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FOREIGN MEDICAL GRADUATES
Position Paper
of the
AMERICAN COLLEGE OF PHYSICIANS
March 3, 1986
INTRODUCTION
There are approximately 75,000 physicians currently receiving graduate medical education in the United States (1). Of these, about 13,500 (18%) are foreign medical graduates (FMGs). More than half of the FMGs (7,386) are U.S. citizens; the remainder are aliens, many of whom are seeking U.S. citizenship. Of the U.S.-citizen FMGs (USFMGS), approximately 78% are native born. Of the 6,139 alien FMGs, 60% are permanent residents of the U.S.A.(l); fewer than 2,000 are exchange visitors (2).
The appropriateness of continuing to fund U.S. postgraduate medical residency training for such large numbers of foreign-educated physicians is increasingly being questioned. Attention has focused primarily on costs to the Medicare program. Medicare reimbursement to teaching hospitals for the cost of training physicians who have been educated abroad seems particularly inappropriate to many in light of a projected U.S. surplus of physicians and national policy to encourage U.S. medical schools to curtail enrollments. On the other hand, foreign medical graduates often enter residency training positions that do not attract U.S. graduates, and they often serve patient populations that are otherwise medically underserved.
This paper attempts to show that the issues concerning FMGs today are substan- tially different from those facing the nation in the early and mid-1970's that prompted legislation to restrict the influx of alien physicians. Likewise, the paper attempts to demonstrate that the solutions required today must corres- pondingly be different. The College policy positions reflect the view that in an era of increasing federal budgetary constraints and an apparent abundance of physicians, public expenditures for the provision of patient care services should continue to support medical residency training for graduates of accredited schools of medicine and osteopathy, but should not support residency training for.graduates of unaccredited foreign medical schools. The College favors some special funding provisions, outside of patient care revenues, for the residency training of physicians who are exchange visitors or political refugees. However, the College maintains that all candidates for admission to residency training, regardless of their source of funding, should be required to meet the same standards of knowledge and clinical skill.
To assist the reader, an addendum is provided which summarizes the medical educa- tion process, accreditation mechanisms, and the medical examination and licensure process. Definitions of immigration terms are included in Appendix A.
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SUMMARY OF POSITIONS
1.
2.
3.
4.
Educational programs accredited by the Liaison Committee on Medical Education (LCME) and the American Osteopathic Association (AOA) are the most appropriate means for educating physicians for medical residency training and for future practice in the United States. U.S. public funds should, therefore, support undergraduate medical education in accredited programs, but should not be used to assist U.S. students to attend unaccredited foreign medical schools. Similarly, public expenditures for the provision of patient care services should include money to support the residency training of graduates from accredited medical schools, but should not financially support residency training for any graduates of unaccredited foreign medical schools.
Opportunities for appropriate graduate medical education in the United States should be provided for limited numbers of alien physicians who enter as exchange visitors and who will return to their cquntry of origin upon comple- tion of training. Barriers to entry into graduate medical education for exchange visitor physicians should be modified, and educational experiences for such physicians should be of the highest quality and in disciplines appropriate to practice in the home country. Funding for the residency training of exchange visitors should be from sources other than patient care revenues, including where possible sources from the physician's home country. The United States‘ role in international medical education should also include fostering the development of educational resources in other nations.
U.S. medical residency training programs should require all foreign medical graduates, including those who have their own sources of funding, to meet the same standards of medical knowledge in the basic and clinical sciences and possess clinical skills comparable to those required of graduates from schools accredited by the LCME and the AOA.
There should be federal financial support for the .graduate medical education of refugees who meet all examination and certification requirements for admission to an ACGME-accredited U.S. medical residency training program.
BACKGROUND
During the 1960's and until the mid-1970's, national health manpower policy was shaped by the perception that the United States had a serious shortage of physicians and other health care professionals. Consequently, federal and state governmental policies sought to stimulate the education and training of increasing numbers of health care professionals. Financial support was provided for the construction and expansion of hospitals and educational institutions, and federal scholarship and loan programs were devised to assist students financially. In addition, foreign-trained physicians were encouraged by preferential immigration policies to enter U.S. medical residency training positions and to remain in the United States.
As increasing numbers of U.S.-trained physicians became available and the numbers of FMGs continued to grow, supply of physicians.
the nation began to face the possibility of an over- The number of FMGs in the United States rose from 31,000
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in 1963 to over 85,000 in 1976. At a peak in 1972-73, FMGs occupied 33% of all filled U.S. medical residency training positions and accounted for 46% of all new medical licentiates (3).
Criticism mounted that the United States was creating a "brain drain" of scarce physicians from less developed countries. Concern also grew about the quality of care provided in this country by FMGs. Congress responded in 1976, by declar- ing that there was no longer an insufficient number of physicians in the United States and that there was no further need to provide immigration preferences for alien FMGs. The Immigration and Nationality Act was accordingly amended. Temporary "J" visas for alien FMGs seeking entry to the United States for the purpose of obtaining postgraduate medical education were only to be granted to bona fide students enrolled in residency training programs accredited by the Liaison Committee on Graduate Medical Education (now the Accreditation Council for Graduate Medical Education). Alien FMGs were required to pass Parts I and II of the examination of the National Board of Medical Examiners or an equivalent examination, the Visa Qualifying Exam (VQE). Competency in the English language was also required.
Henceforward, all "J visa" physician exchange visitors seeking residency training in the U.S. had first to make a commitment that they would return to their country of origin for a period of at least two years upon completion of training. In addition, their home government had to assure that a position fully utilizing their skills would be available upon their return.
The 1976 amendments to the Immigration and Nationality Act also limited the period of study for physician exchange visitors to two years, with a possible extension to three years upon approval of the home government. To reduce disrup- tion of services in hospitals dependent upon FMGs for patient care, waivers to certain provisions of the act were made available. The law was further amended in 1981 to permit physician exchange visitors sufficient time in this country (up to seven years) to satisfy requirements for completion of a program of specialty training.
Stricter entrance requirements for a U.S. visa and tougher certification require- ments for eligibility for admission to residency training have acted to reduce the number of alien FMGs entering the U.S. for medical residency training. Nevertheless, the total pool of FMGs in U.S. relatively high (See Appendix B).
residency programs has remained Most significant has been the development of
proprietary medical schools, primarily in the Caribbean Islands and in Mexico. These profit-making institutions have produced increasingly large numbers of U.S. citizens with foreign medical degrees.
POSITION
1. Educational programs accredited by the Liaison Committee on Medical Educa- -- tion (LCMt) and the American Osteopathmociation (AOmmhe most appropriate means-for educating physlclans for medic~s~nc~r~ lng and formrepractlce in the United States. U.S public funds should, therefore, support und= raduate medical educatkin accredited
ut shoulde use W+
__$___* cre lte .forelgnicT schox
to asslsm students toattend unac- sliy, public cxpen?Kturesorthe --
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rovision of patient care services should include money to support the +- resi ency trai5ZKj3 muates from accre_dit~cascho5s,butoTiTh not financially support residency training for graduates of unaccredited foreign medical schools.
