Family practitioner in the United StatesBMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7119.2 (Published 22 November 1997) Cite this as: BMJ 1997;315:S2-7119
If the thought of working in the United States brings to mind Marcus Welby MD, ER, or Chicago Hope think again: the daily reality for this nation's 650 000 doctors is somewhat different.
Former president Calvin Coolidge said that “the business of America is business,” and medicine in the United States is a business, on which 15% of the gross domestic product of the world's largest economy is spent. Many American doctors disagree with this philosophy, but no change is foreseen after the Clinton plan to introduce national health care was thrown out by Congress in 1993. For British doctors willing to make the cultural adjustment, opportunities are good: market driven reform of health care is increasing the role of primary care and reducing costs. Making the move is fraught with bureaucratic obstacles but the golden door is still narrowly ajar.
What is a family practice?
In the United States a family practitioner is defined as a medical doctor who has graduated from a three year residency programme. The family practitioner is a generalist who treats patients of all ages in the office and hospital, but is expected to refer complex cases to specialists. A general practitioner is a doctor who has not graduated from a residency programme. Few such doctors remain in practice, mainly in remote areas, since group practices and employers recruiting new doctors will insist on a residency graduate.
Family practitioners are only one group of doctors who may call themselves primary care providers (PCP) and receive payment from insurance companies. Internists, paediatricians, obstetrician/gynaecologists, and even doctors of osteopathy may also be a patient's PCP.
Training for family practice
Medicine is taught as a postgraduate course, so entrants to medical school must already have completed a college degree, which takes three to four years after graduating from high school at age 17-18.
Applicants to medical schools must have taken premedical basic science courses at their college to be eligible. Admission criteria include the candidate's grade point average from college, medical college admissions test score, curriculum vitae, and interview. Entry to medical school is highly competitive, and medicine is seen as a financially attractive and prestigious career. The medical course of four years begins with clinically relevant basic sciences, but the second to fourth years are clinically based instruction. Most attachments are hospital based, but some rotations are in private physician's offices and community clinics. In addition to the medical school's own assessment examinations, there are two national exams the student must pass: the US medical licensing exam (USMLE) part 1, which consists of basic science, and part 2, which is more clinically orientated.
Advantages and disadvantages
Variety of work and settings, including inpatient, with continuity of care
No delays in tests, referrals, and admissions. No NHS
Higher income and standard of living than in Britain
Litigation risk low for family practice
Difficulty in obtaining licensing and visa
Residency - long hours, poor pay
Cultural adjustment required - medicine is a business
Training for medicine is expensive - a college can cost $8000-$20 000 (£5000-£12 500) a year for tuition alone, and medical school $15 000-$30 000 a year. Grants and scholarships are available, but many students will graduate from medical school with an educational debt of $100 000-$200 000. Most students receive some assistance from parents and work part time to help defer living expenses.
Unlike in Britain, medical students have to select a specialty before graduation by applying for a residency programme. A residency is a training programme with a defined end point. To British juniors this seemed attractive in the pre- Calman days, but now American residents would be grateful for the Britain's “new deal” terms and conditions. In most states there is no limit on hours worked, and no pay for overtime. Annual resident salaries range from $28 000 to $42 000 depending on the cost of living in the area.
Family practice residencies consist of a three year rotational training programme, usually starting and ending in July. They are offered by universities, hospitals, and private healthcare companies. All must be accredited by the American Council for Graduate Medical Education (ACGME) and approved by the National Residency Review Committee.
Individual programmes vary, but most include hospital and community based rotations in medical and surgical specialties, emergency room, community medicine, rural medicine, obstetrics and gynaecology, electives, and family practice. There is no division between hospital medicine and the family practice el- ement, which is usually at the institution's own clinics. During the residency the USMLE part 3 is taken. It consists of clinical scenarios. Once passed the clinician is then eligible for a state license. On completing a residency, a family practitioner can apply for a variety of employment options. Some will require board certification by the American Board of Family Practice (ABFP). This requires passing a two day written examination taken at the end of the residency.
The medical marketplace is a confusing mass of acronyms, but there are four forms of employment that a newly graduated family practitioner could seek.
(1) Solo or group practice - The most common option. You can set up an office anywhere, but this would be financially difficult for a graduate who is likely to be carrying a large amount of educational debt. Existing practices that are recruiting replacement or additional partners typically offer partnership after one to three years, with the first year spent as an associate with a guaranteed minimum income, currently between $100 000 and $140 000. With the high demand for family practitioners, a signing bonus of $15 000-$25 000, loan repayments, and a productivity bonus are possible. As a partner, the doctor receives a percentage of billings generated, the remaining percentage covers practice expenses.
