USMLE and residency

Introduction of the new work permit laws in the United Kingdom may mean that training opportunities have become tougher for international medical graduates. These sudden changes have left many doctors feeling anxious and uncertain about their medical careers. For this reason, further training in the United States, via a residency programme, is being considered a more favourable and secure option. The exam and selection process for a residency programme may seem long and arduous and discourage candidates. We aim to highlight how to make the process as smooth as possible, enhancing your chances of getting the residency programme of choice.

Why USMLE
All doctors wishing to practise in the United States have to take the United States Medical Licensing Exam (USMLE), irrespective of whether they are US graduates or international medical graduates. International medical graduates may take the USMLE to apply for a residency programme, research programme, or work in a superspecialised area. Once you have passed the USMLE and have been certified with the Educational Commission for Foreign Medical Graduates (ECFMG), there is no distinction between international medical graduates and US graduates when applying for programmes.

Whats is residency?
Residency is a period of training (equivalent to senior house officer level) an individual has to do after graduating from (US) medical school. It lasts three to eight years, depending on the specialty. For licensure in the United States you have to complete residency training and step 3 and have ECFMG certification. After this you can apply for a fellowship (equivalent to specialist training).

What is USMLE?
The USMLE has several steps: step 1, step 2 clinical knowledge and clinical skills, and step 3.

Step 1 is an eight hour multiple choice exam and tests basic medical sciences such as anatomy, physiology, biochemistry, and microbiology and their clinical applications. It is a computed exam and it can be taken in several parts of the world, including the United Kingdom.

Step 2 clinical knowledge is a nine hour exam and tests the clinical specialties such as internal medicine, surgery, obstetrics and gynaecology, and psychiatry. This is also a multiple choice computed exam, and it can be taken in several parts of the world including the United Kingdom.

Step 2 clinical skills tests an individual's clinical skills and ability to communicate with patients and can be taken only in the United States. Participants must register for the exam before 1 July and take the exam by 31 December to qualify for a residency starting the next year.

Step 3 tests the clinical management of patients and is administered only in the United States. The programme will normally specify if step 3 should be taken before or during residency.

The step 1 and step 2 exams may be taken in any order. To register for the exams go to www.ecfmg.org for steps 1 and 2 and www.fsmb.org for step 3. All associated costs are listed on the application form.

USMLE Scores
Scoring highly in the USMLE step 1 and step 2 clinical knowledge exams makes the difference between getting a cutting edge residency programme and an average one. In general, scoring 75 percentile (60% to 70%) is enough to pass step 1 and step 2 clinical knowledge, but may not be enough to get into a residency programme. Exams cannot be retaken to improve a score once an individual has passed. You should aim for percentiles in the late 80s and early 90s for an internal medicine residency and late 90s for a surgical residency.

USMLE Preparation
Preparation times range from three to six months for step 1 and step 2 clinical knowledge and one to two months for step 2 clinical skills. It is worth starting study by January 2007 for a residency starting in July 2008. Generally residency programmes like candidates to have less than five years' experience after graduation, so starting the USMLE process soon after graduation is advantageous. However, this varies from programme to programme and scores on the USMLE are particularly important, as are further degrees such as membership of the Royal College of Physicians and strength of the application.


How to apply for residency programme
Before applying for a residency programme you have to be ECFMG certified. This requires your medical degree, medical school transcripts, and step 1 and step 2 clinical knowledge and clinical skills scores.Then you need to enrol in the National Resident Matching Program and apply for a residency programme using the Electronic Residency Application Service. There is no limit to the number of programmes you can apply for, but each application has to be paid for. Programmes rank candidates and in turn candidates rank programmes through the matching programme, essentially leading to a "match." The matching programme main match is defined as "an impartial venue for matching applicants' preferences for residency positions with program directors' preferences for applicants." Matching takes place in March, and both the candidate and the programme are legally bound to the outcome of the match. Residency programmes prefer candidates who have some US hospital experience, so enrolling for an elective in the United States may be something worth thinking about. A letter of recommendation from a US consultant is high on the list for a residency match, but letters from UK consultants may be the next best thing. A detailed personal statement is also required.

Timeline
Ideally a candidate should spend about two years preparing for residency. However, this depends on the individual and in some cases preparation can be achieved in a year. The following guide is for candidates wishing to start a residency in July 2008²:

• Begin study for step 1 and step 2 clinical knowledge in January 2007 (January 2006 at the earliest and March 2007 at the latest)
  
• Step 2 clinical skills should be applied for before 1 July and taken before 31 December 2007
  
• Complete step 1 and step 2 clinical knowledge exams by August 2007
  
• Consider attending observerships in the United States before submitting an application for residency as this is a bonus point on your curriculum vitae
  
• Submit residency application by October 2007 as interviews are generally held in November or December
  
• Scores for step 1 and both steps 2 should be submitted by December 2007 at the latest
  
• Rank programmes in February 2008
  
• Match in March 2008
  
• Residency starts in July 2008.
  

You should allow enough time for getting letters of recommendation from referees. You may also need to get advice on writing a personal statement and interview preparation. If you are not called for interview it is highly unlikely that you will be offered a residency position.

Matching
There are three opportunities to match. The main event is the match in March. After this there is a post-match scramble, where a list of unfilled vacancies from the match is posted on the Electronic Residency Application Service and unmatched candidates have an opportunity to obtain a position. Lastly, www.findaresident.com also posts unfilled positions.

Preparing in UK
You can obtain USMLE videos and notes from this site:
http://www.usmlestep.com/