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Posted by TISH from IP 204.235.227.142 on January 05, 2010 at 14:56:28:

Paging Foreign Doctors: How to Get into the System and Succeed in the United States
By Med Hunters Staff

Paging Foreign Doctors: How to Get into the System and Succeed in the United States

By Suvarna Sheth
SAN FRANCISCO -- At a time when a shortage of doctors in the U.S. is expected to grow to as much as 200,000 by 2020, international medical graduates (IMGs) remain in great demand, especially since many of these physicians work in medically underserved communities and small towns.

Foreign doctors currently make up 23% of the U.S. physician workforce and 24% of residents. But, before getting into the system, foreign medical graduates face many challenges. Read on to find out what challenges some stellar foreign physicians faced and how they were overcome.

There are a number of steps to take before becoming a practicing physician in the U.S., including taking the United States Medical Licensing Examinations (USMLEs), obtaining an Educational Commission for Foreign Medical Graduates (ECFMG) certificate, going through the electronic residency application system (ERAS), acing interviews, and matching into a residency program through the National Residency Matching Program (NRMP). After all these hoops, it's time to secure a medical license and visa.

"Foreign medical grads definitely go
Z through additional challenges," says Dr. Khurram Nasir, a cardiologist who trained at Johns Hopkins University in Baltimore, Maryland. "After med school, it's takes up to two years to go through the whole process, all the exams, interviews, etc."

Nasir came to the U.S. after finishing medical school in Pakistan in 2000 and joined a MPH Biostatistics and Epidemiology program at Johns Hopkins School of Public Health. After deciding where to take his career, he pursued a cardiology fellowship at Johns Hopkins Hospital, and then a cardiac imaging fellow at Massachusetts General Hospital in Boston, Mass. He is going to Yale University in July to finish up his cardiology training.

"I have been fortunate to work at different institutions and it has been a very rich experience," Nassir says, "but of course the transition was hard because you have to acclimate to a different culture and things work differently here compared to back home."

Nassir says doing his MPH helped in his transition. "Starting out in a highly prolific academic center made it much easier especially since it was very global the school of public health has people coming from all over the world you can almost find a physician from every part of the world there," he says. He found his experience at Hopkins very positive, and found that everybody was very open and helpful to him achieving his academic goals.

According to Nassir, one of the greatest challenges for doctors coming to the U.S. is they lack the broader vision American graduates have since they are exposed to four years of college before going to medical school. In other parts of the world, particularly Asia and some European countries, students go directly from high school to medical school and then into training.

"When I see people that don't take time off and broaden their experience when they come to the U.S., they have tunnel vision because they go from med school to residency to fellowship and then to clinical attending and that's it."
For Nassir, his time spent doing research was very enriching. "I was able to explore a lot of different things and come to terms with what I wanted to do," he says, "As far as helping me develop in an academic career, this was the best thing I could have ever done."

On the other hand, doing a master's to get a foot in the door has its pluses and minuses. According to Dr. Graham McMahon, a practicing endocrinologist and assistant professor at Harvard Medical School, the older you are the more difficult it's going to be to enter a program.
"Once you're 30 or older, your competitiveness starts to wane," he says. However, McMahon says if a candidate thinks a master's is what their C.V. needs to be competitive, an advanced degree can be helpful. Still, he says, it's worth recognizing the cost of such a program can be quite high. "You have to think whether the debt-burden is worth the investment," McMahon says.

McMahon graduated from the Royal College of Surgeons in Ireland and completed a medical residency at the Brigham and Women's Hospital in Boston, Mass. He found matching into an American program a tough process and thinks the biggest challenge is proving to residency programs and admissions committees that you're just as good and trust-worthy and competent as an American graduate.

