Step by step

Many doctors are lured to the United States to practise medicine. But getting there is a drawn out and costly process, as Katherine Brazzale explains

I am immensely proud of the fact that I survived my gruelling house officer year in the United Kingdom and became a fully registered member of the General Medical Council. I am also proud of the fact that throughout medical school I had not had to resit a single exam. However, my life has since become more complicated following my liaison with an American. I decided to embark on the lengthy paper trail that would lead to a license for a residency position in the United States.

The whole process began with acquiring certification from the Educational Commission for Foreign Medical Graduates, to enable you to take the United States Medical Licensing Exams. This involved getting transcripts from my university - a complete breakdown of my grades and reports over the duration of the course, a dean's letter (sealed), copies of my medical school diploma, and a "certification statement" signed by the dean to verify that these documents and photos are indeed of me. Collating all this, while working every daylight hour, was no mean achievement considering the hospital I was working at was nowhere near my university. But thankfully the university was used to such circumstances, and made my life as easy as they could.

After I had posted the paraphernalia to the US, I had to wait to see if I was deemed suitable. Inevitably, this was peppered with several hitches - many documents were lost in the unreliable UK postal system. Eventually, having coughed up more than £600 ($1100; &#euro;870), I was sent a fluorescent orange permit to enable me to schedule my first exam.

When initially applying, I was asked to specify where in the world I wanted to take the exam. To take it outside of the US incurs an extra cost (I took mine in the US). On the permit you are offered a three month window within which to sit the exam. In the UK, there is only one centre and it is in London. These centres do not only cater for the US step exams but for lots of others too. They therefore get very busy, so it is necessary to arrange the exam early to ensure that the test centre is not already completely booked.

Once scheduled, you can postpone the exam so long as it is more than five working days before the original date chosen. You can also change location - but only within the US or country originally specified. You cannot change countries. Should you need to do this, you have to wait until that scheduling period is over and renegotiate your plight.

Forgotten memories

I found Step 1 the hardest. For those who have already graduated and been practising, it is very difficult to dredge up all those preclinical memories. The syllabus covers long forgotten subjects such as biochemistry, genetics, and physiology. The Krebs cycle, metabolic pathways, eponymous metabolic diseases, and rare genetic disorders are favourite topics for baffling the examinees. Revision of embryology, anatomy, and neuroanatomy was arduous. Clinical experience had long ago told me that knowledge of metabolic pathways and of purines and pyrimidines is not instantly applicable to everyday practice within the hospital setting.

The exam questions are in blocks of 50. I am sure that these multiple choice questions are designed to confuse you - every likely option is listed.

You can take a break totalling 45 minutes throughout the day, distributed as you see fit. But breaks are forbidden in the middle of a block. At the end of each of the seven blocks, you can either continue with the next one, or to leave your computer and reacquaint your eyes with the daylight.

To say that this exam is tiring is a severe understatement. It is taxing, exasperating, and exhausting. By the end of block seven I was seeing stars and almost willing to put any answer, just so long as I could get out of the freezing air conditioned, neon lit, room.

Step 2 is scheduled via the same procedure as Step 1, but, thankfully, having already proved my academic achievements, I only needed to resubmit a signed certification statement - something that is fairly easy to attain. This exam is clinically based, and despite it being as long, it was less tricky for me as it was based upon recent working practice.

One for the foreigners and US citizens alike

This left one more exam - the clinical skills test. This has recently replaced what used to be a clinical skills section required for foreign graduates only. This new exam is for US citizens and foreign graduates alike. Arranging it was difficult. It must be taken at specialised centers, and there are only a few of these, all of which are in the US.

Further delay was caused by the fact that US graduates all leave college at set points in the year. This means that the number of US students far outweigh the foreign graduates in certain months. Conversely, at the time I was due to take it, there was an oversubscription of foreign graduates. Much to my irritation, the authorities closed certain centres to foreign graduates in an attempt to maintain equal numbers of foreign to US applicants. This meant that getting a space within a month of my Step 2 exam was based purely on chance. I scanned the computer every day and leapt as soon as a slot became free, scrambling to book my airline ticket to one of the designated locations, in my case Atlanta.

The timing of this exam leaves much to be desired. Once again, it is an eight hour ordeal, but for the small number of centres to cater for the many medical graduates, sessions are scheduled for morning or afternoon. Morning sessions begin at 8am and afternoon ones start at 3 pm and finish at 11pm at night. This means, whichever session you are scheduled for, an overnight stay is a necessity. The exam fee alone is about $1000, but when flights and hotel rooms are factored in, failure is financially devastating.

