FELLOWSHIP WITHOUT / BEFORE RESIDENCY : PART 2

I have been so totally smitten by the latest show on Discovery channel called "Man vs Wild"! and the host, survival expert Bear Grylls, has joined the ranks of my inspiring heroes of entrepreneurship and innovation. In the latest show on surviving a hike across the stunning beautiful Alaskan Mountains, he says,:

"One of the core tenets of survival is to be open to every single opportunity".

And since this blog is about helping Medical grads explore all possibilities & opportunities into the medical practice scene in the US, I thought I might just mention it.... Awwrity then ! Enough of trying to set up the mood, let's look at the Fellowship entrance scene for IMGs in USA a little more closely....


Do you need to take USMLE Steps for direct fellowships ?

One of the first questions that IMGs ask and hope to hear a "No" is: Is taking USMLE Steps needed to do clinical fellowships in USA without a US Residency ? Unfortunately, the answer is a "Yes" and in fact, IMGs need to be ECFMG Certified before beginning any clinical or clinical-research fellowship.

So how do you apply to such positions ?

- The NRMP Fellowship Match. As the NRMP Fellowship site says: "Applicants who have not completed prerequisite training in an accredited ACGME program in the U.S., or a similar program in Canada accredited by the Royal Colleges of Physicians and Surgeons of Canada, must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG)". Note that this is is a pretty tough pathway for IMGs without a American Residency.

- Looking at unfilled positions after the Match. It's a good idea to begin a dialogue with fellowship program directors by contacting via email or phone and expressing an interest and making inquiries about whether your home-country residency is recognized. Start with programs hosted by places that are known to be IMG friendly to gather information about their requirements and your eligibility.

Eligibility:

You should have completed a 'approved residency' in their home countries (MD / MS or other post-graduate medical / surgical degree that are recognized in the US) and should be ECFMG certified by the time of starting the fellowship.


Some Examples of eligibility criteria:

Total Joint and Adult Reconstructive Fellowship for International Physicians at Stanford:-

"Eligible orthopaedic surgeons will have recently completed their orthopedic training, be board certified in their home country and hold junior academic teaching positions at their home institutions."

Cardiothoracic Surgery Fellowship at Baylor College of Medicine:-

"Applicants for the program must have completed an approved residency in General Surgery within either the United States or their home country by the time they are to enter the program."

Breast Imaging Fellowship at University of Washington at Seattle:

"Radiology Board certification in your home country, Washington State Medical License and an Approved work visa"
Note: Interested IMGs should take note that the above program also offers observerships called 'mini-fellowships' for a fee - information on this is present on the same link provided above.

The Prestigious Washington University at St. Louis, Missouri, is also known to offer Radiology fellowships to IMGs directly without residencies.

Update: I just heard about a dude getting a direct Cardiovascular Imaging Fellowship at the Cleveland Clinic - ofcourse he had 99/99s and did a Radiology residency from one of the top places in India.

What after completing the fellowship without residency? Can you practice like other 'regular' docs ? Do you still need to do a Residency ?

I fancy imagining the Residency-Fellowship system like a tunnel with two inlets - the Residency entrance and the Fellowship entrance. And this is a tunnel with a difference : After taking the Residency route, you may exit mid-way and get yourself a good job, but if you take the Fellowship entrance, the mid-way exit in this case leads back to your home-country or rarely, some limited license, low-paying jobs in underserved areas. But yes, you may either continue forwards towards the Residency side or get back onto the Fellowship side to do another fellowship.

Why so from the Fellowship entrance ? Because, Almost all physician jobs need you to be 'Board Certified' - or at least 'Board Eligible'. A Fellowship without a residency does not grant you Board Certification - Nor does it grant you Board Eligibility in the specialty.

Here's how the normal route to Board Certification works for IMGs :

Medical School --> USMLE Steps --> ECFMG Certification for IMGs --> Limited / Restricted practice License (Residency) --> Step 3 --> Unrestricted State License --> 'Board Eligible' --> Take Board Exams --> 'Board Certified' --> Fellowship / Sub-specialty training --> Sub-specialty certified

Thus, in the American System, the Physicians who complete all requirements for board certification except the Board examination may be identified as "board-eligible." Do note that the American Board of Medical Specialties (ABMS) has officially scrapped the term "Board Eligible" - but job advertisements continue to use the term.

If you were to search for specialist jobs in physician career sites or sites like Monster.com, careerbuilder.com, you will read job requirements like these samples I came across:

"Sioux Valley Health System is looking for BC/BE physicians in primary care and various subspecialties to practice in rural and metro practice locations" - BC/BE = Board Certified / Board Eligible

"Lehigh Valley Hospital, a premier academic community hospital in southeastern Pennsylvania seeks a BC/BE oncologist for a superb, expanding group practice"

"Mayo Clinic is expanding its cardiology practice in Jacksonville, Florida, and is seeking board-certified/board-eligible cardiologists in three subspecialties"

" The Department of Radiology at Boston Medical Center has an opening for a board certified breast imaging radiologist."

"American Clinical Resources, ACR, has an excellent opportunity for a Locums Radiologist to help our nation’s military at Oak Harbor Naval Hospital while enjoying the great outdoors in beautiful Washington. Earn 225$/Hour. Requirements - Board Certified or Board Eligible, WA State License, BLS"

"Explore the possibilities at the Veterans Affairs Medical Center, a primary care medical center in Erie, Pennsylvania. Full-time Urologist position is available in our Surgical Care Program.Board certification in Urology or board eligible within four years of residency or fellowship is a requirement for this position."

In short, a residency is pretty much unavoidable if wish to continue staying in the USA and get good academic or other employment positions. The bright side of this is that US-Fellowship trained IMGs may stand a better chance at the corresponding residencies than fresh IMGs without US clinical Experience - often in the same place they did their fellowships at. The dark side of doing a residency after the fellowship, if I dare call it so, is that you might experience a 'boss-reversal' ;-) i.e. The guys who worked 'under' you as residents may become fellows at the same program while you become a resident there.



Take home points:-

1. Direct Fellowships without Residency in USA is possible for IMGs
2. Such positions are best sought by directly contacting fellowship program directors and beginning a dialogue.
3. IMGs must have completed post-graduate medicine / surgery in home-countries.
4. IMGs must have finished USMLE steps and should have obtained ECFMG certification before starting fellowship
5. Job Opportunities in USA are highly limited after fellowships without residency, if any - A residency must still be done to be board certified and eligible for well-paying jobs.
6. It's a great option for IMGs who wish to go back to home countries after the fellowship.
7. Fellowship directors like research and US clinical experience (observerships, externships, etc. ) - try to have that on your resume !



IMGs are known to secure Radiology, Ophthalmology and Orthopedic Fellowship along this route on both J1 and H1 visas (J1s preferred by programs)

Check out this list of Fellows at the University Iowa Health Care Ophthalmology Fellowship programs - you do see some profiles of IMGs who came for direct fellowships





Disclaimer: This topic is wrought by fuzziness, inconsistencies and lack of enough experiences. I may be wrong in some areas and I welcome corrections from readers with first-hand experiences or knowledge. Which also means that the content of this post may change periodically :-)