McMahon says the absence of any standardization across international schools makes it very difficult to make comparisons between what is normal practice here in the U.S. compared to what is the medical standard internationally.
Additionally, he says the challenge with the USMLE is that it measures medical knowledge and really has little applicability to how you are as a physician. "Programs continue to use USMLE step 1 which is knowledge of basic biochemistry and physiology which almost has nothing to do with how you're going to be as a physician," McMahon says. "We use a completely un-connected metric to judge comparability of an international medical graduate to enter into a residency program here."

Both Nassir and McMahon agree that another very real challenge is overcoming the obstacles to obtaining a visa, which continues to be a really enormous difficulty for many people.
There are two types of visas for IMGs: the H-1 and the J-1. For the J-1 educational visa, the home country requests the physician be trained outside of the home country. Once you're done with the training, you're obliged to go back to the home country and work there for at least 2 years. To get this requirement waived, IMGs can work at least three years in an under-served area in the U.S. After 3 years, IMGs are able to transition to an H-1 visa, after which the employer can sponsor the physician for a green card.

"A lot of people prefer starting their residencies on a H1 visa but the only way you can do that is if the sponsoring institution is agreeable to it and you have to give the USMLE 3," Nassir says.
McMahon says getting a visitor's visa for the U.S. from Syria, Pakistan, Indonesia, or any heavily Islamic nations have become extremely difficult in recent years. "There's absolutely no doubt, if you look at the ECFMG tracking data, that the number of people completing these certifications took an enormous nose dive after 9/11 almost entirely because access to the clinical skills examination became much more difficult to access in parts of the world that was traditionally competing this certification and being potentially competitive for U.S. entry," McMahon says.
Still there's ultimately an over-supply of IMGs for the positions so it's unlikely to cause a major problem that these examinations are restricted and have high costs because there's still a lot of competition for the places that are available.

With all these factors to consider, McMahon says it's important to be thinking proactively about when and IMG is going to come and start planning both the visa strategy and examination strategy so you're going to be done in time to match effectively.
Both Nassir and McMahon also suggest coming to the U.S. for an internship while in medical school under the mentorship of an American physician.
"Go to a place where someone is likely to be an advocate for you," McMahon says. He encourages medical students to do clerkships, but says it's not necessarily important to go to Harvard and Yale.
"These are highly regarded institutions and competition is frankly tight," McMahon says. He says there are many places around the country that offer free clinic clerkships, that sometimes even support your accommodation while you are at these places and are more appropriate tied to programs that student might be more competitive for.
Nassir advises foreign grads coming in to the U.S. to do elective work, rotations, and research work. He says by the time you are ready for your application, you can get some good application letters from individuals within the system.
Yet another problem IMGs face is cultural issues and sensitivities. What is considered the norm in the U.S. may be regarded differently in the physician's home country.

Nassir says most of countries IMGs are coming from don't have computer based electronic medical records. This may be another adjustment in comparison to American graduates who have trained within the same system.
He says the transition would be much smoother if additional training was provided on some of the cultural sensitivities, the HIPPA laws, the computer systems and some of the litigation issues.

Even if an IMG shares the English language with a patient, it doesn't mean you share the same values. Many patients here may have different values compared to Europe and Asia with regards to experiences in death and dying or attitudes to transplants, taking medication, or genetic diseases.
Institutions and directors care passionately about the patients that come to them for help and go on to recruit the very best people that not only will contribute to the program but by interpersonal skills and by practicing proficiently. Therefore, McMahon says there's a whole series of reasons why it's appropriate to be concerned about the match of an IMG into a particular program but there's also great reason to be open minded and optimistic about the potential of an ING to fit in and do extremely well.

Overall, the job market for foreign physicians once they have passed through the residency and training process is very open and there is zero unemployment amongst physicians.
McMahon says as long as you're geographically flexible about where you're going to be in the country and that you have a visa that allows you to work after residency, chances of you being unemployed are essentially zero.

"A lot of people think getting into a super-specialty or doing something very competitive is next to impossible for a foreign grad," Nassir says, "My only advice is nothing is impossible here. The only thing you need is to put in some extra effort and be different in what you want to do, because once you're in the system everything will work out the best for you."


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