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RATIONALE
The accreditation processes of the LCME and the AOA provide the only mechanisms for assuring that undergraduate medical education programs meet high minimum standards of quality required to prepare students for graduate medical residency training in the United States. The LCME accredits undergraduate medical programs in the United States and Canada; the AOA accredits undergraduate programs only in the United States. No uniform mechanism exists to evaluate the quality of undergraduate medical education abroad or to assure that foreign medical schools meet the same high standards required of U.S. and Canadian schools.
In the past, when the training capacity of U.S. medical schools was perceived to be insufficient to meet the nation's medical manpower needs, physicians educated at foreign medical schools were recognized as a valuable source of additional manpower. It was deemed to be to this nation's benefit to provide additional pathways for physicians trained outside the United States to qualify for practice in this country. Alien physicians were given immigration preferences to come to the United States for graduate medical training. Alternatives were also devised to permit U.S. citizens to receive recognition for medical study abroad. The Coordinated Transfer Application System (COTRANS) was developed to enable U.S. citizens studying abroad to transfer with advanced standing into domestic medical programs. The Fifth Pathway program was devised for U.S. citizens who complete a four-year medical program in a country where an additional year of internship and/or social service is required to obtain a medical degree and licensure. Under this program, such students could qualify for U.S. postgraduate residency training without first having obtained the medical degree, if they satisfied all undergraduate educational requirements abroad and completed a one-year clinical clerkship in a program sponsored by an LCME-accredited medical school.
Most indicators show that the United States is now producing at least a suffi- cient aggregate number of physicians to meet its physician manpower needs for the near future. Now that there appears to be a national abundance of physi- cians, it is no longer necessary to provide alternative pathways to medical licensure or public financial support for the graduate medical education of U.S.-citizen graduates of foreign medical schools. Likewise, it is no longer reasonable to use limited public funds to support the residency training of alien FMGs who seek to remain in this country.
National policy since the mid-1970's has sought to better balance the numbers of physicians with national health care needs. of physicians has been discouraged.
Expansion of the aggregate supply Capitation support to medical schools to
expand enrollments has been discontinued, medical students has been curtailed.
and federal scholarship support for However, meaningful manpower policy cannot
be achieved by voluntary efforts of U.S. medical schools to limit class size, if there are ineffective restraints on the supply of FMGs.
While U.S. medical school enrollments have stabilized (See Appendix C) and the numbers of alien foreign medical graduates entering the United States have been reduced, the numbers of U.S. citizens in medical schools abroad have been expanding. No accurate data exist on the total number of applicants to foreign medical schools or on foreign medical school enrollments. Recent estimates indicate that 13,000 to 19,000 U.S. citizens are currently studying medicine abroad (4). Each year since 1981, the number of U.S.-citizen foreign medical graduates (USFMGS) applying to the National Residency Matching Program (NRMP) has increased (See Appendix D). The number of USFMGs obtaining residency train- ing positions has also been increasing; although there was a slight decline in 1985.
Many of the proprietary foreign medical schools that have been founded since the 1970's are believed to exist solely to attract aspiring U.S. students. At one point, the Dominican Republic alone had twelve medical schools. Most provide no clinical sciences training (4,5). Few offer clinical clerkships, and those that claim to have sponsored clerkships in the U.S. have been reluctant to divulge the names of hospitals with which they have affiliation relationships. Many U.S. medical educators question whether students from these "offshore medical schools" receive any supervised clinical training.
U.S. citizens cannot be denied the right to pursue education abroad. Education abroad can be a valuable learning experience. Nevertheless, the medical profes- sion, teaching hospitals, and the federal and state governments should act to discourage U.S. citizens from attending medical schools that are not accredit- ed either by the LCME or the AOA. Students should be aware that graduates of unaccredited medical schools face increasing difficulty in obtaining admission to graduate medical residency training and have slim prospects for passing neces- sary qualifying examinations (See Appendix E). Much disappointment, as well as time, effort, and expense, might be avoided if ways can be found to advise American students before they embark for a foreign medical education of the unlikelihood that they will ever successfully qualify as a physician in the United States.
U.S. citizens benefit from childhood from various forms of public support for education. However, there is no compelling reason why public funds should sup- port education abroad that is of questionable quality and dubious value. Yet, the General Accounting Office (GAO) reports that almost 3,000 guaranteed student loans amounting to over $9 million were granted by the Department of Education between 1980 and 1985 to U.S. citizens studying medicine abroad. The GAO further reports that, during the same period, the Veterans Administration provided millions of dollars in educational benefits to qualified veterans, their spouses, and dependents to attend unaccredited foreign medical schools (4).
In an era of fiscal constraint and growing abundance of physician graduates from accredited medical programs, it is difficult to justify the expenditure of public monies to support either undergraduate medical education at foreign medical schools or residency training for graduates of such unaccredited schools. How- ever, abrupt withdrawal of all public financial support for FMG residency train- ing could cause severe problems for those teaching hospitals that rely heavily upon FMGs for the provision of patient care services. Many such hospitals are located in urban centers and serve predominantly poor and underserved populations.
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Elimination of public funding might mean that FMGs who manage to obtain a resi- dency position will have to personally bear a greater share of their educational costs. A phasing-out of public funding would allow current FMG medical residents an opportunity to complete their specialty training. Without such a provision, many FMGs might discontinue residency training as soon as they complete the minimum time period required for licensure. The unintended consequence could then be that those FMGs already "in the pipeline" might engage in practice without having received the training they need to practice more in accord with U.S. standards. Thus, cessation of public funding for residency training of FMGs should be implemented gradually with a transitional period to avoid substantial disruption problems for patients, institutions, and residents-in- training.
POSITION
2.
RATIONALE
The United States, as a world leader in the basic and clinical medical sciences, medical education, share its
and medical research, has an ethical and moral obligation to knowledge with physicians from other nations for the benefit of man-
kind. In addition, in a world brought closer by diminishing barriers of travel time and heightened economic and cultural interaction, the health of people in the United States is interdependent with health conditions abroad. Failure to treat and prevent disease in other countries threatens not only U.S. travelers, but all Americans, as evidenced by the spread of various forms of influenza and other contagious diseases.
