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New Hampshire Physician Licensing Guide

1. WHAT YOU NEED TO KNOW BEFORE YOU START

This guide is intended for International Medical Graduates (IMGs) who already have permanent work authorization through permanent residence or refugee or asylee status in the United States.

About becoming a doctor in the US as an International Medical Graduate (IMG):

  • It is a complex process.
  • The process is difficult, but not impossible.
  • It is not only about passing USMLE Tests.
  • Not all FMGs can become licensed doctors in the United States.
  • Timing is very important. It is important to make decisions early; the more time you take, the fewer the chances you have.
  • You are not done until you are done.
  • The only way to become a doctor in the United States is to be trained as one.

Planning

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

  • Caution: It is extremely important that you DO NOT take any of the United States Medical Licensing Examinations (USMLE’s) without first achieving a minimum score of 500 on a National Board of Medical Examination (NBME) practice test. Residency programs will receive all of your USMLE attempts and scores. More than one failure usually will exclude you from further consideration by training programs.
  • Money: You will need significant savings, a loan, or a job that helps pay for this long process.
  • Test preparation: Your ability to pass your exams at the first sitting can be a very important factor in your appeal during the Residency application 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.
  • 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.
  • Applying to Residency: For applying to medical Residency programs, you will have to prepare U.S.-style marketing materials, perfect your interview and presentation skills, research your target programs, and prepare to participate in the Supplemental Offer and Acceptance Program (SOAP) if you are not matched with a program.
  • 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.
  • 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.
  • Consider alternative careers: The likelihood of successfully completing all components from being a Foreign Medical Graduate to becoming licensed in the U.S. is lower for people who are from another country, and lower still for those who have been out of school for several years. Consider alternate careers in the medical field such as Physician’s Assistant. It does require completion of a new degree in the U.S. and may initially appear more expensive, but it is able to be completed sooner, with the possibility of getting back to work with a reasonably high salary much more quickly than going through the U.S. physician’s licensing process. See the spreadsheet links in Sections 5 (Time and Costs) and 6 (Other Medical Careers) for helpful time and cost comparisons.

2. HOW THE PROFESSION IS ORGANIZED IN NEW HAMPSHIRE

Regulation of MDs in New Hampshire

The New Hampshire State Board of Medicine (NHSBM) 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 can 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 also have to register with the Federation Credentials Verification Service (FCVS) where you begin your Physician Information Profile. The FCVS obtains, verifies and carefully stores your personal information as well as information about your medical education, Residency, and examinations. They help you by having your credentials verified and in one place for when you are ready to apply for your physician’s license in the State of New Hampshire.

Before you can obtain your license you will 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.

New Hampshire Physician License

You are eligible to obtain a New Hampshire Physician License after completing two years of your Residency in any state (though Residencies are usually for at least three years), and passing the USMLE tests (Step 1, Step 2 CK, Step 2 CS and Step 3 exams.) You will apply for the Physician License with the New Hampshire State Board of Medicine (NHSBM).

This article looks at all of these elements in detail, particularly in Eligibility for Licensing (Section 3) and Tests (Section 4).

Employment as an MD in New Hampshire

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 as of 2007 there are 243,457 IMG physicians in the U.S. from 127 different countries. This totals 26 percent of all the physicians in the United States.

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 $150,000 are common, while the best-paid specialties, such as anesthesiology frequently earn twice as much. Often, though, medical school graduates have a substantial amount of debt to repay (U.S. medical school can 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 (those with normal office hours), desirable geographic regions, or prestigious 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 medicine, general internal medicine or pediatrics 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 will create more demand for primary care providers.

The cost of insurance for physicians to protect against malpractice, especially for higher-risk specialties such as Obstetrics and Gynecology is high. This cost of doing business is an important consideration for some candidates who are considering practicing medicine in New Hampshire.

3. ELIGIBILITY FOR LICENSING: PROCESS AND TIMELINE

This section explains 4 major steps that you need to complete before becoming licensed to practice medicine in New Hampshire.

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. – IV.).

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. “https://imed.faimer.org/”

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 the Step 1 or the Step 2 Clinical Knowledge exam, 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.

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, about $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 (Section 4).

II. Register with the Federation Credentials Verification Service (FCVS)

The Office of the Professions requires all IMGs to register with the Federation Credentials Verification Service (FCVS.) The FCVS was created by the Federation of State Medical Boards (FSMB) to provide a centralized and uniform process for all state medical boards in the United States to obtain verified, primary source records of physicians’ core medical credentials obtained in the U.S. or abroad. The FSMB is a trusted source and guarantees your information will remain secure and confidential.

