O S E A S * E U R O P E

Update on ECFMG and US Medical Study

Minutes recorded by:

Chair: George C. Dariotis, Educational Adviser, US Educational Foundation in Greece, Athens Greece

Remarks by Dr. Marie Schafron, Vice President for Operations, ECFMG

Medical Education in the US:



Graduate Medical Education


First-year residents:


USMLE - 1994 statistics
52,000 examinations administered to 35,000 examinees
50,000 credentials were evaluated by ECFMG
- 9% were from Western Europe
- Over 8000 certificates were issued.
- Of these, 54% to addresses in the US
- Germany had 7% of certificates issued world-wide

(ECFMG may be able to verify credentials when direct verification from medical school is not possible due to political upheaval, emigration restrictions, etc.)
Of 127 countries:


This difference in practical medical training of medical graduates led the US medical community to require additional evaluation of clinical skills to determine the clinical behavior of foreign medical graduates. For this reason the Clinical Skills Assess ment will be introduced sometime after mid-1996.

At the same time, the minimum educational credential requirement will become graduation from a recognized medical school, and not licensure (or equivalent) in country where physician received medical education.

Clinical Skills Assessment

1) Taking a medical history (how focused is the examinee?)
2) Physical examination
3) Diagnosis and patient management (Trained patient will answer checklist questions about the examination).
4) Assessment of Spoken English

Steps to Graduate Medical Education (GME):
1) Obtain information, talk to program directors
2) Send ECFMG Letter of Eligibility
3) Register for National Resident Matching Program

ECFMG Sponsorship
- Graduate Medical Program must be in a clinic affiliated with an accredited medical school
- Visa for a maximum of seven years or duration of program, whichever is shorter
- One transfer is allowed within first two years.

Requirements:
- Approved prior medical education
- Approved medical science examination (ECFMG-USMLE)
- English Test
- Signed contract for GME
- Home country statement of need
- Proof of adequate health, accident, repatriation of remains, and medical evacuation insurance
- Statement of good standing

Average stay is 5-7 years. At present there are 12,000 participants.

For an H-1b visa - physician must demonstrate satisfaction of all requirements for licensure in the state where the FMG will be working.

Remarks by Dr. Demetrios Linos, Surgeon, Hygeia Hospital, Athens, Greece:

Criteria for residency position:
- recognize that your status as foreign medical graduate is a stigma - you must offer more than only a medical education:
= Publications
= Additional training
= Previous development of skills through famulatur, PJ in USA
- Use US-textbooks to supplement medical education
- establish personal contact to program directors
- demonstrate motivation through practicums.
- Keep eye on un-matched positions (information available from NRMP)
- Visit likely programs in fall one year prior to start of residency
- Be aware of stigmatization
- Be realistic in developing your ranking list
- Do research in US medical schools (for instance, for doctorate)
= make use of facilities, opportunities while in US
= have US address on your publications
- Be willing to start in non-illustrious institution, then transfer.

Text of Remarks by Corrie Schweigler, Educational Adviser, International Office, University of Munich, Munich, Germany

In the interest of developing a dialogue, I am making these comments from the standpoint of an adviser, not as someone who has found all the answers, and keeping in mind that the ECFMG is the Educational Commission FOR Foreign Medical Graduates.

Our work as advisers is devoted to informing students of opportunities to study or train in the United States and to encourage them, when appropriate, to do so.

Increasingly in the field of medical exchanges, I have the feeling that a heavy door is slowly closing.

At a time when training in all fields is becoming internationalized, when the sharing of scientific advancements has become imperative, and when communication and understanding are more necessary that ever, the United States medical profession seems to be shutting itself off from student and young professional exchanges.

Certainly the United States has the right and obligation to provide its population with the most qualified medical care possible, to train only that number of physicians necessary for the care of its population, and to assure that these physicians are abl e to find positions when they have completed their training.

At the present time, there are strong indications that the number of graduate medical students (residents) in certain programs is greater than the society's need for specialists in these areas.

Both of these factors, the need to assure quality and the need to strike a correct balance, make it understandable that access to graduate medical education leading to permanent positions must be restricted to those numbers which the system can support an d to the most qualified participants.

But the United States should not lose sight of the fact that the graduate medical programs can be enriched by the presence of foreign medical graduates. They enter the system with a different educational and cultural background, and they approach their ed ucation from a different perspective. American students and programs will profit, both professionally and personally, from this interaction.

Also, foreign medical graduates can profit immensely from their training in the American system, returning home with expanded scientific knowledge and new ideas for the improvement of their own medical systems.

As academic advisers and distributors of USMLE Information Booklets, we almost naturally become on-sight advisers for the ECFMG testing program and its policies and for the application process to graduate medical programs.

