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Reference

AAMC

Association of American Medical Colleges

 

ATT

Authorization to Test

 

CK

Clinical Knowledge

 

CS

Clinical Skills

 

CTS

Continental Testing Service

 

ECFMG

Educational Commission for Foreign Medical Graduates

 

ERAS

Electronic Residency Application Service

 

FAIMER

Foundation for Advancement of International Medical Education and Research

 

FCVS

Federation Credentials Verification Service

 

FSMB

Federation of State Medical Boards

 

GME

Graduate Medical Education

 

IMG

International Medical Graduate

 

IWA

Interactive Web Application

 

NBME

National Board of Medical Examiners

 

NRMP

National Resident Matching Program

 

OASIS

On-line Applicant Status and Information System

 

PTAL

Postgraduate Training Authorization Letter

 

USMLE

United States Medical Licensure Examination

California Physician Professional Licensing Guide

1. How the Profession Is Organized in California
2. Eligibility for Licensing
3. Tests
4. Time and Costs
5. Other Careers and Credentials
6. Beyond Licensing
7. Important Links
8. Tips

1. How the Profession Is Organized in California

Regulation of MDs in California

The Medical Board of California regulates the licensing and practice of physicians in the state.

The medical profession, however, has a complex system of training and exams at the national level that you need to go through before you get to apply for a license at the state level.

As an International Medical Graduate (often referred to as an "IMG"), you will have to first become certified by the Educational Commission for Foreign Medical Graduates (ECFMG), which includes passing Steps 1 and 2 of the United States Medical Licensure Examination (USMLE).

You will then need to return to training, competing for a multi-year graduate medical education program (a "residency") and specialization. Often, competing successfully means that you may choose to relocate to a new state and adopt a specialization different than what you practiced before immigrating.

Your will have one or two application processes to complete with the Medical Board of California, depending on the state where you complete your medical residency:

  • Postgraduate Training Authorization Letter (PTAL): If you are accepted into a California residency program, you will need to apply for a Postgraduate Training Authorization Letter (PTAL) which gives you limited practice for the purposes of your residency.
    • California Physician License: You are eligible to apply for a Callifornia Physician License after completing two years of your residency in any state, and after passing the last USMLE test - the Step 3 exam.

      This article looks at all of these elements in detail, especially in its Eligibility for Licensing and Tests sections.

      Employment as an MD in California

      It is difficult and costly for an International Medical Graduate (IMG) to become licensed in the United States, but you can be successful. The American Medical Association reports that there are 22,230 IMG resident physicians in the U.S. California ranks 2nd in the U.S. for the number of IMGs in practice (post-residency) with 25,408. This represents 23% of the state's practicing physicians. As a result, you are likely to find many mentors in the California MD community to consult as you advance in this process.

      According to the Bureau of Labor Statistics, physician salaries are some of the highest professional salaries in the U.S.  Family practice often earns on the lower end of the scale where salaries of $190,000 are common, while the best-paid specialties, such as anesthesiology, can easily pay twice as much. Often, though, medical school graduates have a huge amount of debt to repay (U.S. medical school can easily cost $175,000!).

      Debt is one big influence on a medical student's choice of specialty. Other factors are an interest in ‘controllable lifestyle' specialties (with normal office hours), desirable geographic regions, or prestige programs. U.S. medical graduates usually have advantages in competition for residency, including familiar medical schools, career services support, and recent graduation. The competitive conditions that result can lead many International Medical Graduates to consider changing medical specialties in order to return to medical practice.

      Primary Care specialties such as family practice, internal medicine or Obstetrics and Gynecology provide more residency opportunities and there is high public demand for these doctors.

      Generally speaking, demand for doctors is increasing due to an aging U.S. population and expanded treatment options. Certain healthcare reforms may also increase demand; if more people become insured, for example, providing them with regular medical care should create more doctor demand.

      California's laws around medical malpractice limit the amount of money you as a physician can be ordered to pay a patient if you are found guilty of malpractice - of injury or loss caused by improper treatment. California allows a maximum of $250,000 in non-medical damages (money given to a patient to compensate for pain, suffering, disfigurement, etc.). This limit, also called a 'cap,' is viewed as favorable to physicians and lowers their cost of doing business because it controls the cost of malpractice insurance, which can be very high in states without a cap. The subject of caps is a controversial subject in medicine, however, since many people argue that caps favor the doctor and insurance companies at the expense of patients' rights.

