A visa is not required for US Citizens and Green Card Holders. If the husband gets a green card after marriage, then the wife also automatically gets a green card at the same time. If the applicant is neither a US Citizen nor a Green Card holder, then he/she needs to apply for one of the following visas:

 

         H-1B

International medical graduates who apply for the H-1B visa must be certified by ECFMG. However, it is the graduate medical education program that petitions the U.S. Immigration and Naturalization Service on behalf of the physician. ECFMG is not involved in the H-1B visa application process. Some residency programs DO NOT sponsor H1-B visa and hence one cannot apply to those programs.

 

         J-1

ECFMG is authorized by the U.S. Department of State to sponsor physicians on the J-1 visa to participate in accredited U.S. programs of graduate medical education or training. ECFMG sponsors all J-1 physicians in clinical training programs in the U.S. One of the catches with the J-1 Visa is that the holder needs to go back to his/her home country for 2 years after completion of the course. It may be possible to get a waiver for this requirement from the home country.

 

To be eligible for ECFMG sponsorship, an applicant must

         Have passed USMLE Steps 1 and 2.

         Hold a valid standard ECFMG certificate

         Hold a contract or an official letter of offer for a position in an accredited program of graduate medical education or training

         Provide a statement of need from the Ministry of Health of the country of nationality or last legal permanent residence. This statement must provide written assurance that the country needs specialists in the area in which the physician will receive training. It also serves to confirm the physician's commitment to return to that country upon completion of training in the US.

 

In its role as a J-1 visa sponsor, ECFMG evaluates each applicantís eligibility for sponsorship, according to the preceding criteria. For eligible applicants, ECFMG issues Form IAP-66, Certificate of Eligibility for Exchange Visitor (J-1) Status.

Individuals generally apply to the US Dept. of State for the J-1 visa through US embassies and consulates abroad. The Form IAP-66, issued by ECFMG, is only one of the elements considered by consular officials in determining an applicant's eligibility to enter the United States. All requirements, including the applicant's ability to prove non-immigrant intent, are evaluated by consular officials, who have broad discretion in determining whether to issue the visa. After the visa has been issued, the U.S. Immigration and Naturalization Service (INS) is responsible for reviewing required documentation at ports-of-entry into the US.

 

ECFMG tracks the status of J-1 physicians after entry to a US residency program. These physicians are required to renew their sponsorship with the ECFMG annually.

 

 

ERAS (Electronic Residency Application Service)††††††††† www.aamc.org/eras

 

ERAS is the Electronic Residency Application Service. Medical graduates or medical students most commonly used to apply for specialized graduate training in residency programs in the US. ERAS is a service that transmits residency applications, letters of recommendation, Deans Letters, medical school transcripts, USMLE transcripts and other supporting credentials from you and your Designated Deanís Office to residency program directors using the Internet. ERAS is used for an initial application to residency programs. Following ERAS, some programs might invite you over for interviews and based on that you can decide which colleges to finally apply to using NRMP.

 

 

NRMP (National Residency Matching Program)††††††††††††† www.nrmp.org

 

The National Resident Matching Program (NRMP) is a private, not-for-profit corporation established in 1952 to provide a uniform date of appointment to positions in graduate medical education (GME) in the United States.

 

International medical graduates who wish to participate in the Main Residency Match must have passed all examinations required for ECFMG certification by the NRMP's rank order list deadline, which is February end. Examinees who take Step 2 CS later than December 31st are unlikely to have results in time to participate in the next yearís match.

 

One specifies their choice of institutions in the NRMP ranking process. The system then takes oneís choices and matches them with the choices of the colleges. The NRMP releases information about results of the Match over a four-day period during Match Week. Hospitals will forward letters of appointment to all applicants who have matched to their programs after the general announcement of Match results. Applicants are expected to return one copy of the letter of acceptance to the program before the stated deadlines. Both applicants and programs are bound by the Match results.

 

Note: There are 3 main areas in the US where there is a congregation of residency programs, viz. California, Texas and New York/New Jersey. Traditionally the New York/New Jersey area has been known to be more tolerant and open to admitting IMGs (International medical graduates).

