Gary Zhou 周星光, MD (Class-78)
Yale University School of Medicine
New Haven, CT
 

I. Introduction

International medical graduates (IMGs) comprise about 26% of the ~800,000 U.S. physician population. This number represents a 2.5-fold increase from the early 1960s. For the past two decades, there have been about 10,000 IMGs each year certified by the ECFMG (Education Commission for Foreign Medical Graduates). Historically medical graduates from India, and to a much lesser degree, from Pakistan, comprise the majority of IMGs in the US, with about 20% of the certified IMGs from India. However since the mid-1990s there has been a steady increase of US citizens graduating from medical schools abroad (US IMG), mainly in the Caribbean islands, Mexico and Israel, and today this group has reached about 20% of the total certified IMGs. In the past few years only 3% of the certified IMGs are from Chinese medical schools, which represents a dramatic decrease from the mid-1990s.

For a medical graduate to practice medicine in the US, he or she must have at least two years of graduate medical education (GME or residency training) in an accredited hospital. To get into a GME program, an IMG must hold a diploma from a medical school listed in the International Medical Education Directory (IMED) (though this requirement is set to change in 2023), and be certified by the ECFMG. In order to obtain an ECFMG certificate, an IMG must register with ECFMG and file an application, pass USMLE Step1, Step 2 CK (clinical knowledge) and Step 2 CS (clinical skill). Since the introduction of clinical skill test in 2004, the English proficiency test is no longer needed. During the residency training, every resident must also pass Step 3 to be eligible for applying for an unrestricted (state) medical license.

Information on ECFMG certificate application and processes are available on www.ecfmg.org and www.usmle.org. Chinese medical graduates can now take Step 1 and Step 2 CK at the ECFMG test centers located in Beijing, Shanghai and Guangzhou. After passing these two tests, all IMGs must schedule and come to the US for Step 2 CS.

There are many books available to guide your study for the USMLE:

“First Aid” for USMLEs has been the most popular series in the US since mid-1990s. Recently, however, information in this series has become a bit overloaded and is sometimes incorrect.

Books on USMLEs by Kaplan Medical are quite popular in China. Some believe they are more concise, realistic and easy to read.

“Getting Into A Residency, A Guide for Medical Students” by Kenneth Iserson is an old-fashioned, but excellent book to start. Iserson’s book provides valuable information about selecting a medical specialty and obtaining a residency position.

“The Successful Match: 200 Rules to Succeed in the Residency Match” by Rajani Katta and Samir Desai is a new book published in 2009 and now the best-selling and most highly-rated book in this field. The information and advice provided in this book are also valuable and more up-to-date.

If you already reside in the US, visit a medical school bookstore and speak to the staff, who often can provide additional information on selecting the appropriate books.

In China, a website called Beijing USMLE Group (BUG-online.org) provides information, study guidance and aids, review courses and group discussion on USMLE. Over the past few years (since 2009?) there are some success stories but insufficient statistics to form an objective judgment. Nevertheless, it may prove to be a good starting point for those living in China.

Obtaining the ECFMG certificate after passing USMLE Step 1 and Step 2 (CK and CS) is the first step on the road to practicing medicine in the US. It is my belief that if you are a top student in a good medical school, and you have read some English medical textbooks while in medical school, you should not have too much trouble passing the exams as long as you put effort to the preparation. For example, from 2009 and 2011, approximately 72% of IMGs passed Step1, 83% passed Step 2 CK, and 76% passed Step 2 CS on the first attempt2. During the 20-year period between 1986 and 2005, more than 267,000 IMGs applied, and 57% of them ultimately achieved, ECFMG certification. As the tests evolve periodically, we will seek alumni who are in, or recently graduated from, residency for some specific tips on USMLE preparations.

Once ECFMG certified, the next step is to get into a residency program. It should be noted that over recent years only about 44% of ECFMG certified IMGs are matched into residency programs through the National Resident Matching Program (NRMP). IMGs of US citizenship (US IMGs) have a slightly higher success rate (~49%) than non-US IMGs (~41%)2,3. This correlates with their Step 2 CS passing rate, despite their lower Step1 and Step 2 CK passing rate4. Historically, the increase in residency positions has paralleled the increase of US medical graduates. Over the past 25 years, IMGs fill about an average of 40% of the residency positions, but their match rate varies from 22% in the mid-1980s, due to restrictions, to 63% in the early 1990s when the available residency positions were more than the total applicants5. Data on Chinese medical graduates’ performance in the match is currently unavailable; however, it is believed to be lower than the average 41%. These data reveals the importance of the residency application and interview for those who don’t have English as the primary language and/or have limited knowledge of American culture. Unfortunately, most students, both US and IMGs, spend considerable time on preparing for the tests but only a limited amount of time preparing for the residency application and interview. As most of IMGs are educated and grow-up in an English-speaking environment, the residency application/interview process is of the utmost importance for Chinese medical graduates, and will be discussed in detail later.

The battle is not over after being matched into a residency program, as the excitement will give way to significant stress and culture shock. Be patient and work hard, and you will grow to understand and appreciate the American system. Respect and be willing to learn from everyone, including all non-physician staff, and communicate with your attendings and fellow residents. Keep studying, as you must pass Step 3 and obtain your medical license. Make sure to stay on course, progress in your in-training exams and to prepare for the specialty Board exam as early as possible. Passing the specialty Board exam and being certified by the specialty Board is almost required nowadays to join a practice in an urban area. We will provide tips on surviving the residency later.

Before finishing residency you will also need to decide between private practice or academic medicine. We will have a discussion on this topic and explore the differences between the two.

References

1. ECFMG certification data 1986~2010 (www.ecfmg.org)
2. ECFMG Fact card summery data
3. IMG performance in the 2012 match, ECFMG news, 3/27/2012
4. ECFMG 2010 annual report
5. 2011 Main Residency Match Results and Data, NRMP (www.nrmp.org)