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      2. Eligibility for Licensing

      This section explains 4 major steps that you need to complete before becoming licensed to practice medicine in California. They are:

      CA_Physician.png

      Each of these steps is complicated and involves a large investment of your time, money, and effort. They include foreign degree evaluation, multiple tests, and tough competition among doctors for placements. This topic will look at each one separately.

      i. Certification by the Educational Commission for Foreign Medical Graduates, or ECFMG

      The Educational Commission for Foreign Medical Graduates or ECFMG is the organization that certifies International Medical Graduates and qualifies you to compete for medical residency positions in U.S. teaching hospitals. For you to enter the certification program, your foreign medical school and its program at the time of your graduation must be listed in a special directory managed by the Foundation for Advancement of International Medical Education and Research: the International Medical Education Directory.

      The ECFMG Certification process

      • Your contact with the ECFMG Certification process starts when you register for a USMLE/ECFMG Identification Number and begin to build your profile. Be very careful to give accurate information from the beginning; if you need to fix any errors later in the process it will require documentation and can be expensive.
        • ECFMG will not process any information until you submit an application for one of the United States Medical Licensure Exams (USMLE): either Step 1 or Step 2 Clinical Knowledge exams, or both. At this point you should also submit your medical credentials.
        • Your file will grow to include test results and all required documentation. You need to meet all testing and documentation requirements to be approved for certification.

          Online services

          ECFMG offers these services through paper forms or an online system. The online system includes full application services in its Interactive Web Application (IWA). Another important online tool is the On-line Applicant Status and Information System (OASIS), which helps you collect important details about your profile and track the status of applications and test results.

          Here are a few highlights of the required documentation and testing you will complete before receiving ECFMG Certification (this is not a complete list):

          Medical education credentials:

          • A certification statement or certification identification form from your medical school
          • Final medical school transcript, including any transfer courses
          • Medical diploma

            Examinations:

            • USMLE Step 1
            • USMLE Step 2: this is a test taken in 2 parts, Clinical Knowledge and Clinical Skills (called "CK" and "CS", respectively)
            • Note: passing the TOEFL is no longer a requirement for Certification

              Exam fees: $790 for Step 1, $790 for Step 2 CK, and $1,375 for Step 2 CS
              Fees to prepare credentials vary.

              Proof of Certification

              ECFMG has a Certification Verification Service that you will use to send proof of your Certification to both medical licensing authorities and hospitals where you apply for residency. 
              Fee: $35

              For more information

              Links to ECFMG and other websites can be found in the Important Links section at the end of this page. Testing information will be covered in more detail in the next topic, Tests.

              ii. Find a Residency

              Residency strategy: competition and presentation

              Now that you are certified, finding a residency is your next step. For International Medical Graduates, the biggest obstacle to becoming a licensed physician in the U.S. can be to find a medical residency program or fellowship, also known as a Graduate Medical Education program (GME). These programs are accredited by the Accrediting Council on Graduate Medical Education and vary in length from 3 to 7 years depending on the specialty. Occasionally hospitals will accept IMGs as second-year residents, however these are rare cases and you should be prepared to start at the beginning and go through a full program.

              Finding a residency requires careful strategy, organization, and initiative. You need to develop U.S. style job search and presentation skills in order to compete at the same level as graduates of U.S. medical schools, who benefit from more established networks and familiar credentials. You should dedicate time to such activities as:

              • Building networks and identifying physician mentors currently practicing in your specialty by attending meetings and seeking volunteer opportunities.
              • Creating error-free and persuasive presentation documents like American-style resumes or online profiles, emphasizing your special skills and achievements.
              • Practicing for interviews by preparing answers to common questions and conducting research on your target programs.

                You will also increase your chances if you are flexible about both the residential specialties and locations you will accept. You are more likely to find residency programs:

                • In medically underserved areas (rural and/or economically-depressed areas)
                • In lower-earning specialties
                • In specialties with more demanding work hours

                  The residency search process Part I: Pre-Match

                  If you have developed a special relationship with a residency program through private or professional connections, you may be lucky enough to receive a residency offer without having to compete in the standard process described in Part II: Matching.

                  This is a rare occurrence. However, some experienced foreign doctors may be in this position due to international cooperation over their careers or careful networking after resettling in the U.S.