 

 

Scramble

Beginning at noon Eastern Time on Tuesday of Match Week, a brief period of time is set aside for those applicants who did not match to give them an opportunity to contact unfilled programs and possibly secure a position before Match Day. This time period is commonly known as the "Scramble". Applicants can find out whether they are matched or unmatched beginning at noon eastern time on Monday of Match Week from the NRMP System. The NRMP prepares the list of unfilled programs by specialty to help unmatched applicants identify unfilled positions.

 

 

FindAResident††††††††† http://www.aamc.org/students/findaresident

If scramble also fails to get you a seat, then you need to try the FindAResident service FindAResident is a powerful, web-based search tool to help you find open residency and fellowship positions. It can put you in direct contact with the programs looking to fill these positions. It is also an effective resource if you wish to change specialty, location or residency program. FindAResident is open year-round giving you access to unfilled residency and fellowship positions ranging from PG-year-1 through PG-year-6 in a variety of specializations.

 

 

1.3†††††† Program Availability

 

         Internal Medicine

135+ seats in Bay Area.

Duration: 3 yrs

Av. Work hrs: 70/week

Duration: 3 yrs

 

         Microbiology

Very few institutes in US offer residency in Microbiology, none in California.

Duration: 4 yrs

Av. Work hrs: 70/week

 

         Pathology

466 seats total in US, 39% offered to IMGs last year.

17 seats in Bay Area.

Duration: 4 yrs

Av. Work hrs: 70/week

 

         Pediatrics

Only 2 institutes In Bay Area offer the course, about 8 in California.

Duration: 4 yrs

Av. Work hrs: 80/week

 

Data not formalized about other specializations.

 

Note: All work hours exclude emergency calls and they are only valid for 1st year. Load is slightly less in others years. Work hours were obtained from college websites.

 

 

 

2.†††††††† MS/PhD

 

2.1†††††† Introduction

 

The other track for an MBBS from India is to embark on a research oriented career. This track involves doing a Masters or a PhD. Following this education, one can:

1.       Embark on a research career in a University

2.       Become a Professor

3.       Join a TODO: (verify) medical organization and work in their lab

4.       Join a medical company and do lab related work

 

This career offers great opportunities in hot fields of genetics, bio-informatics and biotechnology and other biosciences.

 

 

2.2†††††† Requirements

 

To get admission into an MS/PhD program, one needs the following

 

1.       Take the GRE (Graduate Record Examination).

Preparation Time: 4-5 months (depending on how good your English and Analytical Skills are)

2.       Take the Subject GRE (most Universities require this).

Subject GRE is basically an exam in a specialized area like Biology or Molecular Biology or Biochemistry or some others.

Preparation Time: 2-4 months

3.       Submit 3 letters of recommendation from MBBS instructors

 

Life in an MS/PhD track is much comfortable with not more than 8 hrs/day.

 

An MS by itself takes 2 years to complete. A PhD takes 5-5.5 years on an average. Some Universities do not have terminal MS programs and one has to complete a PhD. It is essential that one have a research frame of mind to do a PhD.

 

Note: MS/PhD programs are offered only by Universities and not by small colleges.

 

 

2.3†††††† Program Availability

 

In the Bay Area, such programs are offered by

 

         Stanford University†††††††††††††††††††††††††††††††† http://med.stanford.edu/phd

Stanford Biosciences Programs has 12 branches offering graduate studies. Intake in each branch is small and competition is very high. Hereís some information on one of the branches:

 

PhD Program in Microbiology & Immunology

Yearly Intake:††† 6-8 students

Student Profiles:††††††††††† GRE in 80s percentile

††††††††††††††††††††††††††††††††††† Bachelors with First Class

††††††††††††††††††††††††††††††††††† Subject GRE (not given so much weight)

Scholarship Scene:††††††† NIH government grants are only for Green Card Holders and Citizens.

1-2 Fellowship opportunities are available, but given only to exceptional students.