(2) Academic practice - Some family practice graduates undertake a fellowship for one to two years to obtain certificates of added qualifications in geriatrics, sports medicine, or public health. These can also lead to faculty positions at medical schools, combined with clinical practice. Salary is typically $100 000-$120 000, and a productivity bonus may be offered. These posts attract those interested in teaching, and offer relative job security without the administrative burden of running a practice.
(3) Staff model health maintenance organisation (HMO) - A salaried job with an integrated healthcare system. Salaries again are around $120 000, and a prod- uctivity bonus, signing bonus, and loan repayments may be available. (4) Government - Various government agencies employ family practitioners. Salaries are $80 000-$120 000, but these jobs are decreasing as government withdraws in favour of contracts.
According to a survey by the American Academy of Family Practice (see table), the average family practitioner sees 20 patients a day in the office, one to two patients in hospital, and one at home or in a nursing home. The usual appointment is 15 minutes, though some patients will have longer for screening physical examinations, procedures, or the management of complex multiple pathology. Tests and referrals can be ordered from the office, and there is usually no waiting period for either. Home visits are unusual - patients needing home health care, including hospice services, are visited by nurse practitioners, nurses, and physician assistants who are supervised by a medical doctor - but doctors do visit nursing home patients on a programmed basis.
At the end of each visit or procedure, a billing form is completed detailing the diagnosis and level of service. The billing level depends on the number of problems dealt with as well as their complexity and the time spent with the patient. Bills are submitted to the patient's insurer for reimbursement. Correct coding is important, since insurance companies will automatically reject combinations of diagnoses and levels of service that seem inappropriate; disputing it takes time and is costly. Some referrals and procedures require advance permission from the insurer.
Good note keeping is essential clinically, to justify insurance claims and for defence in the case of litigation. Family practice has low litigation rates and malpractice insurance costs. The two most common reasons for suits against family practitioners are failing to follow up abnormal test results and failing to diagnose cancer in a timely way.
On call rotas depend on the number of doctors participating within or across practices. Out of hours telephone calls are fielded by message services or a triage service staffed by nurses and then passed to a doctor. Doctors have the choice of seeing the patient themselves at the office, urgent care clinic, or emergency room or asking the duty emergency room physician to assess the patient.
Hospital based meetings for continuing medical education serve as a focal point for an area's family practitioners to meet and exchange views. Medical student and resident teaching is possible if the practice is within reach of a teaching centre. Since the rejection of the Clinton national healthcare plan, pressure from industry to reduce insurance costs has led to “managed care”. Traditional fees for service insurance paid 100% of bills from any doctor the patient had consulted.
To reduce these costs, health maintenance organisations (HMOs) were formed to offer comprehensive health care for an annual premium, with limitations on coverage, copayment by patients to see a doctor ($10 per visit), no visits to specialists without a primary care physician's referral, no expensive surgery or procedures without prior authorisation, and a “deductible” (an excess to be paid by the patient before insurance will cover expenses). Prescriptions must be filled by generic drugs if available: patients pay $5-$10 per item, with the insurer meeting the rest if prescription coverage is included. To further cut costs at the expense of physicians, health maintenance organisations also formed preferred provider organisations, a list of doctors willing to accept their patients at a discount - that is, 60% of the bill would be met in return for being on the insurer's list that patients had to use. Naturally, health maintenance organisations' policies were not popular with physicians, who felt a loss of clinical autonomy. The percentage of patients covered by managed care varies from 30% to 70% depending on location.
Once considered a threat, managed care is now seen by many as a means of practising population based medicine under a capitation system using multidisciplinary teams: NHS general practitioners have many years experience of this. The changes mean more generalists and less specialists are required. The current shortfall of generalists will continue until the year 2005. Opportunities have never been better.
Acronym guide to US healthcare
AMA American Medical Association (http://www.ama-assn.org/) Similar to BMA, represents American doctors interests, lobbys congress, provides continuing medical education and physician credentialling services.
AAFP American Academy of Family Practice (http://www.aafp.org/)
Represents family practitioners nationally, membership requires 50 hours continuing medical education credits per year.
ACGME American Council for Graduate Medical Education Approves post graduate training programs.
ABFP American Board of Family Practice (http://www.abfp.org/) Issues board certification based on examination, similar to MRCGP.
HMO Health Maintenance Organisation
A for profit corporation, or a not for profit organisation providing healthcare benefits for an insured population. Typically a HMO requires referrals from a Primary Care Provider for access to specialists. Usually the cheapest form of insurance.