                  You can look for a pre-match placement while also participating in the matching process (Part II), but you must withdraw from the match program before its deadline (when rank lists close). If you do not, you could be responsible to more than one residency program and will have violated match rules. If you think a pre-match is likely, make sure to get documentation of the offer before the matching deadline.

                  The residency search process Part II: Match

                  Matching is the process most medical school graduates go through to find a residency program. There were about 23,400 first-year residency positions available through the match in 2011.

                  It can be broken down into 4 steps, which will be discussed in more detail below:

                  1. Researching residency programs.
                  2. Compiling documents and applying to programs.
                  3. Phone and in-person interviews with residency programs.
                  4. Ranking of schools by candidates, and vice versa, resulting in a match.

                  You will need to use two services in the Match process: the Electronic Residency Application Service (ERAS) to make applications, and the National Resident Matching Program (NRMP) to collect feedback from you and the programs you visit and turn it into a binding Match agreement for your residency placement.

                  This annual process has a timeframe that is similar from year to year, however, you will need to confirm actual dates.

                  • August: Match "season" begins; candidates and programs accept match participation terms; applications and interviews occur
                  • January: candidates and residency programs can begin to enter rankings for each other
                  • Mid-February: rank lists close
                  • Mid-March: matches are announced on Match Day

                    A. Researching residency programs

                    You should begin this stage well before Match season begins in August. You will need to do a lot of your own research to learn what residency programs interest you and which are more likely to favor your application.

                    You can gather information in many ways, including:

                    • Networking in-person or online
                    • Make sure that when you ask for advice, you tell people that you do not require visa sponsorship. Many people assume that as an IMG, you require visa sponsorship. This can limit their thinking about what residency programs are available to you. Remember that this guide assumes you are an IMG who already has permanent work authorization through permanent residency or refugee or asylee status
                    • Searching for official information on residency programs
                    • FREIDA online is a searchable database managed by the American Medical Association. It provides key information on participating residency programs. It is a good first place to look for programs that interest you

                      B. Compiling documents and applying to programs

                      Once you have a list of residency programs you want to target and as soon as you are eligible to start the Match process (around August each year), you should use the Electronic Residency Application Service (ERAS) to collect and send applications and documentation to residency program directors. For foreign medical graduates, ERAS is accessed through the Educational Commission for Foreign Medical Graduates (ECFMG). This service involves fees for processing, ordering exam transcripts, and sending applications online. You can pay extra to send applications to more residency programs, which can be a good investment to increase your chances of receiving requests for interviews.

                      You also need to open an account with the National Resident Matching Program (NRMP), agree to its terms, and provide all required information. 
                      Fees: $70 per Match season for ERAS and $50 for NRMP

                      Among the documents you will need to submit are Letters of Recommendation (LoR) from U.S. licensed physicians. The best way for IMGs to obtain positive LoRs is to work or volunteer in a hospital setting. Networking with U.S. healthcare professionals increases your chances of finding physicians willing to recommend your work. All programs have a maximum of 4 LoRs. You can get different LoRs for your applications for various specialties, which means that you can make your application more personalized for each specialty. This can help you become more competitive when applying for a specialty different than the one you practiced in your home country. Your recommendations should come from physicians who know you in a working context; never ask a relative to write you a recommendation.

                      You will also need to submit a personal statement, which you can tailor if applying to multiple program specialties. A personal statement should be 1-2 pages and should highlight you assets as a candidate. It is always a good idea to ask someone to read over your personal statement for grammar, spelling, and sentence structure. Mistakes in your personal statement can reflect poorly on you as a candidate.

                      By now, you should have taken the time to develop U.S.-style materials that market your education and experience. You should be comfortable talking about this information and providing clear examples of your skill based on your work and education history.

                      C. Phone and in-person interviews with residency programs

                      You may be contacted by residency programs for phone screenings or in-person interviews. Prepare yourself for these interactions because they are critical to your success. You should also have money saved for this purpose, because candidates for residency normally pay their own expenses when visiting for in-person interviews. The typical U.S. medical school graduate will go on more than five interviews; if you are able, you should target more. Be sure to include a range of programs, not only your top choices, to improve your chances of a match.

                      D. Ranking of schools by candidates, and vice-versa, resulting in a match

                      When you have completed interviews and visits to residency programs, you must rank your choices in the NRMP system. Residency programs will do the same, ranking their candidates in order of preference. In ranking a candidate, a residency program is committing to accepting that candidate if the match is made, and vice versa. Do not rank a program unless you are prepared to commit to it!