Course Details:

PhD only course. MS given only in exceptional circumstances. Admission not given to anyone who applies for an MS. PhD takes 5-6 years. The course is totally research based. Although some Professors do clinical work, graduate students are mainly restricted to research work.

 

Job Opportunities:††† Academic research/teaching, Biotechnology Industry.

 

         University of San Francisco†††††††††††††††††††† http://saawww.ucsf.edu/graduate/degree.htm

         San Francisco State University†††††††††††††† http://www.sfsu.edu/~gradstdy

         University of California, Berkeleyhttp://www.grad.berkeley.edu/programs

         San Jose State University††††††††††

http://www2.sjsu.edu/depts/Biology/programs/graduate.html

 

In other cities of California, such programs are offered by

 

         University of California, Irvine†††††††††††††††††† http://www.bio.uci.edu/grad_students/index.html

         University of California, Los Angeles††††††† http://dgsom.healthsciences.ucla.edu/

         University of Southern California, LA††††††† http://www.usc.edu/schools/medicine/ksom.html

         University of California, San Diego†††††††††† http://biomedsci.ucsd.edu/

 

 

3.†††††††† Master of Biotechnology (MBT)

 

3.1†††††† Introduction

 

Master of Biotechnology is a professional program that integrates advanced hands-on training in laboratory-based core biotechnologies with MBA-level business courses in management and marketing. The program prepares individuals for successful careers in fields of biotechnology. Students graduating from this course work in pharmaceutical and biotech firms as Project Leaders, Laboratory Team leaders and Managers. Since this program combines medicine and MBA skills, students can choose to concentrate on either of the skill-set as per their desired job preferences.

 

 

3.2†††††† Course Details and Requirements

 

Course Duration:††††††††††† 2 years

Offered at:†††††††† †††††††††† San Jose State University (SJSU) (http://www.science.sjsu.edu/mbt/ )

Program Intake:†††††††††††† 18(about 30% Indians admitted to this course)

Applicants this year:††††† 70

Accepted Student:†††††††† Graduates in Chemistry, Pharmacology, Medicine, and Biology

Profiles

Course Requirements:††† GRE, Subject GRE

Course Prerequisites:†††† Courses in Molecular Cell Biology, Cellular Immunology and Molecular Genetics

Program Director:†††††††††† Dave Bieber ( dbieber@email.sjsu.edu )

Prerequisite Details:

One needs to talk to the program director to figure out if one needs to take any of the above course prerequisites. The prerequisites need to be satisfied before start of the course and not at time of application. It is advisable to take at least 1-2 courses at SJSU so that Professors get to know you and you hold a better chance of getting into the program. In order to register for those courses at SJSU, it is advisable to apply to SJSU for a Bachelors (as Bachelor students get preference to register for courses).

 

 

 

 

4.†††††††† Clinical Lab Scientist (CLS)

 

4.1†††††† Introduction

 

CLS is a 1-year certification program offered in various hospitals and colleges. All highly complex blood tests, urinalysis, toxicology, and microbiology ordered by health care providers must be performed by a licensed CLS. Sixty-six percent of the health care decisions are made on the basis of lab test results generated by licensed CLSs. Outside of the acute care environment, CLSs can do research, marketing and sales, education, quality assurance and consulting work. Besides hospitals and clinics, CLSs can work in industrial, research, public health laboratories, forensic and pharmaceutical laboratories.

 

The majority of CLS work in hospital, independent, and public health laboratories.Additional opportunities are available in physician office laboratories, molecular diagnostics, biotechnology companies, in vitro fertilization and research laboratories.