Strange signs

Unlike my medical clinical finals, for which I had real patients with real clinical signs and histories, these patients were all actors. This made nonsense of any more subtle clinical signs that in practice, many of us illicit. The actors would often fail to pick up on these - hence asking the patient to sit up (when secretly looking for signs of peritonitis, rigidity, or pain) would result in the actor following your instruction but failing to exhibit the expected sign. Thankfully, there was at least the opportunity to write up full notes after each clinical encounter, meaning such observations could be clearly documented.

Another amusing aspect of the clinical encounter would be the obvious question that each "patient" had been primed to ask. After the first two encounters it became very apparent that each had a specific query, and coping with this question in a non-committal and polite manner was all part of the task.

We saw patient after patient in a very regimental way - with a short break and a vast array of food provided in the middle. By about 9 pm, my energy was flagging. We were strictly policed at all times hence chatting about previous cases with colleagues was unthinkable. Besides, we were all so focused that break times were relished as a chance to take a deep breath away from these strange constructed scenarios. The patients (actors) actually mark your performance themselves which, bearing in mind their clinical knowledge, I found quite distressing. Thankfully clinical professionals mark the notes you write after each encounter.

It is necessary to pass in all of the three categories being tested - ability to communicate well in English, ability to perform an adequate clinical examination, and ability to clearly document notes with recommendations for continued evaluation methods.

The timing of all these exams is crucial if you want to apply for a residency programme. All residency programmes start in July, so anyone currently doing a house officer job in the UK, cannot make an immediate switch because first year rotations finish in August. To do so, you need to make special arrangements to avoid jeopardising your GMC registration.

Applications for residency programmes begin as early as October the preceding year with the first rounds of interviews taking place in late November. Unbeknown to me at the time, you do not have to have all your examination results, meaning that you can still apply even if you have not yet sat the exams.

The residency programmes in the US offer better job satisfaction, education, and experience than the UK. I had two hours teaching a week in the UK (and half of that was repeated lectures, or I, or even the lecturer himself, often could not make it due to commitments on the ward), I was astonished to find that the residents had at least two hours a day - which was protected and highly informative.

Only a few regrets

My biggest regret is not having tackled Step 1, if not Step 2, while still in my preclinical years at medical school. I do not yet know whether this year will prove lucky for me, but I want to work here in the US, despite the many difficulties. It seems to be more fulfilling, with a better work ethic and more appreciation of time and effort. The exhaustion, bitterness, and disappointment I witnessed in my seniors while working in the UK has resulted in my career path definitely lying outside of Britain.

Since writing this article, Katherine Brazzale has been successful in her residency applications, taking up a place at the University of Florida. She begins in June, and will be studying at the Shands Hospital for the next three years.

Katherine Brazzale doctor, USA
Email: Drkate.brazzale@zoemail.net


studentBMJ 2005;13:221-264 June ISSN 0966-6494

   

           

	CAREERS Step by step       Katherine Brazzale(June 2005)
	Wen-Hann Tan December 3rd, 2005       doctor, USAwtan@partners.org
	I would like to clarify a few points in this useful article by Katherine Brazzale: Certification by the Educational Commission for Foreign Medical Graduates (ECFMG) can only be obtained after a foreign medical graduate has passed both USMLE Steps 1 and 2 (including the clinical skills exam). It does not "enable" a person to sit for the USMLE exams as she had implied. Medical Licensing is done at a State level, with each state stipulating their own specific requirements for licensure. Nonetheless, many states require applicants for licensure to pass all 3 steps of the USMLE exam within a 7 year period. Michigan requires applicants to pass all 3 steps within a 5 year period. Those who aspire to practise medicine in the USA "in the future" should consider the time frame in which they are able to complete all 3 steps of the USMLE exam. However, there is no need to sit for USMLE Step 3 unless one wants to obtain a full license to practise medicine independently in a given state. ECFMG certification is sufficient to obtain a limited license for participation in residency programs. Nonetheless, ECMFG requires foreign medical graduates to begin training in an accreditated program within a specific number of years after passing the first USMLE exam (either step 1 or step 2). The bell curve in the US is very flat, and that is reflected in the residency programs too. The quality and quantity of teaching in residency varies greatly between programs, even within a single institution. The morale of the residents also varies significantly between different programs. Generally, residents work far longer hours in the US than their counterparts in the UK. Moreover, despite recent improvements, there are still many places where residents are on-call "q3", i.e. 1-in-3. There is no standardised pay for residents in the US, and there is no system of pay banding nor "Additional duty hours". Consequently, on a 1:1 exchange rate, residents are generally paid less than their equivalent counterparts in the UK. Depending on the location, the cost of living is not necessarily lower than that in the UK. This can be a great country to train in, but it is not without its faults, and it is important to remember that the grass is not greener on the other side of the pond -- it simply tastes different.