Career Focus

Specialty training in the United States

BMJ 1998; 317 doi: (Published 25 July 1998) Cite this as: BMJ 1998;317:S2-7153

The BTA diploma (“Been to America”) was the traditional add-on during the long gestation of the registrar and senior registrar years but Calman had changed all that. Glenn Matfin discusses the issues

  1. Glenn Matfin, senior visiting associate
  1. National Institutes of Health, NIDDK, Phoenix AZ 85014, USA

    For five centuries, travellers have been bringing their hopes and dreams to America. Every visitor to the United States has some idea of what to expect through the medium of films and television but junior doctors considering spending substantial time in the United States should first visit the country - and preferably the city or region where they would work. Junior doctors will not receive reimbursement for interviews in the United States.

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    Healthcare delivery

    Americans have the best healthcare system in the world - true or false? From a patient's perspective, it depends on where you live, what your income is, and, more importantly, whether you have health insurance. Most people have private healthcare insurance: a third party agency will pay their medical bill for consultations and other expenses. However, patients may have to meet some of the expenses incurred themselfves.

    The boom in health maintenance organisations (HMOs) over the past few years has revolutionised health delivery. The old days of “fee-for-service,” are virtually extinct. Consequently, many physicians' salaries, independence, self esteem, and job satisfaction have declined.

    Other healthcare delivery systems include the Veterans Administration (delivers care to former servicemen and women), public clinics and hospitals that care for those with no healthcare insurance, and university affiliated institutions. Most teaching programmes will include exposure to most of these diverse settings.

    Who should consider it?

    Family (general) practice is not as advanced in the USA as in Britain, and it may be advisable to set your sights elsewhere for overseas training. However, the need for qualified family practitioners is substantial.

    If you wish to do research, either basic or clinical, than a spell in the States can be useful, especially if you wish to be at the cutting edge of your specialty. Research in the United States still commands massive funding compared with many countries.

    If you are a specialist registrar you can have the opportunity of working with an internationally renowned leader in your chosen field. Apart from the kudos, you may gain skills (particularly in high tech procedures) that you can subsequently help to introduce to your training region.

    Medical training

    American and British undergraduate and postgraduate medical training are dissimilar. American undergraduate training typically begins at the age of 18, when a student takes a Bachelor's degree in either an arts or scientific subject (the “Pre-Med”). The graduate then enters medical school for a further four years (typically two years preclinical and two years clinical). During medical school, students sit various preclinical and clinical exams similar to those in the United Kingdom. However, all students in all schools sit the same “Final” exams. These are in two parts, preclinical (USMLE 1) and clinical (USMLE 2). The exams are all based on multiple choice questions, and each exam takes two days to complete. There is no negative marking.

    If you wish to apply for a clinical position in the United States, you must have passed both USMLE 1 and 2. In addition, you must pass an English (or, rather, American) test. The USMLE 1 and 2 and English test are presently offered twice a year only (and require lengthy verification of credentials, so plan well in advance). You can sit the exams in London and Liverpool. The price of USMLE 1 and 2 is $495 each, and the English test costs $40. For purposes of certification by the Educational Commission for Foreign Medical Students (ECFMG), there is no limit to the number of times that USMLE 1 and 2 may be taken until the exams have been passed. From 1999, the USMLE exams will be administered by computer throughout the year.

    Unfortunately, from 1 July 1998, the Clinical Skills Assessment (CSA), including an assessment of spoken English proficiency, will be administered throughout the year at the ECFMG Clinical Skills Assessment Center in Philadelphia and is mandatory for “Foreign (International)-Medical Graduates.” The assessment evaluates an examinee's ability to gather and interpret clinical patient data and communicate effectively in the “English” language. It consists of 10 testing stations, and at each station examinees encounter a “standardised patient,” a lay person trained to accurately and consistently portray a patient. The exam can be performed only in Philadelphia and costs $1200 (plus the cost of travelling to and staying in Philadelphia).

    Information regarding all issues pertaining to foreign medical graduates can be directed to the Educational Commission for Foreign Medical Graduates.

    Obtaining a position

    The position depends on your needs (do you want to work in the United States indefinitely or just “pass through”?); the level of training required (are you applying for residency - similar to senior house officer grade - or fellowship - specialty training); and whether you are interested in clinical practice or research.

    Most research positions with only minimal patient contact do not require USMLE examinations. These positions can be obtained by directly contacting your desired mentor, replying to an advertisement (for example, in a medical or scientific journal), or applying to the National Institutes of Health. The salary can come from your present institution (particularly if it is a specific part of the scheme), an external agency (such as the Medical Research Council), or can be met by the Americans (may involve “soft money” or funding by the National Institutes of Health, etc).

    Information about clinical positions can be obtained from various sources, including “job fairs” held in various parts of Britain, word of mouth, medical journals (the New England Journal of Medicine contains the most comprehensive classified listing, see, and the internet (most major institutions have their own website). If you want a residency or fellowship, and you think your credentials are excellent (for example membership of one of the Royal Colleges), apply directly to the programme director. However, most other people will have to go via a “matching” system - the National Resident Matching Programme (NRMP). This programme is a mechanism for matching applicants with programmes according to the preferences of both parties. FREIDA Online is a database containing information on about 7,500 graduate medical education programmes accredited by the Accreditation Council for Graduate Medical Education (ACGME). A list of these programmes is also printed annually in the American Medical Association's Graduate Medical Education Directory (informally known as the “Green Book”). The directory also includes information on residency programme requirements and board certification requirements as well as medical licensure, the National Resident Matching Programme, and the entry of foreign medical graduates to the United States.

    When you finally get offered a position, you have got to get all the necessary documentation from the Educational Commission for Foreign Medical Graduates (or the National Institutes of Health if they are sponsoring your visa) prior to applying for a visa. Typically, most exchange visitors will get a J-1 visa (apply at your local American embassy). Please note that it states in the agreement of your acceptance of this visa that you must return to your own country for at least two years before applying for a definitive job. Trying to overcome this (by obtaining a “J-1 waiver”) is becoming extremely difficult.

    Is it all worth it?

    Time spent in the United States can result in an unforgettable experience, both educationally and socially, though it will require a good deal of planning and expense. If you get the opportunity, I'd say, “Go for it!”

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