PPO Preferred Provider Organisation
A health insurance plan requiring doctors consulted to be drawn from a list which the insurer has contracts with. No referral is needed to see a specialist.
FFS Fee For Service.
Health insurance where any doctor may be consulted. This traditional form of American health insurance is now very expensive and few patients can afford it.
PCP Primary Care Provider
The patient's personal doctor through choice, or through a HMO plan requiring a named coordinator of all care. A PCP may be a family practitioner, internist, paediatrician, ob/gyn or a doctor of osteopathy.
IPA Independent Physician Association
A grouping of practices negotiating contracts with insurers collectively to ensure better terms. An IPA may also try to reduce administration and purchasing costs by buying collectively.
MSO Medical Service Organisation
A corporation or not for profit group which provides all services a physician needs to run an office, in return for fixed fees or a percentage of the billings. This relieves the doctors of the need to spend time administering the office.
MCO Managed Care Organisatio
A HMO or IPA conracting to provide managed care services for an insurer or the government.
The Federal health insurance program for those aged over 65 who have made sufficient social security tax contributions during their working life. The program is highly complex and continually reformed. Recent changes have been good for family practice with the inclusion of preventive services and higher reimbursement for primary care. Specialist fees have been reduced. The program needs major reform to avoid bankruptcy between 2009 and 2012 as the baby boom generation ages and becomes eligible.
The State run medical assistance program for the poor. Because reimbursements for Medicaid patients are so low, eligible claimants have difficulty finding a doctor to accept them.
Recently States have begun enrolling Medicaid patients in managed care schemes but as the capitation rates for often demanding patients are so low, again claimants have difficulty obtaining care. Most doctors see some uninsured and Medicaid patients for free as a public good and some areas have formalised this arrangement so that this work is evenly spread.
How to work in the USA as a family practitioner
This section assumes that your primary medical qualification is from Britain, but there is little difference for graduates from other countries, other than needing all documents translated. British, Canadian, New Zealand and Australian graduates who are already members of the RCGP do have an advantage in obtaining US Board Certification though. The first section is common to all would be US doctors, subsequent sections depend on whether you intend to visit the USA to work and return, or wish to stay permanently. Before even embarking on this process think long and hard about whether this is really for you. The obstacles and pitfalls are many, rules are constantly changing, the process can be prolonged and expensive. Luckily the internet has speeded communications and allows you to check information instantly avoiding postal delays. At each stage be prepared to justify your credentials yet again, provide more photographs and pay more fees.
(1) Register with the Educational Commission for Foreign Medical Graduates (ECFMG). http://www.ecfmg.org/
Obtain forms online or write to ECFMG at,
3624 Market St
They will check your primary medical qualifications and determine eligibility to take the United States Medical Licensing Examinations (USMLE). http://www.usmle.org/
(2) Enter for Steps 1, 2, English Test and after June 1998, Clinical Skills Assessment. Medical students may also take the examinations at various stages of training, refer to the ECFMG booklet for exact details.
The written exams may be taken in London, Liverpool or Dublin, along with other centres around the world. Each written exam consists of four multiple choice exams, of three hours length. Single answer and extended matching formats are used, as are tables and photographs. Step 1 consists of basic science questions, Step 2 is more clinically orientated. Bear in mind that this is the same exam taken by American students and that some knowledge of American terminology, eg how old is a 7th grader ? and the meaning of medical terms not commonly used in the UK, eg diaphoretic, is useful. You must think what an American doctor would do, not what would be done in the UK in a given situation, ie a MRI scan as a first investigation is allowable.
The English exam consists of multiple choice listening comprehension answers, vocabulary, syntax. This should not be a problem for any doctor practicing in Britain.
The new Clinical Skills Assessment comes into effect from June 1998 and requires a visit to Philadelphia for a day long assessment, using standardised patients and other tests of clinical skill. Refer to the ECFMG website to check for further information about this new test as it becomes available.
ECFMG Registration No charge..
Step 1 USMLE $495.
Step 2 USMLE $495.
English Test $40.
Clinical Skills Test $1200.
The overall pass rate for foreign graduates taking both USMLE 1 and 2 is about 35% - do not be disheartened, I suspect that the figure is higher for British graduates who have the advantage of being trained in the same language and within a culturally similar system.
(3) Once you have passed the four ECFMG required examinations, and received an ECFMG Certificate you can now apply for jobs in the United States. The ECFMG certificate is dated and if you do not take up a post within two years you must retake the English test. However since you don't have a State license in reality the only jobs you can apply for are Residency or a Fellowship. To obtain a State license you need to take the USMLE Part 3 examination and in most states you cannot take that unless you have undertaken at least 6 months of a residency or fellowship.
