IMG Anesthesiologists planning Direct Fellowships: Good News...

Thanks to a pilot program designed pretty much on the same lines as the alternate pathway for board certification for Non-US trained Radiologists that I blogged about before, IMG anesthesiologists (i.e. IMGs with MDs in Anesthesiology in a Non-US country ) too can now qualify for American Board certification in Anesthesiology after Direct fellowships in US without having to do a residency again ...

So ! the new part is not really about direct fellowships without residency - ( IMG anesthesiologists have been doing than since years now ) - but what's new is the fact that after a fellowship, there is no need to do a residency again to qualify for Board certification.

To revise, to get a complete access to the US physician job market, you first need board certification in your primary specialty - but before that you need to be 'board eligible'. Most American boards need completion of a ACGME certified residency to be board eligible, but because of short supply and increasing fellowship branches, a few boards are relaxing some rules to take advantage of foreign-trained qualified residency-trained docs.

Here's what the 2007 newsletter of the American Board of Anesthesiology says:

" The ABA has approved a seven-year pilot program that would allow international medical graduates, certified by the national anesthesiology organization in the country where they trained in the specialty and practicing anesthesiology in the United States, to qualify for entrance into the ABA examination system for initial certification in the specialty at most once via an alternate entry path.

- International medical graduates interested in using the alternate entry path must complete a total of four years of prospectively approved, continuous experience in one anesthesiology department that commences on or after July 1, 2007.

- At the time the anesthesiology department enrolls the international medical graduate with the ABA, the department must have an ACGME-accredited anesthesiology residency or fellowship training program that has continued full accreditation and a review cycle of three years or more

- An anesthesiology department can have no more than two international medical graduates enrolled in the pilot program at one time.

- the department chair must submit to the ABA a four-year plan, co-signed by the physician, for prospective approval by the ABA Credentials Committee. This experience will consist of four years of resident or fellowship training, research, faculty experience or combination thereof, in the same institution in which the anesthesiology program resides. "

Pretty much like the Alternate pathway designed by the American Board of Radiology eh...

Check out some more details here

American Board of Anesthesiology


So good luck fellas - and maybe you too would make it to the news for buying million dollar homes like this IMG anesthesiologist ;-). Not too long ago, the American Board of Anesthesiology did allow IMG anesthesiologists to get board certified with direct fellowships without residency, but stopped it for some reason.


Also Read:

- Nurse Anesthetists: Nurses who earn more than some docs in U.S.
- Anesthesiologist Incomes in the USA
- Average Malpractice Rates for U.S Anesthesiologists in 2007

USMLE Step 3 & Direct Fellowships Without Residency

This is just a short post to bring it to the attention of direct fellowship seekers that passing the USMLE Step 3 prior to start of training is a requirement for fellowships, irrespective of your need for a H1b visa. Most (or maybe all) fellowship programs need incoming candidates to be eligible for state licenses before the start of the fellowship and hence Step 3 will be needed whatever your visa / Immigration / Citizenship status might be.

Am putting this up since I happened to know of someone who failed his step 2 CS, thus delaying the eligibility of the ECFMG certificate, which in turn delayed the eligibility to take the Step 3 exam and he lost out on the year despite quite a few direct fellowship interviews.

As far as I know, this is true for all states in America but if there are changes to this information, this post will be modified.



Also Read:

- Top reasons to take the USMLE Step 2 CS Early
- Step 3 and the H1b visa connection
- USMLE Step 3 - CCS Tips and Tricks



Search keywords to this article:

- "is Step 3 compulsary for direct fellowship without residency"

FELLOWSHIP WITHOUT / BEFORE RESIDENCY: PART 1

Not all roads in life are one ways ! A residency is not the only way for IMGs to get entry into the medical scene in US - an alternative 'short-cut' for IMGs to do fellowships without first doing a residency does exist- of course you need to have a Post Graduate MD in the field in your home country first.

What ! Vacant Fellowship Positions in US with all this competition for residencies ? Yes, there are and you may find vacancies in even high competition specialties like Radiology too...not easy of course, but definitely possible after efforts (may get tougher as more IMG home-country-Post Graduates consider this option). For example, in 2006, only 54% fellowship positions in Radiology were filled - See the official statistic here


We shall look into the technicalities in a subsequent post, here lets analyze some reasons why fellowships are not always a choice for people after completing a residency in USA.


1. Economics ! Thinking in the shoes of the AMGs (American Medical Graduates) - Fellowships are a low-pay committment for AMGs after 3-4 years of Residency and with average post-medical school loans of $120,000/- to $150,000/- with accruing interests, a lot of them get out into the job-market to start earning the big bucks to settle off loans, get a house.etc. And once you get wired into a high-income lifestyle, family, etc., it's not that easy or sometimes even economically impossible to take a pay-cut. Contrast this to the comparatively minimal loans, if at all, that IMGs from low-cost medical school countries have. I am in no way suggesting that there aren't many AMGs doing fellowships, there are plenty. But this post rather attempts to explain why some fellowship vacancies still exist when logic would suggest the opposite given the high competition for residencies.

2. J1-Visa Issue: Those with J1 visas might prefer a waiver-job to fellowship since waiver-jobs are tougher to come by. The practical choice is often to get that green card in hand first and then consider fellowships later in life, rather than risking 2 years back in home countries. In fact, IMGs on J1 have been known to quit fellowships when a waiver job comes by.


3. H1-Visa Issue: Those with H1b visas too may consider first doing a job to get the labor certification required for green card eligibility, rather than being forced to leave the country at the end of 6-year and returning back after a year to reset the H1b visa tenure clock. (usually fellowships do not grant a labor certification). Again, in both visa cases, as life settles off with starting a family and lifestyle builds around the 150,000/$ a year salary, it's not always easy to revert to a low-pay fellowship lifestyle ( around 45,000$ to 60,000$ a year, depending on the city).


These facts apart, there is a general consensus that the IMG mindset is wired to make them more likely to take up fellowships than the AMGs.


Q. Are USMLE Scores Needed For such Direct Fellowships ?
A. Yes - In fact You need to Be ECFMG Certified before starting the fellowship. Read about ECFMG Certification Here.

Q. Which Visa is offered for such Fellowships ?
A. J1 is more commonly offered - though H1 is not impossible. H1b visa needs Step 3 scores just like for Residencies.

Q. Does this J1 for Fellowship have the 2-year home country residence requirement ?
A. Yes - any ECFMG Sponsored J1 will have that requirement. Read More about that Here.


Enuf food for thought Eh ?




So what AFTER completing such Fellowships - can you practice in USA ? The details are a little fuzzy yet - but do read some analysis on Fellowships Without Residencies - Part 2




Also Read:
- Visa Basics for IMGs

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 :-)