You have the option to fill out the application form online or send it in by mail. If you submit a hard copy and do not apply online, an extra fee of $50 will apply. On the application you will need to provide the FCVS with detailed information and photocopies of your personal information, medical education, clinical clerkships, postgraduate training, examination history, ECFMG Certification, and more. The FCVS will then contact the sources where you obtained your records and by such means verify your credentials. It is important that you do not try to obtain transcripts from third parties yourself. These will not be accepted by the FCVS. The FCVS will obtain the documentations regarding your credentials directly from the third parties.

The advantage of using FCVS is that once your credentials have been verified you will have a permanent lifetime record of all your core credentials, which on your request can be forwarded to any beneficiary. The FCVS charges a fee of $325 for the initial request, and $65 for additional requests. These fees are subject to change and surcharges may also apply. When you apply for your New Hampshire Physician License you will make such a request to be sent to the New Hampshire State Board of Medicine.

The application process for FCVS can be found online at www.fsmb.org.

III. Find and Complete a Post Graduate Medical Training/Residency

Now that you are certified with the ECFMG and have started your FCVS profile, finding a Post Graduate Medical Training Program (usually called Residency) is your next step.

For New Hampshire, you must apply for a New Hampshire Residency License ($50.00), which allows you to work under supervision in Post Graduate Medical Training/Residency.

For International Medical Graduates, the biggest obstacle to becoming a licensed physician in the U.S. can be to find a medical Residency program, also known as a Graduate Medical Education (GME) program. 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. Most Residencies are based at hospitals and affiliated with a medical school – but not necessarily located together.

New Hampshire has a small number of Residency training programs at Dartmouth Hitchcock Medical Center or Concord Hospital

Once you have accepted an offer to join a Graduate Medical Education Program for your Residency you may have to acquire a limited permit to practice medicine for the purpose of your Residency. In New Hampshire this is called a Residency License. Your new Residency program will inform you of their Residency License requirements.

Residency Strategy, Competition and Presentation

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, and
  • 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 26,392 first-year (PGY1) Residency positions available through the match in 2013. Since the 1980’s there has been a trend of more applicants than of positions offered through the 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

It can be broken down into 4 steps (a. – d.), which will be discussed in more detail below:

a. Researching Residency programs.

b. Compiling documents and applying to programs.

c. Interviewing with Residency programs.

d. Ranking of programs by candidates, and vice-versa, resulting in a match.

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. Apply to as many as desired and remember you must travel to the interview and move to attend the Residency. Therefore, apply only to programs you would be interested in attending as you will be obligated to those you are matched with.

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 residence 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 application for various specialties, which means that you can make your application more personalized for each specialty. This can help you be 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 your 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 skills based on your work and education history.

c. Interviewing 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 still have a chance to find a match through what is now called the Match Week Supplemental Offer and Acceptance Program (SOAP – previously referred to as “scrambling”). During this first 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 will 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 took effect in 2012.

All match applicants will receive notification from NRMP on the Friday before Match Week at 12 p.m. Eastern Standard Time (EST) indicating eligibility for SOAP. Unmatched candidates who qualify for SOAP will be given a list of unfilled programs at 12 p.m. EST on Monday of Match Week. You will then be able to apply for unfilled positions starting 2 p.m. EST 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 12 p.m. EST 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 just 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 3 p.m. Wednesday, 9 a.m., 12 p.m. and 3 p.m. EST on both Thursday and Friday, for a total of seven rounds. SOAP concludes at 5 p.m. EST on Friday of Match Week. All placements are finalized by 5 p.m. EST 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.

Residency, Year One

Once you have accepted an offer to join a Graduate Medical Education Program for your Residency you may have to acquire a limited permit to practice medicine for the purpose of your Residency. In New Hampshire this is called a Residency License. Please check with the hospital in question to find out what their Residency requirements are.

The New Hampshire State Board of Medicine will accredit your Residency, if it is approved by the Accreditation Council for Graduate Medical Education (ACGME) and if it meets the minimum length of 2 years. If you decide to do your Residency in another state, make sure you research specific state or individual hospital requirements to practice during your Residency. You need to make sure you obtain the necessary authorization of the hospital and state in which you wish to practice your Residency.

IV. Take Exam and Apply for a New Hampshire Physician License
Once in the 1st year of Residency in New Hampshire, you may apply for the Exam. Examination candidates who wish to take USMLE Step 3 in New Hampshire shall apply directly to the Federation of State Medical Boards (FSMB).