The ACP has long been committed to the belief that the United States should share its medical knowledge with physicians from throughout the world. From 1949 to 1969 the College administered a program funded by the W. K. Kellogg Foundation which brought 167 selected Latin American Physicians to the United States and Canada for graduate study, usually for a period of two years. A 1980 ACP survey of former participants in this fellowship program found that 133 had current addresses in Latin America, 8 were residing in the United States or Canada, 19 had unknown addresses, and 7 were deceased. Of 146 former fellows known to be in Latin America: 119 had academic appointments, 7 were rectors or deans of medical schools or universities, 7 were physicians in government service 6 were in private medical practice, and 4 had retired. From 1982 to 1984, thi
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ACP, again with assistance from the Kellogg Foundation, provided special three- month refresher experiences for ten former fellowship participants per year. The College has also granted scholarship awards to distinguished foreign physi- cians seeking postgraduate fellowship training in the United States (6).
In 1981, the College adopted a position paper supporting amendments to the Immigration and Nationality Act to permit exchange visitors sufficient time in this country to complete a recognized course of postgraduate specialty training. In March 1985, the ACP position paper on Financing Graduate Medical Education reaffirmed the College's long-standing belief that the United States should maintain its preeminence in international medical education and should not abandon its role as a trainer of foreign physicians. The College concluded that the number of FMGs permitted entry to the United States should be part of a comprehensive national health manpower policy. The College also stated that sufficient residency training positions should be provided to accommodate limited numbers of exchange visitor physicians who would return to their country of origin upon completion of training.
The Bureau of Health Professions of the U.S. Public Health Service estimates that since 1979, only 400-600 exchange visitor physicians per year have entered U.S. residency training (3). Both the number of new entrants and the total number of exchange visitor physicians in all years of graduate residency training have been declining steadily since the early 1970's (See Appendices F and G). Although there are approximately 2,500 new exchange visitor physicians entering the United States per year, graduate medical education.
only about 20% enter to participate in a program of Many exchange visitor physicians come for teaching,
research, consulting, or observation.
The Educational Commission for Foreign Medical Graduates (ECFMG) is the only organization authorized by the United States Information Agency (USIA) to sponsor exchange visitors for participation in residency and fellowship training. ECFMG sponsorship indicates that an alien physician has completed a program leading to a medical degree, is fluent in the English language, and has mastered a level of medical knowledge (as demonstrated by obtaining passing scores on ECFMG examina- tions) requisite for U.S. residency training. In the academic year 1981-82, the ECFMG sponsored a total of 1,552 FMG exchange visitors, of whom only 544 were new entrants. Of the new entrants, only 370 were aliens entering U.S. residency training positions with medical degrees from schools outside the United States and Canada. The remainder consisted of 114 graduates of LCME accredited Canadian schools, 10 alien graduates of LCME accredited U.S. medical schools, and 50 students entering for individually arranged advanced medical training not consi- dered graduate medical education (e.g., research, observerJ(3). the ECFMG sponsored 1,915 exchange visitors,
In 1984-85, of whom 719 were new entrants (2).
The American College of Physicians believes that opportunities should be main- tained for specialty and subspecialty training in the United States for those relatively few foreign physicians who enter as exchange visitors. The College also supports current requirements that once training is completed, exchange visitors should return to their country of origin for a period of at least two years. There, it is hoped, .they will help to disseminate the knowledge and training that they obtain in the United States. Many will become medical educa- tors. Based upon past experience, many will assume other
P ositions of influence
and leadership in their native lands, including positions 0 political leadership.
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It is the responsibility of the United States to assure that exchange visitors receive the type and quality of graduate medical education for which they come to this nation. Particular attention should be given to providing training in teaching and educational techniques that will enable these physicians to better spread their medical knowledge.
All ECFMG-sponsored exchange visitor physicians engaged in postgraduate residency training are enrolled in programs accredited by the ACGME. Thus, all are trained in programs that meet the basic requirements for graduate medical education and that satisfy the specific standards for a program of specialty training. Never- theless, it is generally acknowledged that FMGs, including exchange visitors, typically are able only to obtain residency training positions in programs that are considered by U.S. medical graduates to be the least desirable. In general, these are residencies at inner-city teaching hospitals serving predominantly the urban poor or in community hospitals with small teaching programs in remote locations. It is frequently alleged that FMG residents in some teaching hospitals are often utilized as the least costly means of providing patient care services, and that they consequently have little exposure to formal educational activities. Whether this is true for exchange visitor physicians in residency training is not clear.
There are data, however, indicating that of the entire pool of roughly 13,500 alien and U.S. citizen FMGs who have obtained residency training positions, most have done so by accepting positions in locations and in specialties that have difficulty attracting U.S. medical graduates. Specialties with a high prevalence of FMGs include physical medicine, anesthesiology, pathology, therapeutic radi- ology, nuclear medicine, and psychiatry (7). Many FMGs have been concentrated in programs that trained few or no U.S. graduates. Currently, 1836 programs participating in the NRMP have 75% to 100% of their positions filled by graduates of LCME-accredited schools; overall only 2% of the residents in these programs are not graduates of LCME-accredited schools, and only 1% of residency positions remainded unfilled. However, in 784 programs that are less than 50% filled by graduates of LCME-accredited schools, almost 40% of the positions are filled by FMGs and more than 40% of the residency positions are empty (See Appendix H)(8).
The purpose of admitting physician exchange visitors for U.S. residency training should be to share our medical knowledge with foreign physicians for the benefit of people throughout the world, not to provide an inexpensive source of physician manpower to serve our nation's needs. These physicians will return to their home countries and their views and interpretation of their experiences in the United States will undoubtedly have an impact on how the United States is perceived by peoples of other nations. Thus. in a verv real sense exchange visitor physi- cians should be considered as observers and" emissaries Certainly, such physicians should receive the educational them with the training they need.
of their native lands. experience that provides
Responsibility for the funding of residency training for exchange visitors should be shared among a variety of sources. Where possible, the home government or other sources in the home country should provide financial support. Federal agencies with responsibilities for international, cultural, and educational exchanges or foreign relations should assume funding responsibilities in conjunc- tion with their program responsibilities. However, patient care revenues, parti- cularly from the Medicare program which is primarily intended to serve the needs of elderly patients, visitors.
should not be used for the education of exchange
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Residency training in the United States is not necessarily the most effective means of helping foreign countries to meet their health care needs. Training in modern American medicine, with its emphasis on high technology, may not be readily transferable to less developed nations without the facilities or the resources upon which our system depends. To help address the public health needs of the people in developing countries, emphasis should be given to strengthening programs that provide training for foreign clinicians in epidemiological research and primary care. Subspecialty training may be needed, but other demands may be more pressing in countries lacking basic health care services. Clearly, the United States should also explore other means of international medical education, including sending U.S. medical trainers abroad and assisting in the development of educational resources.
Organizations such as the Kellogg Foundation and the Pan American Health Organization have sponsored cultural and exchange programs in which physicians can obtain needed fellowship training unavailable within their home country. Individual universities have developed special relationships with foreign schools ( e.g., Johns Hopkins University and the American University of Beirut) which foster interchange of faculty and ideas. U.S. foundations and schools have also contributed financial capital and medical equipment to provide foreign schools with the resources required for modern medical care.