In this function we are experiencing increasing frustration on the part of our highly-motivated, and often very gifted students wanting to spend a period of advanced training in the United States.

This began with the introduction of the United States Medical Licensing Examination (USMLE) two years ago.

The USMLE brought clarity and consistency to the maze of medical examinations which had developed previously. But it is often perceived as the effective annulment of all previous, and hard-earned, qualifications obtained by passing the FMGEMS for licensin g purposes.

Although we advisers can try to explain that the FMGEMS was never a licensing examination, the perception remains among examinees that they have been deceived.

Furthermore, the introduction of the USMLE is a good example of how a lack of timely information, a lack of clearly understandable explanations of program goals and a lack of empathy for the needs and concerns of foreign medical graduates has led to the g rowing feeling that they are unwanted and that American authorities are seeking to erect barriers to discourage them from applying to American medical programs.

Also, with the introduction of the USMLE, former FMGEMS test centers were consolidated. Examinees must now travel long distances and stay overnight, which significantly increases the effort and cost of taking the examination. This problem is compounded by the fact that Steps 1 and 2 are not held on consecutive days.

Participating in fourth-year clinical electives programs is one of the few opportunities for foreign medical students to experience US medical school education. However, an increasing number of medical schools are requiring the ECFMG English Test, and not the TOEFL, as a prerequisite for admission to their fourth-year practical medical training.

The cost and time spent traveling to distant examination centers to take the ECFMG English Test stands in no relationship to the cost and length of the test itself and often imposes an insurmountable burden, also due to time restrictions (the ECFMG Englis h test is offered only twice a year), on foreign students applying to fourth-year programs.

Another source of frustration is the inaccessibility of ECFMG to answer examinee questions.

We advisers have been generally well-served when we have posed direct questions to ECFMG. The organization has been helpful and responsive to our individual questions.

But we are not in a position, nor de we have the expertise, to answer many detailed questions on test registration, score reporting or ECFMG certification.

The constantly busy phonelines at ECFMG and the endless transferring or placing on hold of examinees calling from overseas have caused a number of angry comments in my office, where the applicants vent their frustration.

And finally, of course, the planned introduction of the Clinical Skills Assessment (CSA) will further frustrate, if not indeed hamper access to graduate medical programs, particularly if it is offered only in the US or in an even more restricted number of overseas centers. The cost of registering for this additional examination combined with the cost of traveling to the examination center will make the cost of the ECFMG certification process prohibitive for many young foreign medical graduates.

The CSA will impose yet another element in the testing process and will be perceived by many as yet another barrier to keep foreign medical graduates out of American programs.

If the United States medical profession, as reflected in the policies of ECFMG, is going to continue to be interested in enrolling foreign medical graduates in US residency programs, and I, personally, would very much hope that this is the case, then I wo uld like to submit a few suggestions for consideration:

First, advisers who distribute ECFMG information brochures - and other interested advisers, should receive regular and complete information on programs and policies, including those in planning.

This information should go well-beyond a short newsletter. It should also contain current statistics, broken down on a country-by-country basis, of examination results. The blanket reporting of international results is of little use to advisers in evaluat ing the difficulty and problem areas of the USMLE for takers in their own country or region.

Second, if possible, ECFMG should establish an information hotline, easily accessible via telephone, fax and/or e-mail. It might also consider, if it has not already done so, setting up a WWW or Gopher site with complete and up-to-date information on its programs.

Third, ECFMG should consider publishing information and statistics of interest to foreign medical graduates applying for residency programs. Although the information provided by the National Resident Matching Program and in the Green Book (Directory of Gr aduate Medical Education Programs) is very good, it would be most helpful to have available in one publication information of particular interest to foreign medical gradutes.

This might include: Information on the contents of Step 3 of the USMLE, country-by-country USMLE statistics, information on foreign medical graduate accessibility to specific residency programs, projections of future need, information on state policies fo r licensure of foreign medical graduates.(The information available in the Federation of State Medical Board's publication "Exchange" is very helpful, but I have found it difficult to obtain this publication overseas).

Fourth, ECFMG should also consider re-opening test centers in an increased number major metropolitan areas overseas.

And finally, ECFMG should very seriously reconsider whether the Clinical Skills Assessment should be a prerequisite for ECFMG-certification for initial entry to a graduate medical education program, or if it could be delayed until after one or more years of US graduate medical education.

Again, I offer these comments and suggestions because I remain strongly convinced of the mutual benefit to be gained from international exchanges at all levels of the medical community.

All of us will profit from a vital and large exchange, not only All of us will profit from a vital and large exchange, not only of established medical scholars and experts, but also of young physicians destined to become leaders in their own countries. Th e door through which these professionals pass must remain open.

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