 

General Information about a Clinical Lab Scientist can be found at www.camlt.org/train.html

 

Requirements:†† Green Card

 

More detailed information about career opportunities can be found at:

http://www.ascls.org/jobs/careeropps.asp

www.ascp.org/bor/medlab/careers/page2.asp

 

San Jose State University (SJSU) Program:†††††††† www2.sjsu.edu/cls

Univ. of San Francisco (UCSF) Program:http://pangloss.ucsfmedicalcenter.org/cls/index.html

 

 

 

4.2†††††† Program Requirements

 

Requirements:†† Bachelors degree

 

UCSF Program Details:

 

UCSF has 4 training disciplines in CLS program and the requirements for each are:

1.                   Microbiology: Required undergraduate courses in medical or pathogenic or clinical microbiology or bacteriology. Courses in immunology, mycology, parasitology, virology, molecular biology, and genetics are recommended.

2.                   Chemistry: Required undergraduate courses in analytical (quantitative) chemistry and instrumentation. Courses in immunology and molecular biology are recommended.

3.                   Hematology: Required undergraduate course in hematology. Courses in immunology and genetics are recommended

4.                   Immunohematology: Required undergraduate course in genetics and immunology. Course in immunohematology is recommended.

 

 

 

5.†††††††† Physician Assistant (PA)

 

5.1†††††† Introduction

 

Physician assistants are health care professionals licensed to practice medicine with physician supervision. PAs employed by the federal government are credentialed to practice. As part of their comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and in virtually all states can write prescriptions. Within the physician-PA relationship, physician assistants exercise autonomy in medical decision-making and provide a broad range of diagnostic and therapeutic services. A PA's practice may also include education, research, and administrative services.

 

General information about the Physician Assistant program can be found at www.aapa.org/geninfo1.html

 

5.2†††††† Course Details and Requirements

 

Program Duration:††††††††† 15 months

Requirements:†††††††††††††† Green Card

Pre-Requirements:†††††††† 3000 hours (1.5 years) of prior clinical direct patient experience. Residency period cannot be counted as experience. Experience need not be that of a doctor.

††††††††††††††††††††††††††††††††††† Courses in Anatomy, Physiology and Microbiology MUST be completed from a US institution before applying for the course.

Course offering:††††††††††††† Offered only at Stanford Hospital in the Bay Area.

††††††††††††††††††††††††††††††††††† http://pcap,stanford.edu

Student Intake:††††††††††††† 50

Number of Applicants:††† 200-850 (depending on economy)

 

Admission Process Note:

 

Statement of Purpose (SOP) should talk about workload and pressures handled in the past so that they can get a feel of oneís capabilities. Special achievements/duties in college or work should be highlighted.

 

Grades are not that important, except for the 3 courses mentioned above.

 

Once applications are submitted, then scan the applications and invite 100-150 students for interviews. Interview process consists of 2 interviews with faculty members and 1 interview with a student. 1 writing sample (essay) on a topic related to the medical profession in general or the PA program is taken during one of the interviews. After the interviews, around 50 students are selected.

 

Note:††† This courses requires a Green Card or Citizenship

 

Most part of the course is preceptorship (i.e. internship with a medical doctor or hospital or clinic). Students should find their own preceptors, although the department does provide help with the same.

 

The course credits can be used towards a Masters Degree in Public Health (aka. PA course = 1 yr. of MS).

 

 

Conclusions

 

It is pretty obvious that becoming a practicing doctor in the US is no piece of cake. It requires dedicated hard-work and long hours of work/study; besides the uncertainty of location of residency. All in all, it is a big compromise on family life. Lots of people go through the whole process; some give up in the middle and others take a break and continue later. Getting a PhD also requires great dedication and an internal desire to push oneself for research-oriented education for 5 years. For a more relaxed lifestyle with a career, the choices are PA, CLS, MBT and MS. While some of these require a Green Card, I think it is possible to take a break in studies and continue these courses once Green Card has been obtained. If clinical line is the only line one is interested in, then PA and CLS are simpler choices. Before starting a PA or CLS education, one can volunteer in various medical facilities in the Bay Area to gain some clinical experience (although maybe not direct patient care) and pass oneís time fruitfully. Lastly, if the Residency route is to be followed, one needs to start planning right now to avoid losing a year. As shown above, due to the long hours, thinking about a family life is almost impossible until one is in the last year(s) of the residency program, so it is advisable to plan residency before jumping into it.