We believe that greater efforts should be made to enhance the training of foreign physicians in their native countries. Development of educational and patient care institutions abroad may be a much more effective method of contribut- ing to a nation's ability to provide for its health care needs than training a very small number of physicians in the United States. Furthermore, investments in medical facilities could be devoted to providing the kinds of medical services actually needed and training could occur with patients and in situations that the physician-in-training would be more likely to continue to encounter.
Consideration should be given to the development of mechanisms by which American physicians and medical educators can volunteer for service abroad. Organizations are needed to provide the administrative machinery to place U.S. physicians in teaching and patient care positions that best utilize their skills. Such programs should include purely voluntary programs with coordination from international organizations, private sector efforts by medical organizations and teaching hospitals, programs sponsored by foundations, and governmentally funded programs similar to the Peace Corps or the National Health Service Corps.
Service commitments could range from three months to several years, depending on the needs of the foreign country and the willingness of the U.S. physician.
The American College of Physicians has much to contribute in the area of international medical education. programs for foreign physicians,
In addition to its scholarship and fellowship the College could act as a facilitator to assist
foreign exchange visitors to secure residency training positions that can best provide the education and training required in their home country. The College could also serve to develop and enhance professional relationships among physi- cians on an international basis. Further, the College could serve as a major resource of physician educators and practitioners willing to volunteer for temporary service in which they might share their knowledge and experiences with physicians in other countries.
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POSITION
3. U.S. medical residency training programs should require all foreign medical graduates, including those who have their own sources offunding, to meet the same standards ofxc!knowlemn the basic and clinical sciences andpossess clinicaTsmomparable t'tEe=requiredof graduates from schools accredited by the LCME and the AOA. ------
RATIONALE
Medical residency training in the United States involves learning by observing, by personally performing patient care services, and by teaching others. All medical residents must possess a high degree of knowledge in both the basic and the clinical medical sciences. They all must have the clinical skills to take patient histories, perform physical examinations, and to provide "hands-on" patient care under varying degrees of supervision. Accreditation by the LCME and the AOA signifies that a medical school meets rigorous educational standards and that its academic and clinical facilities have been reviewed and comply with accreditation standards. Graduation from an accredited U.S. or Canadian medical school with a medical degree indicates that the student has mastered a specific academic program and has also demonstrated under supervised conditions that he or she possesses the clinical competence necessary to provide patient care in residency training.
There are no comparable accreditation mechanisms to evaluate programs of medical education at foreign medical schools. Consequently, the only means of determin- ing whether or not an FMG has received adequate education and training is through an examination process that assesses candidates' knowledge and ability. This process should objectively test knowledge in the basic and clinical sciences and determine ability to apply factual knowledge in the treatment of patients. The American College of Physicians believes this process should evaluate foreign medical graduates according to the same standards applied to graduates of LCME and AOA medical schools, recognizing that the process will need to include assess- ments of clinical competence to make up for the lack of accreditation of foreign medical programs.
Currently, ECFMG certification is required for all FMGs seeking U.S. medical education.
graduate Certification requires achievement of a passing score on
both parts of the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), and verification that the applicant has graduated from a school listed in the World Directory of Medical Schools, published by the World Health Organiza- tion (WHO) 1 Listing in this directory indicates only that the government of a country belonging to WHO has reported the existence of such a medical school. WHO listing does not indicate any accreditation, approval, or review according to any standards.
FMGEMS replaced the separate ECFMG examination and the Visa Qualifying Exam (VQE). The ECFMG exam had been required for all FMGs seeking entry to residency training, and the VQE had been an additional requirement that only applied to alien FMGs. FMGEMS was first administered in July 1984 (See Appendix E). It includes a one-day test in the basic medical sciences, a one-day clinical science examination, and an English language test. Test questions are selected from
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the same pool of questions developed by the National Board of Medical Examiners for the NBME examinations, and FMGEMS is considered equivalent to Parts I and II of the national boards. The ECFMG and the NBME are currently seeking to develop a Part III in the FMGEMS sequence that would evaluate ability to diagnose and solve clinical problems in a realistic patient care setting.
POSITION
4. There should be federal financial support for the graduate medical education bf~*o meet all examination anicZ%ification requirements for admission to an Am-accredited U.S. medical residency training program. --
RATIONALE
Physicians who enter the United States as refugees* should be allowed opportuni- ties to pursue medical careers in this country. To qualify for medical licen- sure in any state, they must (like all foreign medical school graduates) complete a minimum of one or more years of graduate medical education in an ACGME-accredited residency training program. Requirements for admission to graduate medical educa- tion for refugees should be the same as for all foreign medical school graduates, including obtaining passing scores on standardized examinations of medical knowledge, satisfactory demonstration of clinical competence, and fluency in the English language. However, because of the special circumstances of refugees, who must leave their home country involuntarily for fear of persecution and often without any financial resources, special federal funding support should be available for the residency training of those who can satisfy the rigorous require- ments for admission. Such funding has been provided in the past under special federal programs for Cuban and Vietnamese refugees.
Federal financial support for graduate medical education should permit qualified physicians who are refugees fleeing from political, racial, or religious perse- cution to obtain the training necessary to resume their medical careers in the United States. This federal funding would not be intended for the support of residency training for FMG immigrants who come to the United States for economic reasons or for those who seek citizenship in order to remain in this country with a spouse or dependents who are U.S. citizens.
CONCLUSION
National health manpower policy seeks to balance the physician manpower supply with national medical manpower needs. Implementation of this policy is not succeeding because the United States is graduating sufficient numbers of physi- cians each year to more than meet anticipated future needs while large numbers of FMGs, particularly U.S.-citizen FMGs, continue to enter the U.S. pool.
manpower To improve the quality of medical care and achieve a better balance
between supply and need in a time of constricted public funding for medical education, we recommend that public funding support for graduate medical residency training be available from patient care revenues only to graduates of LCME and AOA accredited medical schools.
* See Appendix A: Definitions of Immigration Terms
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Separate sources of funding should permit opportunities for limited numbers of foreign physicians as exchange visitors, who would receive a high quality U.S. graduate education and then return to their home country. Physician refugees, who satisfy all requirements for admission to medical residency training, should also be eligible for federal funding support. No other public funding support should be provided for students or graduates of unaccredited foreign medical schools. All physicians, including foreign medical graduates with their own sources of funding, should satisfy the same high standards for admission to U.S. medical residency training.
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ADDENDUM
SUMMARY OF THE MEDICAL EDUCATION AND LICENSURE PROCESS
A stringent and complex system has been developed in the United States to assure the public that those who are allowed to practice medicine and surgery are fully qualified by training and experience. This system in- volves a series of screens of knowledge, experience, and achievement. It also includes accreditation mechanisms to assure that high minimum stan- dards of quality are maintained at each educational and training facility at every level along the long continuum of the medical education process.