                      Rank lists close in February and NRMP applies a software program to the ranked preferences. The resulting matches are announced during Match week in mid-March.

                      The residency search process part III: Supplemental offer and acceptance program (Soap)

                      Matches can only be made when both a candidate and a residency program rank one another in the NRMP system. This means that there are many candidates who do not receive a residency match; there are also many residency program openings that remain unfilled.

                      If you do not get a match when the first matches are announced, then you will have a chance to find a match through what is called the Match Week Supplemental Offer and Acceptance Program (SOAP). During this week, programs with unfilled positions offer unmatched applicants remaining residency spots. The entire process is conducted through ERAS, so you will use the same account during Match Week to apply to unmatched positions. You will need to apply through ERAS to unmatched programs. Then, the programs will review the applicants and make offers. You may receive more than one offer during this week, but you may only say yes to one. Details for the process are below. This process has replaced "Scramble" and will take effect in 2012.

                      All match applicants will receive notification from NRMP on the Friday before Match Week at 9 a.m. Pacific Standard Time (PST) indicating eligibility for SOAP. Unmatched candidates who qualify for SOAP will be given a list of unfilled programs at 9 a.m. PST on Monday of Match Week. You will then be able to apply to unfilled positions starting 11 a.m. PST on Monday of Match Week through ERAS. During this week, unfilled programs and unmatched candidates can communicate via ERAS. However, no match offers or agreements can be made until 9 a.m, CST on Wednesday of Match Week. Unfilled programs will be given seven opportunities over the next three days to offer matches to candidates. When an offer is made candidates have two hours to respond. The process works as follows:

                      In each round, programs rank the candidates and give residency slot offers to their top candidates. As the rounds continue, programs continue to offer spots to the remaining candidates in order of their preference for candidates. Candidates may receive more than one offer during SOAP. These offers are sent at 12 p.m. PST Wednesday, 6 a.m., 9 a.m., and 12 p.m. PST on both Thursday and Friday, for a total of seven rounds. SOAP concludes at 2 p.m. PST on Friday of Match Week. All placements are finalized by 4 p.m. CST on Friday of Match Week.

                      Unfortunately, SOAP is the last major opportunity you will have in a given year to compete for a large number of residency placements.

                      You will need to consider your options if you are not placed in a residency at this time. If you choose to go through the Match process again, you must make sure you take steps to keep your skills current and also to improve your appeal as a candidate.

                      iii. Apply for a Postgraduate Training Authorization Letter

                      The PTAL application process

                      If you have been accepted into a residency program in the state of California, you will need to apply to the Medical Board of California for authorization to practice medicine in a limited way for the purposes of your residency. In California, this is done by applying for a Postgraduate Training Authorization Letter (PTAL). The form you use to request the PTAL is the same form you will use to apply for a California medical license after you complete two years of residency.

                      The Postgraduate Training Authorization Letter is linked to the hospital where your training will be given and is not portable. You cannot legally practice medicine outside of your training program until you apply for a license - the earliest you can apply is after your second year of residency; some residents, for example those in long specialization programs, may choose to wait longer.

                      A link to the complete application, with all its instructions, can be found in the Important Links section. Your application for the Postgraduate Training Authorization Letter should include the following items:

                      • Application Forms L1A-L1E: this is the main application and includes information about your education, examinations taken, criminal record, and other history
                      • Copy of LiveScan fingerprint form or two fingerprint cards
                      • Form L2: Certificate of Medical Education
                      • Official medical school transcript
                      • Certified copy of medical degree
                      • Scores for USMLE Step 1 and Step 2 (Clinical Knowledge) mailed directly from the testing agency
                      • Form L5: Certificate of Clinical Clerkships
                      • Form L6: Certificate of Clinical Training (if applicable; it documents training that took place outside of the applicant's teaching hospital)
                      • Fees: $491

                        Special considerations for a successful application

                        The Medical Board has very specific instructions for the application; you need to pay very close attention when preparing it. Some important details:

