Practising in the United States

Editor—I would like to clarify a few points raised by Katherine Brazzale in her useful article in June's studentBMJ.¹

1. 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 Brazzale implied.
2. Medical licensing is done at a state level, with each state stipulating its own specific requirements for licensure. None the less, many states require applicants for licensure to pass all three steps of the USMLE exam within seven years. Michigan requires applicants to pass all three steps within five years.
   
   Doctors who aspire to practise medicine in the United States should consider the timeframe in which they are able to complete all three steps of the USMLE exam.
   
   There is no need to sit USMLE step 3, however, unless you want a full license to practise medicine independently in a given state. ECFMG certification is sufficient to get a limited license for participation in residency programmes. None the less, ECMFG requires foreign medical graduates to begin training in an accredited program within a specific number of years after passing the first USMLE exam (either step 1 or step 2).
    
3. The bell curve in the US is very flat, and that is reflected in the residency programmes too. The quality and quantity of teaching in residency varies greatly between programmes and even within a single institution. The morale of the residents also varies considerably between different programmes.
4. Generally, residents work far longer hours in the US than do their counterparts in the UK. Also, despite recent improvements, there are still many places at which residents are on-call “q3”—that is, one in three.
5. 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.

1. Brazzale K. Step by step. studentBMJ2005;13:238-9.