---Undergraduate Medical Education:
The Liaison Committee on Medical Education (LCME) is the official accredit- ing body in the United States and Canada for educational programs granting the MD degree. To obtain LCME approval, a medical school must satisfy standards concerning the structure and function of a medical school and must meet special criteria for programs in the- basic medical sciences. LCME requirements include provision of supervised clinical clerkships at teaching hospitals. Schools accredited by the LCME are subject to extensive initial and periodic reviews by teams of education experts. As of September 1, 1984, there were 127 U.S. and 16 Canadian medical schools accredited by the LCME (9). A similar accreditation process exists for programs granting the degree of doctor of osteopathy. Osteopathic programs are accredited by the American Osteopathic Association (AOA). There are 15 accredited osteopathic medical schools. No similar authorities are recognized by the United States to evaluate the quality of medical education programs abroad.
Each accredited medical school sets its own admission criteria. Except for some special pre-admission programs and advanced placement programs, most applicants must successfully complete a four-year premedical college program prior to admission. Factors generally considered by medical school admissions committees include the applicant's college academic record, scores on the Medical College Admission Test (MCAT), biographical information, extracurricular activities and faculty evaluations (usually following personal interviews).
Only about half of all applicants are accepted. Of 35,944 applicants to U.S. medical schools in 1984-85, only 17,194 were successful (9). Growing perception of an impending physician surplus, as projected in 1980 by the Graduate Medical Education National Advisory Committee (GMENAC) (101, and consequent changes in national health manpower policies have acted. to discourage further expansion of U.S. medical schools. First year enrollment has accordingly remai,ned relatively stable at around 17,000 since 1979, but previous growth in class size resulted in an average increase of 329 graduates per year from 1978 to 1984 (9). Although competition for admission to U.S. medical schools remains intense, the number of applicants has been declining each year since 1973 (See Appendix I). Total annual U.S. medical school graduation is expected to be about 16,600 each year through at least 1989 (9) (See Appendix C). In addition, in excess of 1,000 osteo- pathic graduates are expected annually (1).
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---Graduate Medical Education:
On September 1, 1984 there were 4,691 U.S. postgraduate residency training pro- grams accredited by the Accreditation Council for Graduate Medical Education (AcGME) (I). Each program is reviewed at least once every five years by a Residency Review Committee (RRC). Programs are evaluated to determine if they meet "General Requirements" that are prerequisites for all programs regardless of specialty, as well as "Special Requirements" peculiar to each specialty.
A total of 20,411 ACGME-accredited postgraduate year one (PGY-1) residency posi- tions were offered in 1984, and 19,698 of these positions were filled on September 1, 1984 (1). Some 20,573 positions were offered in 1985. Approximately 18,500 residency positions were offered through the National Residency Matching Program (NRMP) in both 1984 and 1985 (8). Of these, over 16,000 were filled each year (See Appendices J and K).
All residents in ACGME-accredited residencies must be graduates of LCME or AOA- accredited medical schools or must be certified by the Educational Commission for Foreign Medical Graduates. To obtain ECFMG certification, U.S.-citizen and alien FMG's must pass a two-day Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS). Part I of the exam tests knowledge in the basic medical sciences; Part II tests knowledge in the clinical sciences. Questions for both Parts I and II of FMGEMS are drawn from a pool of questions maintained by the National Board of Medical Examiners (NBME), and the exam is considered to be substantially equivalent to Parts I and II of the NBME exams.
---Licensure:
Graduation from medical school, whether it is from a LCME or AOA-accredited school or from a foreign medical school, does not qualify one to immediately obtain licensure to practice medicine or osteopathy. Most physicians gain licensure by first receiving certification of their qualifications from the NBME and then having their certification endorsed by a medical licensing board. To obtain NBME certification, an individual must: 1) receive the MD degree from an LCME accredited medical school; 2) pass Parts I, II, and III of the NBME examination; and 3) satisfactorily complete one full year of postgraduate residency training in a program accredited by the ACGME.
Beginning after January 1, 1984, all examination requirements for NBME certifi- cation must be completed within seven years. Students officially enrolled in LCME accredited medical schools may take Parts I and II of the exam prior to graduation. Part I is a two-day written exam in the basic medical sciences; Part II is a two-day exam in the clinical sciences. Part III is a one-day, three-part exam designed to test ability to apply medical knowledge to solve clinical problems likely to be encountered in the first year of residency training. To be eligible to take Part III, a candidate must have passed Parts I and II, have received the MD degree from an LCME accredited medical school, and have successfully served subsequent to graduation at least six months in an ACGME accredited residency training program.
-15-
All licensing boards except Louisiana, Texas, and the Virgin Islands will grant licensure to graduates of LCME approved medical schools by endorsement of a NBME certificate (See Appendix L). All U.S. licensing jurisdictions except Puerto Rico use the FLEX examination of the Federation of State Medical Boards as their official medical licensing exam for those not licensed by endorsement (11).
A new FLEX examination, revised with assistance from the NBME, became effective June 1985. It consists of two components. choice questions,
FLEX Component I includes 500 multiple testing knowledge and understanding of basic and clinical
science with special emphasis on diseases and problems encountered in residency training on an inpatient basis. It is admininstered over a 1 l/Z-day period. FLEX component II assesses competence to provide health care to patients without supervision in both inpatient and outpatient settings. Component II consists of a one-day test of approximately 420 multiple choice questions, and an additional l/2 day for 15 patient management problems (11).
All U.S. medical licensing boards, except Indiana, Louisiana, Massachusetts, Missouri, Ohio, New York, and Tennessee require one or more years of accredited graduate training for graduates of LCME-accredited schools (See Appendix L). As of July 1, 1985, New York requires at least one year of graduate residency training in a state-approved institution (11).
To assure that all candidates for medical licensure have adequate clinical training, most licensing jurisdictions have stricter postgraduate requirements for graduates of foreign medical schools (See Appendix M). In Montana and Massachusetts postgraduate requirements for FMGs are discretionary with the licensing board. In all other jurisdictions at least one year of training is required in a residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME). Eight boards require FMGs to complete two years' of accredited residency training and ten require completion of three years' training (11).
-
APPENDIX A
DEFINITIONS OF IMMIGRATION TERMS
Alien - A foreign-born resident who has not been naturalized and is still a subject or citizen of a foreign country.
Exchange Visitor Program - A program designed to promote interchange of persons, knowledge and skills, and the interchange of developments in the field of educa- tion, the arts and sciences, to promote mutual understanding between the people of the United States and the people of other countries.
Exchange Visitor (J visa) - An alien who is a bona fide student, scholar, trainee, teacher, professor, research assistant, specialist or leader in a field of specialized knowledge or skill, who is coming temporarily to the United States as a participant in an Exchange Visitor Program.