                          • Start the application process early: Your application for the Postgraduate Training Authorization Letter and all supporting documents should be done as far in advance of the start of your residency as possible. Some parts take a long time to process - fingerprints in particular - and there is always a large volume of applications before each academic year - it is best to avoid the rush. Your residency program should be able to provide you some support in preparing this paperwork on time.
                          • Fingerprints and criminal record check: Start with getting your fingerprints, which must be checked by both the Department of Justice and the Federal Bureau of Investigation, and can take up to six months to process. There are two ways to get your fingerprints taken (links to both options are in the Important Links section):
                            • LiveScan - a digital service that requires you to go to one of many centers available in California for fingerprinting; costs vary (most $12-20). This is the faster and more efficient choice if you are able to go to on site. Make sure you save your LiveScan receipt! It is required as a part of your credentialing application.
                            • Paper fingerprint cards - this is the option you will use if you cannot travel to a California LiveScan site; you will need to email the Commission to request the cards, and will need to pay them an extra service fee (cost as of June 2012: $25).
                            • Be truthful in your application: There are serious consequences for false or incomplete information in the application - not reporting even a minor offense on a criminal record is considered an ethics violation that can make you ineligible for a license. You are responsible for the information on your application even if someone else prepared it for you.
                            • Translations: These must be done by specific types of certified translators and must be word-for-word translations. Exact information is explained in the application.
                            • Notarization of your complete application: Staple all of the pages of your application together as one document, and only sign this complete document in front of a Notary Public, who will also sign and seal it before you can send it to the Board. Turn in your complete application with all fees to avoid delays, which are common the months before residencies begin and large amounts of applications are being processed. Board staff will not confirm by phone or email if your application has been received - but you will receive a status letter within 90 days of applying.

                              iv. Apply for a California Physician License

                              You can apply for the California Physician License after you have completed two years of graduate medical training through a residency program in California or another state. You must also have passed the last Medical Licensure Exam, the USMLE Step 3, which is explained in detail in the Tests section.

                              The Medical Board of California uses the same application for the Physician License as for the Postgraduate Training Authorization Letter (PTAL). The Board is very specific about how to fill out its applications: read the section called Special considerations for a successful application from the previous section to learn how to put together your best application.

                              As of July 2009 the application packet for the Physician License requires the following:

                              • Application Forms L1A-L1E: this is the main application and includes information about your education, examinations taken, criminal record, and other history
                              • Two fingerprint cards or copy of LiveScan form
                              • ECFMG certificate or status letter
                              • Official examination scores mailed directly from the reporting agency (all USMLE scores)
                              • Form L2: Certificate of Medical Education
                              • Official medical school transcript
                              • Certified copy of medical degree
                              • Official Letters of Good Standing (if you have a valid license from another state, for example, if you have a temporary license for the first years of your residency in another state)
                              • Form L3A-L3B: Certificate of Completion of Postgraduate Training
                              • Form L4: Certificate of Current Postgraduate Training Enrollment (if you are still in a residency program)
                              • Form L5: Certificate of Clinical Clerkships
                              • Form L6: Certificate of Clinical Training (only required if part of your foreign training was given outside of your teaching hospital)

                                Fees as of March 2012:

                                • Application fee or proof of online payment: $491
                                • License fee: $808

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                                  3. Tests

                                  California requires all United States Medical Licensure Exams (USMLEs Steps 1 through 3) for an MD to become licensed in California. It does not require additional tests.

                                  Your main point of contact for exams for Step 1 and Step 2 will be USMLE and the Educational Commission for Foreign Medical Graduates (ECFMG). Step 3, which comes after you have started your residency, is administered by the FSMB. All USMLE Exams except for the Step 2 Clinical Skills test are given at Prometric test centers in the U.S. and abroad.

                                  Some basic information on each test follows.

                                  USMLE Step 1

                                  The USMLE Step 1 exam is a broad-based test that emphasizes the basic sciences used in medicine. Most U.S. medical school students take Step 1 in their second year of medical school and study intensely for it.

                                  While you may not have had to return to these basic topics for many years, there are several reasons why you should take test preparation for Step 1 very seriously:

                                  • Residency programs tend to use Step 1 scores as a predictor of performance in a residency program or specific specialty.
                                  • Many residency programs have established a minimum score for the Step 1 and will not interview candidates with lower results.
                                  • Once you pass the Step 1 you cannot retake it, even if your score was lower than you desired.

                                    Test content and format

                                    USMLE Step 1 is an 8-hour, multiple choice exam taken by computer. There are approximately 322 questions, some containing audio and video references.

                                    The exam looks at general medical principles across systems and also at processes within organ systems. Questions come from traditional and interdisciplinary areas.

