1. Coming to America: Challenges Facing International Medical Graduates Gerald Whelan MD, FACEP Welcoming Center for New Pennsylvanians Philadelphia PA

2. IMGs’ Requirements to Practice in U.S. Graduate medical school listed in IMED (imed.faimer.org) Primary source verification of diploma and transcripts Competitive / Passing scores on USMLE examinations Knowledge based and clinical skills Secure position in ACGME accredited residency Appropriate visa – J-1 or H-1B Successful completion of GME State licensure Permanent Resident / Citizenship

3. Primary source verification of diploma and transcripts Done only by ECFMG Potential political roadblocks Forgeries Administrative delays

4. Competitive / Passing scores on USMLE examinations Step 1, Step 2CK, Step 3 Knowledge Computer based Test taking strategies Step 2CS Clinical skills Medical history and physical exam Communication in spoken and written English Test Preparation Courses

5. Secure position in ACGME accredited residency Applications – ERAS Observorships, Clerkships, Letters of Reference Interviews – intense screening “The Match” – National Resident Matching Program Intense Competition GME cap USMGs, DOs, USIMGS get precedence Dwindling number of vacancies for NonUS IMGs NRMP “All In” = no positions outside the Match

6. Competition!

7. Competition A Closer Look

8. Appropriate Visa Post 9/11 Climate J-1 – Exchange Visitor Home country statement of need Evidence of intent to return 2 year return after residency H-1B – non-immigrant foreign worker Requires program to sponsor IMG 3-6 year limit Passing USMLE Step 3 is prerequisite

9. Successful Completion of GME State licensure

10. Waiver Program Eliminates 2 year return for J-1s 3 year commitment Commonly leads to Permanent Resident status Permanent Resident / Citizenship

11. Beyond Requirements: Acculturation Language – conversational and “medicalese” Discourse – “Talk the Talk” Patient expectations, patient autonomy New concepts Confidentiality Documentation Professionalism The U.S. Healthcare System Range of Healthcare Professionals

12. Obstacles to Success Competition Language skills Step 2CS interviewing Other USMLE Exams Computer based, challenging content in English Only one passing score allowed New restrictions on attempts 7 year rule

13. More Obstacles to Success Age Time out of medical school or practice Dwindling success on repeated attempts Money!!! Exam fees, course tuition Need to support self/family Underlying xenophobia IMGs often felt to decrease prestige of programs Visa issues

14. “Many are called but few are chosen” Between 2000 and 2009, there were in excess of 20,000 ECFMG Certified IMGs who had not entered US GME training Fully qualified Passed all required USMLE/ECFMG Exams Had credentials verified Unfortunately, no data on location or employment status

15. Time For…

16. Plan B Plan A is exhausted or unrealistic Allow IEHP to make use of unique medical knowledge, skills and experience Knowledge, skills and experience will facilitate achieving Plan B Reasonable likelihood of success Reasonable expenditure of time, money and effort Acceptable level of professional pride Acceptable standard of living

17. Plan B Obstacles Resistance – never give up! Unrealistic expectations Each healthcare profession has its own pride of identity and will not readily accept shortcuts Lack of good information Applications, requirements, processes Exam preparation Knowledge, test taking skills and strategies Interim support Financial, professional, personal

18. Plan B Resources Case managers Accurate, up to date information Clear strategy Test preparation Materials preparation assistance Interview preparation Networking Counseling and monitoring

20. Welcoming Center for New Pennsylvanians (www.welcomingcenter.org) Established track record with work legal immigrants in employment and entrepreneurial assistance No focused program for Healthcare Professionals Consultation and Recommendations Course - Introduction to the U.S. Healthcare System for Foreign Educated Healthcare Professionals Focus Groups and focused interviews Funding