Immigrant - An alien admitted for permanent residence.
H Visa - The passport status of an alien who enters the'united States on a temporary basis as a person of distinguished merit and ability to perform services of an exceptional nature as described under paragraph H of Section 101 of the Immigration and Nationality Act. Includes foreign physicians coming to the United States to perform services pursuant to an invitation from a public or nonprofit private educational or research institution or agency of the United States to teach or conduct research, or both.
J-l Visa - The passport status given to a person entering the United States as an Exchange Visitor as described under paragraph J of Section 101 of the Immigration and Nationality Act. Includes people coming temporarily to partici- pate in a program to receive graduate medical education and training.
J-Z Visa - The passport status of the spouse and minor unmarried children of an Exchange Visitor.
Naturalization - The confering of nationality of a state upon a person after birth by any means whatsoever.
Permanent resident - A person accorded the privilege of residing permanently in the Unlted States as an immigrant in accordance with immigration laws.
Refugee - A person outside his or her country of nationality who is unable -unwilling to avail himself or herself of the protection of that country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or politi- cal opinion, excluding those who ordered, incited, assisted, or otherwise participated in such kinds of persecution.
Sponsor - An organization that has an approved program under its sponsorship as an Exchange Visitor program.
Sources:
U.S. Dept. of HHS, Public Health Service. Exchange Visitor Program, May 1983.
Report to Congress on Physician
Section 101, Immigration and Nationality Act [8 U.S.C. 11011.
1981
1982
1983
1984
APPENDIX B
Number and percent of Residents on Duty Septemner 1, 1981 - 1985 who are FMG's.
Number
13,194
13,123
13,221
13,525
Percent
19.4%
19.0
18.4
18.0
Source: Crowley AE. 1984-1985.
Graduate Medical Education in the United States, JAMA (September 27,1985) 254: 12.
APPENDIX C
Medical School Enrollments LCME Accredited U.S. Medical Schools
1964-1989
Year No. of Total First- Schools Enrollment Year Graduates
1964-65 88 1968-69 99 1974-75 114 1978-79 125 1979-80 126 1980-81 126 1981-82 126 1982-83 127 1983-84 127 1984-85 127 1985-86* 127 1986-87* 127 1987-88* 127 1988-89* 127 1989-90* 127
32,428 35,833 54,074 * 62,754 64,195 65,497 66,485 66,886 67,443 67,090
8,856 7,409 9,863 8,059 14,963 12,714 16,620 14,966 17,014 15,135 17,204 15,667 17,320 15,985 17,230 15,824 17,175 16,327 16,992 16,347 16,359 16,634 16,369 16,733 16,356 16,753 16,354 16,630 16,320 16,602
* Projected
Source: Crowley AE et al. 27, 1985; 254:
Undergraduate Medical Education.JAMA, September 12 and September 28, 1984; 252:12
APPENDIX D
Match Rates of FMG's in the
National Residency Matching Program 1981-1985
1981 1982 1983 1984 1985
Total FMG applicants* 2013 .3765 5289 6244 6300 Number Matched 1162 1610 1864 1937 1875 % Matched 57.7 42.8 35.2 31.0 29.8
USFMG Applicants* 886 1373 1671 2032 2044 Number Matched 652 859 915 1015 957 % Matched 73.6 62.6 54.8 50.0 46.8 % of FMG's Matched 56.1 53.4 49.1 52.4 51.0
Alien FMG's Applicants 1127 2392 3618 4212 4256 Number Matched 510 751 949 922 918 % Matched 45.3 31.4 26.2 21.9 21.6 % of FMG's Matched 43.9 46.6 50.9 47.6 49.0
* Active applicants only; excludes those who withdrew or had no rankings ** Includes 5th Pathway graduates
Source: Graettinger JS. NRMP Data, March 1985
-
PERIOD CATEGORY
All Exarlncct
Foreign NltiOMlS
U.S. Citizens
&n;rry, All Exarlnees+ 12,946
Foreign NatloMls 10,277
U.S. Cltlrcns 2,669
1984-85 Grand Totals 25,334
Foreign Nationals 20,131
U.S. Citizens 5,203
Prelininary Data
APPENDIX E
EXAMINEE PERFORMANCE BY DAY ON ' FDRElGR MEDICAL GRADUATE EXAnlNAlION IN THE IIEDICAL SCIENCFS (FWNS)
Requtred of All Forelgn Hedlcal Graduates
plAJ
12,388
9,%4
2,534
DAY 1 BASIC SCIENCE ONLY
TIkc Pass 'Percent
3,444 984 28.6X
2,343 667 28.5X
1,101 * 317 28.8g
4,118 993 24.15
2.8% 700 24.21
1,222 293 24.01
7,562 1,977 26.11
5,239 1,367 26.1X
2,323 610 26.31
DAY 2 CLINICAL SCIENCE ONLY
@& Pass Percent
1,521 599 39.41
1,301 554 42.61
220 45 20.51
2,128 799 37.51
1,797 718 40.0%
331 81 24.51
3,649 1.3% 38.31:
3.0% 1,272 41.11
551 126 22.9X
DAY 1 AND DAY 2 ROTH 8&W AND CLINICAL SClEJKE
E & Percent
7,423 1,295 17.41
6,210 1,249 20.1a
1,213 46 3.8X
6,700 901 13.41
5.584 %2 15.4%
1,116 39 3.51
4,123 2.1% 15.5%
1,794 2,111 17.9%
2,329 85 3.611
l Data are provided from 143 of 145 examinatlon centers throughout the world frem uhlch results have Deen received and tallied at the tlr of thls hearing on llrrch 25, 1%5.
Source: ECFKG
APPENDIX F
Number of ECFMG-Sponsored Exchan Education or Training, Both r9”
Visitor Foreign Medical Graduates in Graduate Medical ew Entrants and Total, for the Years 1972-1982”
l lncludn aI1 individuals under ECFMG sponsorship by l udomic yur. Now onwant data for 1972-73 l ra not wail&la. Total ~onsorod - now l ntr8ntr l continuations from prior year. Data tar 1962-63 we thru g/7/82 and l rm still preliminary.
SOURCE: Educational Commission for Foreign Mtiic~I Graduate& Soptombor, 1982.
APPENDIX G
ECPMG-SPONSORED EXCHANGE VISITOR PMGs: NEW ENTRANTS AND TOTAL SPONSORED, ACADEMIC TEARS 1972-73 TO 1981-82
Academic Year New Entrants Number of Total PMGs Countries Represented Sponsored*
1972-73 109 9,474
1973-74 2,917 101 8,369
1974-75 2,337 92 8,270
1975-76 1,628 88 * 7,389
_
1976-77 1,196 88 5,311
1977-78 901 81 3,660
1978-79** 296 54 2,557
1979-80 442 65 2,020
1980-81 666 73 1,890
1981-82 544 66 1,552
1982-8351 412 NA 1,292
* Total sponsored - new entrants + continuations from prior year.