                                    Traditional medical disciplines:

                                    • Anatomy
                                    • Behavioral sciences
                                    • Biochemistry
                                    • Microbiology
                                    • Pathology
                                    • Pharmacology
                                    • Physiology

                                      Interdisciplinary subjects:

                                      • Genetics
                                      • Aging
                                      • Immunology
                                      • Nutrition
                                      • Molecular biology
                                      • Cell biology

                                        Fees: The Step 1 exam costs $790

                                        USMLE Step 2: Clinical Knowledge (CK)

                                        The USMLE Step 2 Clinical Knowledge exam is a 9-hour long exam consisting of 346 multiple-choice questions given by computer. It assesses whether you can apply medical knowledge and understanding of clinical science that is necessary for providing patient care. It emphasizes health promotion and disease prevention.

                                        The test looks at your knowledge in these content areas:

                                        • Internal medicine
                                        • Obstetrics and gynecology
                                        • Pediatrics
                                        • Preventive medicine
                                        • Psychiatry
                                        • Surgery
                                        • Other areas relevant to provision of patient care

                                          Most Step 2 CK exams describe clinical situations and require that you provide a diagnosis, prognosi, indication of underlying mechanisms of disease and/or next steps in medical care.

                                          Fees: The Step 2 CK exam costs $790

                                          USMLE Step 2: Clinical Skills (CS)

                                          The Clinical Skills test is a unique 8-hour exam which is conducted in a simulated medical practice environment.

                                          Candidates interact with 12 "standardized patients" over the course of the day. These are people who have been trained to describe specific symptoms and medical histories, many of which can have multiple diagnoses. The test is meant to assess a candidate's ability to gather patient information, perform or order specific exams, and communicate their interpretations to both patients and colleagues. Candidates are judged through observation and by feedback given to testers from standardized patients.

                                          Step 2 CS is given in only 5 locations in the United States: Chicago, Atlanta, Houston, Philadelphia, and Los Angeles. Candidates must cover both travel and accommodation expenses in addition to test costs.

                                          Fees: The Step 2 CS exam costs $1,375, not including travel and accommodations

                                          USMLE Step 3

                                          The USMLE Step 3 is the final exam you will need to take before being eligible for your Physician License. In some states, you cannot take Step 3 until you have completed one year of your residency; this is not the law in California, although many people still wait to take Step 3 after their first year. You cannot take Step 3 until you have passed Step 1 and Step 2 CK and CS.

                                          The USMLE Step 3 exam is a 2-day computer-based exam, which lasts 8 hours each day. The test has approximately 480 multiple-choice questions, broken into blocks of 35-50 questions.

                                          The entire first day consists of 336 multiple-choice questions.

                                          On day two, the first 3 hours will be spent on 144 multiple-choice questions. The rest of the session is dedicated to nine Clinical Case Simulations. The simulations involve real-time patient care scenarios. The candidate must prescribe medications or procedures and the patient's condition will evolve.

                                          Fees: The Step 3 exam costs $745

                                          Test preparation

                                          The National Board of Medical Education (NBME) offers online self-assessments for the Step 1, Step 2 Clinical Knowledge and Step 3 tests. Many other companies offer study programs. You should seriously consider taking a test preparation course if your self assessments are weak; investing early in preparation will save you money on retakes! Also, note that there is a 6 attempt limit on any USMLE Step or Step Component, including incomplete attempts. More information on test preparation resources can be found under Important Links.

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                                          4. Time and Costs

                                          Your progress through the licensing process will certainly be both long and expensive. Still, many factors will ultimately determine how long and costly your own process will be. Just some of these include:

                                          • The completeness of your credentials and the speed of their collection and assessment.
                                          • Your performance on all steps of the USMLE.
                                          • How flexible you are about residency types and locations.
                                          • Your efficiency and effectiveness in the residency search process.
                                          • Your free time and how much money you have to spend.

                                            We provide two sample scenarios below to show some outcomes that immigrant professionals may experience when they seek a Physician License in California. Please do not consider them as minimum or maximum scenarios, only as two reference points out of many. Your experience will vary.

