Postgraduate Medical Placement Procedures in the U.S.

Postgraduate Medical Training in the U.S.

Postgraduate medical training (“med school”) prepares potential physicians for independent practice in a medical specialty and typically takes four years to complete. Med school is split into preclinical and clinical. Preclinical generally comprises the first two years and consists of classroom and laboratory instruction in core subjects such as anatomy, biochemistry, physiology, pharmacology, histology, embryology, microbiology, pathology, pathophysiology, and neurosciences. The clinical component usually occupies the final two years of medical school and takes place almost exclusively on the wards of a teaching hospital or, occasionally, with community-based physicians. The students observe and take part in the care of patients under the supervision of resident and attending physicians.

Throughout the third and fourth years students typically rotate through a combination of required clerkships/rotations and electives. Clerkships give students experiences in all parts of the hospital setting, including the operating room, emergency department, and various other departments that allow learning by viewing and doing. Most medical schools require rotations in internal medicine, surgery, paediatrics, psychiatry, obstetrics and gynaecology, family medicine, and neurology. Some schools additionally require emergency medicine and intensive-care medicine. Furthermore, a graduation requirement is to complete a sub-internship in a specialty, where the medical student acts as an intern. Internships come in two variations, transitional and specialty track. After a physician has completed an internship and Step 3 of the United States Medical Licensing Examination (USMLE), he or she can practice general medicine.

In order to qualify for residency or fellowship training, students are required to meet certain academic qualifications recognized by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME promotes the highest possible standard of medical specialists in the United States by setting high standards for postgraduate medical training and education based upon the knowledge, skills and attitudes necessary for specialist physicians and surgeons. Requirements are outlined below.

ECFMG

All students seeking to study medicine in the United States that are not from the U.S. must apply and get certified through the Educational Commission for Foreign Medical Graduates Certification (ECFMG). The purpose of ECFMG Certification is to assess whether international medical graduates are ready to enter U.S. residency and fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).

ECFMG Certification assures directors of ACGME-accredited residency and fellowship programs as well as the people of the United States that international medical graduates have met minimum standards of eligibility to enter such programs.  ECFMG Certification does not, however, guarantee that these graduates will be accepted into programs, since the number of applicants typically exceeds the number of available positions.

All international students must be certified by ECFMG before entering an ACGME-accredited residency or fellowship program in the United States. International students must also be certified by ECFMG if they wish to take Step 3 of the three-step USMLE.  ECFMG Certification is also required to obtain an unrestricted license to practice medicine.

USMLE

The USMLE assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centred skills, that are important in health and disease and that constitute the basis of safe and effective patient care. Each of the three Steps of the USMLE complements the others; no Step can stand alone in the assessment of readiness for medical licensure.

The ECFMG Certification process

The examination requirements for ECFMG Certification include passing Step 1 and Step 2 (CK & CS) of the USMLE. The Step 2 exam has two separately administered components, the Clinical Knowledge (CK) component and the Clinical Skills (CS) component. The ECFMG certification is process is outlined as follows:

1. Satisfy the medical science examination requirement: Step 1 and Step 2 CK of the USMLE are the exams currently administered that satisfy this requirement. To meet the medical science examination requirement for ECFMG Certification, applicants must pass both Step 1 and Step 2 CK;

2. Satisfy the clinical skills requirement: Step 2 CS of the USMLE is the exam currently administered that satisfies this requirement.

Medical Certification Process

• Pass the USMLE Step 1 (Basic Sciences)

• Pass the USMLE Step 2 CK (Clinical Knowledge) exam

• Pass the USMLE Step 2 CS (Clinical Skills) exam

• Pass the USMLE Step 3 exam

USMLE Step 1 (Basic Sciences):

Step 1 assesses whether students understand and can apply important concepts of the basic sciences to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning. This exam can be done at any time as it is computerized.

USMLE Step 2 CK (Clinical Knowledge) exam:

The USMLE Step 2 CK exam assesses whether you can apply the medical knowledge and understanding of clinical science considered essential for the provision of patient care under supervision including emphasis on health promotion and disease prevention. This exam can be done at any time as it is computerized.

USMLE Step 2 CS (Clinical Skills) exam:

Step 2 CS consists of a series of live patient encounters in which the examinees must see a simulated patient, take a history, do a physical examination, determine differential diagnoses, and then write a patient note based on their determinations.  Since the exam is done with actual patients, space is limited and the exam must be scheduled far in advance.

USMLE Step 3 exam:

Step 3 is the final exam in the USMLE series of examinations.  It is part of the licensing requirements for M.D.s, D.O.s, and FMGs to practice medicine in the United States. It is considered the final step in the series of medical licensure examinations. Step 3 is usually a prerequisite for most state medical licensing boards.

Step 3 assesses whether students can apply the medical knowledge and understanding of biomedical and clinical sciences considered essential for the unsupervised practice of medicine.  Emphasis is placed on patient management and ambulatory settings.  The Step 3 exam is a 2 day exam.  International Medical Graduates can take the Step 3 exam before they start their residency or during the 1st year of residency.

Participating in the Match

International Medical Graduates (IMG) are required to apply to the Match through ECFMG using the ERAS application.  Once a doctor has passed Step 1, Step 2 CK and Step 2 CS ECFMG will certify the doctor and allow them to participate in the Match. 

In September of every year the application process begins.  Doctors set up their application through ERAS and apply to programs of interest.  Residency programs will review the personal statements, scores and applications.  If a residency program is interested they will contact a student to set up an interview.  Interviews will happen between November and February.

Residency programs look for more than high scores.  The ideal candidate will also have a good personal statement, US experience (observership, volunteer work, clerkship), US doctor references and a C.V.  When doing an interview, the Chief Residency will look to find a 1st year residence that is a good fit with the personalities of the current residence.

Most interviews will consist of a dinner, interviews with the multiple people in the hospital as well as a tour.  It is very important that a doctor who is interviewing be as outgoing as they can during the interview.

In March potential residence rank the hospitals they are interested in starting with the one they are most interested in.  Residency programs rank potential residence according to the residence they are most interested in.  All the information is calculated in the computer and doctors are matched to Residency Programs.

On the 3rd Monday in March, doctors find out if they have matched to a program.  On Tuesday the filled and unfilled positions are posted.  Unmatched applicants are allowed to start contacting Residency Programs they are interested in, this is called “The Scramble”.  Match day is the 3rd Thursday of March.  Doctors find out what programs they have matched to.  Residency programs send out contracts to all the doctors who matched.  Once doctors have signed and returned the contracts the residency programs will start the process for a change of status to a work visa. 

Postgraduate Medical Training in the U.S. — Timeline of Requirements