If you are already the graduate of a British vocational training scheme then consider a fellowship, since one year in an ACGME accredited fellowship will allow licensing in most states, and you do not have to spend three years as a junior doctor again.
(4) Find a suitable residency or fellowship position. In family practice the place to start is the AAFP guidebook to residency programs.
Obtain this from the AAFP at http://www.aafp.org/, or
American Academy of Family Practice
8880 Ward Parkway
Some residency programs also have websites and are linked to the AAFP online residency directory. For fellowships it is best to contact the university or medical school directly and ask about what primary care orientated fellowships may be available. Many residency programs (but not fellowships) also require you to enter through the “match”. You can enter the National Residency Matching Program via www.aamc.org/nmrp or write to,
National Residency Matching Program
2501 M St Suite 1
Bear in mind that you will be competing with US graduates, so good USMLE scores are helpful, and consider visits to programs you are interested in. You will probably have to attend for interview. Electronic applications can be made via the Electronic Residency Application Service, see the ECFMG website http://www.ecfmg.org/ for details, but this is not a matching program.
(5) Obtain a visa to live and work in the USA. At this point decide whether you wish to visit the USA and return to the UK, or if you are interested in staying in the USA permanently. If you only intend to visit the USA and work as a resident or fellow and return then it is comparatively easy to obtain a J-1 or H-1 exchange / research visa, sponsored by the employing program.
Warning - avoid the visa trap
If you intend to stay in the USA try to obtain a permanent resident (green card) visa if at all possible before going.
When you enter the USA on a J-1 or H-1 visa it is extremely difficult to have this converted to a green card, you may be required to return home at the end of your training, and jobs open to you on graduation will be limited to health care shortage areas where J-1 “waivers” are issued. Naturally these jobs are in areas where most American graduates do not want to work, the income is very low and you probably would not want to work there either. When you have a J-1 visa and an employer wants you badly enough they may be willing to engage an immigration attorney to help you and try to obtain “labor certification” from the immigration authorities that you are essential and an American could not be recruited. If entitled to a US citizenship or a green card the process is much simpler. You can take a job in the USA without further formality. If you think you may be eligible for a green card through a parent or relative who is a US citizen or resident, pursue this as soon as you can. Eligibility through parent's permanent residence expires at age 21. British citizens are not eligible for the annual green card lottery, but Irish citizens are. However the chance of obtaining one this way is very low so do not rely on it.
Rules are complex and continually changing so check with the Immigration and Naturalization Service at http://www.ins.usdoj.gov/ or write to,
5 Upper Grosvenor Street
London W1A 2JB
(6) Board a plane and head west - congratulations if you have made it this far. =3D
(7) During your first year of residency or fellowship, apply to your local State Medical Board to take USMLE Part 3. Each state has its own entry requirements ranging from no post graduate medical education to three years. If the State you are in is too restrictive to allow you to enter during your first year, find another State in the vicinity which will. The USMLE qualification is national and it does not matter where you take it. The Federation of State Medical Boards (FSMB) www.fsmb.org can supply a list of all state medical boards who will then send you details of USMLE Part 3 entry requirements.
The USMLE Part 3 costs between $400 and $500 to take, depending on the individual state. It consists like Parts 1 and 2 of four multiple choice papers, of three hours duration, with clinical scenarios. The pass rate is high by this stage.
(8) Decide where you wish to work and find out the licensing requirements in the particular state for foreign medical graduates. Use the FSMB list of state medical boards and write to each state you are interested in. There is no point setting your heart on working in a particular state if you cannot obtain a license there. A few states have a three years postgraduate training in the USA requirement, residency within the state requirements, which can effectively bar you from licensure.
Hawaii, Nevada, Arizona are restrictive, and obtaining a license can take many months. The costs varies, eg a Maryland license costs $550, a California license is $1208.
(9) Search for a job - you can do this whilst applying for a state license, if you know where you want to work. Jobs for family practitioners are plentiful, with regional variations. Currently jobs can be found over the entire United States and are only tight in some major east coast cities. Be aware that the cost of living varies more than earnings, so a job in a lower cost or semi rural area could be more attractive overall.
Advertisements can be found in a variety of journals, and online, two sites to look at are http://www.physemp.com/ and http://www.therecruiter.com/ (10) Now that you have a State license you are eligible to apply for the American Board of Family Practice examination if you have passed the MRCGP examination. Board Certification is not essential but may help with getting a better choice of jobs, hospital admitting privileges and being accepted onto insurers lists of recommended doctors.
(11) You've made it - welcome to the American doctor's dream.