                                            Two Hypothetical Scenarios for MD Licensing:

                                            StepMore Efficient Scenario
                                            Approximate
                                            Time and Cost
                                            Less Efficient Scenario
                                            Approximate
                                            Time and Cost
                                            1.
                                            ECFMG Certification
                                            • You have been using a study course and preparing full-time for a year for the USMLE exams when you begin the ECFMG Certification process.
                                            • Using online tools, you and your medical school are able to build your file in 3 months.
                                            • You take Step 1 and 2 CK, passing both in 9 months with good scores.
                                            • You take Step 2 CS in Los Angeles 6 months later and have minimal travel and accommodations.
                                            • 2 1/2 years + $5,000
                                            • Problems with your documents and with proper translations take you 6 months to resolve and are expensive.
                                            • You must pay others in your country to visit institutions for you.
                                            • You study for your exams while working full-time. After 1 year you apply for the step 1 exam and open your ECFMG file.
                                            • Your file is complete in 6 more months but you fail step 1 on the first try.
                                            • You take another year to prepare and pass, but your grade is not exceptional.
                                            • You successfully pass your other exams and receive ECFMG certification within the next year.
                                            • You take step 2 CS in Houston 1 year later and must pay for travel and accommodations. You pass on the first try.
                                            • 4 1/2 years + $6,750
                                            2.
                                            Find Residency
                                            • It takes you just one year to research residency programs and find an acceptable match, because you are willing to relocate and invest great effort in marketing your skills.
                                            • You travel to several sites for interviews.
                                            • 2 years + $3,000
                                            • You have difficulties with the match and go through the application process several times
                                            • You succeed after you become more flexible in acceptable residencies
                                            • You travel to several sites for interviews each year you go through the match process.
                                            • 4 years + $7,000
                                            3.
                                            Postgraduate Training Authorization Letter
                                            • Your California residency program is a big help to you as you prepare your application for the PTAL.
                                            • It takes 1 month to prepare your application and 1 month to be approved.
                                            • 2 months + $600
                                            • You do your application with very little help and have difficulties with some of the paperwork. You turn in your fingerprints last and must wait 4 months for them to be processed.
                                            • Your application is complete after 5 months and it takes 2 months to approve it.
                                            • 7 months + $800
                                            4.
                                            USMLE Step 3 
                                            and California Physician License
                                            • You pass the USMLE Step 3 exam after your first year of residency.
                                            • You apply for your License as soon as you are eligible (after 2 years of residency) and you are approved 6 months later.
                                            • 1 year + $1,200
                                            • You pass the USMLE step 3 exam after your first year of residency.
                                            • You apply for your License as soon as you are eligible (after 2 years of residency) and you are approved 6 months later
                                            • 1 year + $1,200
                                            More Efficient Total
                                            About 5 1/2 years + $9,800 
                                            (plus 1-5 years to finish your residency)
                                            Less Efficient Total
                                            About 10 years + $15,750 
                                            (plus 1-5 years to finish your residency)

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                                            5. Other Careers and Credentials

                                            Lower-level job opportunities

                                            You may want to consider whether taking a lower-level job in healthcare in the short-term can help you meet longer-term goals of licensing as an MD. Working in healthcare in a different capacity and with fewer responsibilities may offer you some advantages:

                                            • Your employer may pay for some costs associated with licensing.
                                            • You can focus more energy on studying.
                                            • You will have a chance to adapt to the U.S. healthcare system and workplace culture in a lower-pressure environment
                                            • An opportunity to network with U.S. healthcare professionals, which may prove more useful when gathering Letters of Recommendation for your application

                                              You may immediately qualify for several hospital staff positions which require little or no additional training, such as Certified Nurse Assistant or Phlebotomy Technician. Some immigrant professionals find jobs as healthcare educators, or use language skills as medical interpreters.

                                              You should be honest with your employer about your long-term plans and be sure that they have benefits such as paying for your tuition or schedule flexibility that will support your goals.

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                                              6. Beyond Licensing

                                              Complete your residency

                                              The state of California allows you to receive a license after your first year of medical residency. At that time you are able to practice general medicine without supervision. Of course, most doctors choose to complete their residency programs, but you also have the option of working unsupervised in your free time and may hold part-time jobs in clinics or other healthcare environments.

                                              Joining a professional medical association

                                              State and national associations for physicians provide opportunities for professional development and networking. They also help set acceptable working conditions for the profession and give information and opinions on policy in California and across the U.S. Their websites may offer useful orientation to medical candidates about the licensing and examination process, including test preparation. They often provide Continuing Education to members as well.

                                              State:

                                              • California Medical Association

                                              National:

                                              • American Medical Association

                                                  There are also professional associations for physicians based on specialty, type of workplace, race and ethnicity, gender, or religion.