** First year that VQE certification was required for new entrant alien PMGs.
21 Through September 7, 1982 - preliminary data.
SOURCE: U.S. Department of HHS, Public Health Service. Report to Congress on Physician Exchange Visitor Programs, May 1983
-
Fig. 9
19
18 17 16 15 14 15 12 11 10
9 8 7 6 5 4 3 2 1 0
APPENDIX ti
GROUPED PROGRAMS - 1985 TYPES OF APPLICANTS MATCHED
A
TPTAL . 75- 1.007. !io-74z. . ’ .0-4-9x
1771 LCME PERCENTAGE OF US5 MATCHED :
m non LCME m EMPTY
PRW POSIT- LCHE NON-LCflE PERCENT USS RAYS IONS NO. PERCENT NO. PERCENT
GROUP A 75-1002 1836 12319 11937 96.9 241 2.0
to.31 bb. 3’2 83.82 11.6Z
GROUP B 50-74z 423 2287 1516 bb.3 257 11.2
13.9’1 12.31 10.6X 12.4Z
6RouP c o-49z 784 3973 784 19.7 1562 39.8
25.BZ 21.42 5.51 76.1Z
TOTAL 3043 18579 14237 76.6 2OBO 11.2 100.01 1oo.oz 100.01 [email protected]
Note: These data include 20 P6Y-2 ‘S’ progrars nith 44 pO5itiOnS
TOTAL EtlPTY POSITIONS NO. PERCENT NO. PERCENT
12179 99.9 74.tz
1773 77.5 514 22.5 10.9x 22.71
liSl! 87.3 100.0’.
141 1.1 6.2X
lb07 40.4 71.02
2262 12.2 lOO.OZ
Source: NRf?P Data, parch 1985 -
APPEt’!DIX I
1964-65 19,168 9,043 * 2.1
1968-69 21,118 10,092 2.1
1973-74 1974-75
40,506 42,624
1978-79 36,636 16,527 1979-80 36,141 16,886 1980-81 36,100 17,146 1981-82 36,727 17,286 1982-83 35,730 17,294 1983-84 35,200 17,209 1984-85 35,944 17,194
Applicants to LCME accredited U.S. medical schools.
Selected years 1964-1984
Ratio Applicants/ Acceptance
Number of Applicants Applicants Accepted
14,335 2.5 15,066 2.8
2’5 2:1 2.1 2.1
:::
Source: Crowley AE et al. Undergraduate 27, 1985;
Medical Education.JAMA, 254:
September 12 and September 28, 1984; 252: 12.
-
APPENDIX J
APPLICAN’B-POSITIONS IN THE NATIONAL RESIDENT MATCHING PROGRAM, 1952434
30,oDo _
28,ODO 0
_ 0 26,DOO - n
24,000 A
_
22,000 _
20,ooo -
18,000 _
3 16,000 _
s 14,ooo_ 2
12,000 _
10,ooo
8,ooO
6,ooO
POSITIONS . TOTAL APPLICANTS USCANADIAN CITIZENS USSENIORSTUDENTS
i952 1955 1958 1961 1964 1967 1970 1973 1976 1979 1982 1985
Data from NRMP
APPENDIX K
3s. 000
wEo1cAL
SMOoL
APPLICANTS
u s HEDICAL EDUCATXON +
SCHOOLS
Natlonal Rerrldent Matching Program
-
APPENDIX L
POLICIES OF STAI e BOARDS OF MEDICAL EXAMINERS FOR INITIAL LICENSURE FOR GRADUATES OF U.S. MEDICAL SCHOOLS
state Wrlften Exam
Endorsement of Natlonal Boards
(NB)
Length of flme NBS
are endoreed?
Graduafe lralnlng Required
No. of Yrr. of Graduate Tralnlng
Requlnsd
Alabama Yes’ Alaska Yes Arizona Yes Arkansas Yes California Yes Colorado Yes Connecticut Yes Delaware Yes District of Columbia Yes Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky
Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska
Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon
Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands
Virginia Washington West Virginia Wisconsin Wyoming
Yes Yes No
Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes2 Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes No Yes Yes No
Yes Yes Yes Yes Yes
NL NL
15 yrs. or See2 -
5 yrs. or See2 NL - NL NL
10 yrs. NL NL NL NL NL NL NL * NL NL - NL - - NL NL NL NL - - NL
NL - NL NL NL NL NL NL
Seer 5 yrs. or See2
NL NL NL NL NL NL - NL NL -
NL NL
8 yrs. NL NL
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes No Yes Yes Yes
No Yes Yes No Yes Yes7 Yes No Yes7 Yes
Yes Yes7 Yes Yes Nag Yes Yes No Yes10 Yes
Yes Yes Yes Yes Yes No Yes Yes Yes Yes
Yes Yes Yes Yes Yes
1 1 1 1 1 2 1 1
13
14
25 1 1 1 0 1 1 1
0 2s 1 0
1 1 0
1
2s
1 0
0
1
0 1
1 1
No - Implies no or not required. NL - Indicates no limit. ‘Applicant must pass an oral examination if 10 years have elapsed since last licensure examination. 2Oral examination required. 3Or 5 years licensed practice. 4As of 9/l/85,3 years for graduates of non-board-approved schools. sApplicant must be “board-eligible” by an American Specialty Board. 811 graduated before 1970, only one year of graduate training is required. 7At discretion of the board. sAt board discretion, years of licensed practice may be substituted for training requirement. sAfter July 1,1985, 1 year of acceptable postgraduate hospital training will be required. lOFirst year of residency in pathology and psychiatry not accepted.
Source: AMA. Medical L.icensure Statistics 1983 and Licensure Requirements 1984.