                                                  Licensing mobility

                                                  The state of California grants licensing to MDs either by examination (the process described in this topic), by acceptance of examination, or by endorsement. A physician must independently meet all California requirements for licensing. The national exams and the mobility of the resident experience do help make licensing in other states a relatively easy process. If you become licensed in California and want to practice medicine in another state, you will need to research the legal requirements for that state.

                                                  Maintaining your California License

                                                  Your California Physician License must be renewed every two years through the Medical Board of California. Your license will expire on the last day of your birthday month. You are responsible to renew your license even if you do not receive a notice from the Medical Board of California; you can renew online or through the mail. The cost to renew on time as of July 2009 was $808. Be careful: if you let your license expire, you will be fined and you may have disciplinary action taken against you.

                                                  Every time you renew your license you must state that you have met a 50-hour Continuing Medical Education requirement or CME. You need to keep the information on file in case you are audited. There are many opportunities to earn these hours, but special rules apply. You should check the Medical Board website for details, or consider joining a professional association that offers CME opportunities to members.

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                                                  7. Important Links

                                                  Common Words used in this article

                                                  California Licensing

                                                    United States Medical Licensing Exams (USMLEs):

                                                    • Through the Federation of State Medical Boards (FSMB), register for MLE Step 3 here.
                                                    • The Federation Credentials Verification Service (FCVS) is an electronic portfolio of your education and residency credentials. It is a way to maintain proof of your most important credentials over time without having to return for original documentation. You may sign up for its Physician Information Profile when you register for the USMLE Step 3 in California. FCVS Help number: 888-ASK-FCVS (this number can be reached only when calling from within the US), or send an email to fcvs@fsmb.org.

                                                      ECFMG Certification


                                                        Medical residency - search and temporary licensing

                                                          Test preparation


                                                            Professional associations

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                                                              8. TIPS

                                                              Planning

                                                              You need a clear and realistic plan to succeed in becoming a licensed MD in the US; it is too difficult, long, expensive and competitive a process to do inefficiently. Take the time to develop a strategy for issues such as:

                                                                • Money: You will need significant savings, a loan, or a job that helps pay for the long process.
                                                                • Preparation: you will need to invest resources in test preparation to pass your examinations; for residency, you will have to prepare US-style marketing materials, perfect your interview and presentation skills, research your target programs, and prepare to participate in SOAP if you are not matched with a program.
                                                                • Network: you will need to rebuild a professional network. It can help to find work in a lower-ranking healthcare position in a hospital if you use the opportunity to actively identify mentors among specialists in your field and International Medical Graduates who have successfully licensed. These contacts can not only help you with advice, but become sources of letters of recommendation for your residency process.
                                                                • Flexibility: you will be more likely to find a residency if you are flexible about geography, program quality, and specialty type.

                                                                  Complete Credentials

                                                                  Invest the time and money early to get complete educational and professional credentials for your foreign degree evaluation process. Follow up carefully with institutions where you studied and practiced medicine to be sure they send documents in the required format.

                                                                  Pay Attention to Detail

                                                                  All documents you submit either on paper or online are official: take your time to fill them out carefully and make sure your name and other information are used in exactly the same way on each document. Mistakes in these simple details are a common source of delays and complications in the licensing process.

                                                                  Get your questions answered

                                                                  Be your own advocate throughout the licensing process. Seek clarification about questions and concerns directly from official sources. Organize your questions and ask for assistance; email can be your most effective means of communication with the State and testing organizations.

                                                                  Invest in test preparation

                                                                  Your ability to pass your exams at the first sitting can be a very important factor in your appeal during the residency process. The results from the USMLE Step 1 exam are often used by Graduate Medical Programs, as predictors of general success or of performance in a specialty area. If you have 6 failures on any USMLE Step or Step Component, you will be ineligible to make another attempt.

                                                                  Market yourself American style

                                                                  Being able to market yourself in a way that appeals to U.S. residency programs can play a deciding factor in your success. You may need outside guidance to assess what parts of your education and experience you should highlight, and how to present them and yourself to potential programs. You must learn how to overcome any cultural gaps and target your presentation to a U.S. audience.  Many people, who are well-qualified, do not find a residency because they are unable to successfully prove their value over other candidates to residency programs. Consider this an opportunity not to play down your international experience, but rather to make it a selling factor in this process.

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