APPENDIX tf
POLICIES OF STATE BOARDS OF MEDICAL EXAMINERS FOR PHYSICIANS TRAINED IN FOREIGN COUNTRIES OTHER THAN CANADA*
State
Flequlres ECFMG
Certificate Before
Admlsslon to FLEX
Permits Candldate Wlthout
U.S. Tralnlng to Take FLEX
Number of Years of
Accredited U.S. or
Physlclans Who Endorses the Canadian Complete a Fifth Canadian Graduate
Permltr Pathway Program Certificate ECFMG Medical Partial Are Qualified (LMCC) When Certificate Education Retake Llcensure Held By an Required for Requlred for of FLEX Candldates FMG Llcensure Llcensure
Alabama Yes No No Yes’ Yes Yes Alaska Yes No No No - Yes Arizona Yes No No Yes1 Yes* Yes Arkansas Yes No No No No Yes California No Yes Yes Yes No No Colorado Yes No No Yes No Yes Connecticut No No Yes Yes Yes No Delaware Yes No Yes No No Yes District of Columbia Yes No No Yes No Yes
1 - 3 1 13
1
2 1 1
Florida Georgia Guam7 Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky
Yes Yes - Yes Yes Yes9 Yes Yes Yes Yes
Yes4 No Yes+5 WO Yes 14
No No Yes’ No Yes 1'3
Yes Yes No No Yes 2 No No No No Yes 2 No No Yes Yes Yes 3s No Yes Yes Yes10 Yes 1 Yes No No Yes1 1 Yes 2 No No Yes Yes Yes 1 No No Yes No Yes 1 No No Yes Yes Yes 3
Louisiana Yes No No Yes’* No Yes 3 Maine Yes13 No No No No Yes13 3 Maryland Yes No No Yes Yes Yes 1 Massachusetts Yes Yes No Yes No Yes board discretion Michigan Yes No No Yes No Yes 1 Minnesota Yes YesI Yes Yes Yes Yes 1 Mississippi Yes No No Yes’* No Yes 3 Missouri Yes No No Yes No Yes 1 Montana Yes No No Yes. No Yes board discretion Nebraska Yes No No Yes No Yes 1 Nevada Yes No No Yes6 No Yes 1'5
New Hampshire Yes No Yes16 Yes Yes Yes 217
New Jersey No No Yes Yes’ No No 1'6
New Mexico Yes No No No Yes Yes 1
New York Yes No Yes’9 Yes Yes*0 Yes 3 North Carolina Yes Yes No Yes5 No Yes 1 North Dakota Yes No Yes Yes’* Yes Yes 1 Ohio Yes No No Yes’ Yes Yes 2 Oklahoma Yes No No Yes5 Yes Yes 1 Oregon Yes No No Yes’* No Yes 3 Pennsylvania Yes No No Yes’ Ye@ Yes 1
Puerto Rico No Yes Yes Yes No No 1 Rhode Island Yes No No Yes Yes Yes 2 South Carolina Yes Yes No No No Yes 322 South Dakota Yes No No Yes1 Yes Yes 1 Tennessee Yes No No No Yes*’ Yes 1 Texas Yes No No Yes1 -5 Yes23 Yes 3 Utah Yes No No Yes Yes Yes 1 Vermont No No Yes Yes’ No No 1
APPENDIX t'i (CON'T)
POLICIES OF STATE BOARDS OF MEDICAL EXAMINERS FOR PHYSICIANS TRAINED IN FOREIGN COUNTRIES OTHER THAN CANADA’
Stat0
Requires ECFMG
Certlflcato Beiore
Admlaslon to FLEX
Permlta Candldate Wlthout
U.S. Tralnlng to Take FLEX
Permits Partial Retake
of FLEX
Number of Year8 of
Accredited U.S. or
Physicians Who Endorses the Canadlan Complete a Fifth Canadlan Graduate Pathway Program Certificate ECFMG Medlcal
Are QuaIltIed (LMCC) When Certificate Education Llcensure Held By an RequIreid for Required for
Candldates FMG Llcensure Llcensure
Virgin Islands Yes No No No No Yes 1 Virginia Yes No No Yes Yes5 Yes 1
Washington West Virginia Wisconsin Wyoming
Yes Yes Yes Yes
No No No No
No No No No
Yes Yes’ Yes’ Yes
~024 Yes’0 Yesa’ No
Yes Yes Yes Yes
‘NOTE: This summary should be verified by direct communication with the corresponding officer of the licensing board in the state in which the physician is interested. /NALL STATESlicenses based on the endorsement/acceptance of a physician’s credentials are granted to those physicians meeting all state requirements. - AT THE DISCRETfON OF THE LICENSING BOARD. Additional information provided by the states follows on page 24.
Yes-Implies Yes No-Implies No or no requirement. -Indicates that state did not respond to the question.
‘After completion of an additional 12-month medical postgraduate program. 2With 3 years postgraduate training in an accredited U.S./ Canadian training institution. JOne year in CA, 2 in other states. ‘One year accredited graduate medical education or 5 years licensed practice in state or country is required. slf passed the ECFMG exam or FMGEMS. 6As of 9/l/85,3 years for graduates of non-board- approved schools. ‘Applicant must be “board-eligible” by an American Specialty board. sTemporary until permanent rule. SOr Visa Qualifying Examination. ‘OOnly if graduate of state-approved medical education program. l1 With 2 years of medical postgraduate training. 12May be counted as 1 year of required postgraduate training. ‘3ECFMG certification (subsequent to July, 1984) obtained on a basis of FMGEMS on/v. VQE, if successfully passed, accepted as a substitute for FMGEMS. “Must show evidence of being admitted to accredited graduate residency training program. IsThree years total in NV. ‘eOnly if originally taken in NH. “At board discretion, years of licensed practice may be substituted for training requirement. ‘8Additional training may be required. ‘9A candidate may retain credit for parts of the examination passed for a period not to exceed 3 years from the examination date. At that time, such candidate shall be reexamined in all parts, mProvided all other licensure requirements are fulfilled. 2’lf passed after May, 1970 (PA); l/1/78 (WI). If passed before lllff8 (TN). 22Graduate education must be in U.S. 231f passed the ECFMG exam. If the Medical Council of Canada was passed after l/l/78, candidate must also pass Day Ill of FLEX. 24LMCC credited for Days II & Ill of FLEX for all MDs.
Source: AMA. US Medical Licensure Statistics 1983 and Licenswe Requirements 1984
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
REFERENCES
Crowley AE. Graduate Medical Education in the United States, 1984-85. JAMA, September 27, 1985; 254:lZ.
ECFMG. Personal Communication, October 7, 1985.
Report to Congress on Physician Exchange Visitor Programs. Bureau of Health Professions, PHS, DHHS, May 1983.
General Accounting Office. Federal, State, and Private Activities Pertaining to U.S. Graduates of Foreign Medical Schools. Sept. 27, 1985, GAO-HRD-85-112.
General Accounting Office. Policies on U.S. Citizens Studying Medicine Abroad Need Review and Reappraisal. November 21, 1980; HRD-81-32.
Samuel P. Asper, MD, MACP, Deputy Executive Vice President, American College of Physicians. Letter to Andrew Pattullo, Sr. Vice President, W.K. Kellogg Foundation, June 20, 1980.
Goodman LJ and LE Wunderman. Foreign Medical Graduates and Graduate Medical Education. JAMA 1981; 246:854-858.
Graetti nger JS. NRMP Data, March 1985.
Crowley AE et al. 254:lZ.
Undergraduate Medical Education. JAMA, September 27, 1985;
Graduate Medical Education National Advisory Committee. Summary Report, September 30, 1980; Public Health Service, DHHS; HRA-81-651, April 1981.
American Medical Association. U.S. Medical Licensure Statistics 1983 and Licensure Requirements 1984. Chicago, IL: 1985.