Candidates for USMLE Step 3 shall:

  • Have graduated from a medical school accredited by the LCME or have completed their medical education from an institution located outside the United States and have such studies confirmed by the ECFMG;
  • Have begun the first academic year of postgraduate medical training at an institution accredited by the ACGME, the Royal College of Physicians and Surgeons of Canada (RCPSC) or the American Osteopathic Association (AOA); and
  • Have passed USMLE Step 1, 2 (CK) and Step 2 (CS) or one of the acceptable combinations of examinations noted in Med 303.01(b). See website: http://www.gencourt.state.nh.us/rules/state_agencies/med100-600.html

Requirements for the NH State Physician License:

  • Education: The NHSBM will assess whether your international medical education meets the requirements set by them. One of these requirements is that you must have completed at least 2 years of college prior to entering medical school.
  • Examinations: To receive your license you need to have completed all 3 Steps of the USMLE examinations and be ECFMG certified. More information about these examinations will be provided in “Tests” Section 4.
  • Experience: The NHSBM requires all IMGs to successfully complete a minimum of 2 years of postgraduate medical training (usually called Residency) in any U.S. State.
  • Registration with FCVS: To receive your license, your completed FCVS Physician’s Information Profile needs to be forwarded to the New Hampshire State Board of Medicine (NHSBM) to show that your medical credentials are verified.

It is important to time your application well in accordance with the examination schedule provided by the Federation of State Medical Board (FSMB). The FSMB oversees the USMLE Step 3 exam and you will have to register with them at www.fsmb.org to partake in this examination. You will need to file the physician’s license application form with the New Hampshire State Board of Medicine at least 3 months before you wish to take the exam. Be sure to check any registration deadlines that may apply on the FSMB website. When you have registered with the FSMB you receive your Scheduling Permit for USMLE Step 3 that you will then use to schedule an appointment with Prometric. You will find links to these services in “Links” Section 9.

Summary of how to apply for the USMLE Step 3 examination:

  1. Register for the USMLE Step 3 exam with the FSMB.
  2. Schedule an appointment to sit the exam with Prometric.

Similar to the Step 1 and 2 exams, you will need biometric information to identify yourself during the Step 3 exam. This is part of the Biometric Identity Management System program (BIMS). All the USMLE exams use biometrics as part of the test procedures. During the exam it is common that you will be asked to provide your fingerprint during check-in, breaks and check-out for identification purposes. Go to the BIMS website for further details. See “Important Links” Section 9.

Once your application is approved, you will have a 105-day eligibility period to take the examination. 90-day extensions are commonly granted if an eligibility extension request form is filed with the FSMB no later than ten days after the 105-day eligibility period expires. The extension fee is $65. For further details, consult the USMLE section of the Federation website.

How to apply for your NH State Physician’s License Application:

  • Go to the NHSBM website: http://www.nh.gov/medicine/physicians/
  • Click on the “New online application process for medical and osteopathic physicians link and follow the instructions for completing the application online. The New Hampshire application fee is $300.
  • You must also complete the FVCS.

If you wish to have a paper application, you must submit a request to the NHSBM in writing. You must still complete the FVCS online.

Notify the FCVS and Office of the Professions once you have completed your Residency and have passed the Step 3 examination to finalize your application and obtain the physician’s license. To do so, fill out the Examination and Board Action History Report Form on the FSMB website, and the FSMB will then forward a certification of your exam results directly to the NHSBM.

4. TESTS

The previous section described the process and overall timeline. Here we will describe the required exams in more detail.

New Hampshire requires a candidate to have passed all United States Medical Licensure Exams (USMLE’s Steps 1 through 3) for an MD to become licensed in New Hampshire, except when they meet other acceptable criteria noted in Med 303.01(b) (see website). Candidates must also have ECFMG certification verified directly from FCVS.

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 Post Graduate Medical Training/Residency, is administered by the FSMB and can only be taken in the United States. All USMLE Exams except for the Step 2 Clinical Skills (CS) test are given at Prometric test centers in the U.S. The Step 1 and Step 2 Clinical Knowledge (CK) tests can also be taken 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 science subjects 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 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. This section is taken after at least one year of completed Residency, but usually taken in Year 3 of your Residency.

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, prognosis, 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 that 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 New Hampshire, 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 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! Do remember that Residency programs will receive ALL your USMLE attempts and scores. More than ONE failure will usually exclude you from being selected for a Residency program. Therefore, it is imperative to only take an exam when you are well prepared! Also significantly important: Please 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”, Section 9.

Please note the following changes for USMLE Step 3 no sooner than 2014:

USMLE Step 3 is going to be divided into two parts effective no sooner than 2014.

The USMLE Composite Committee, National Board of Medical Examiners and the Federation of State Medical Boards recently approved plans to change the structure of USMLE. Step 3 will be the first examination impacted, with changes to this examination to occur no earlier than 2014. The plans call for the division of Step 3 into two separate exams. The two examinations will be scored separately and examinees will be expected to pass each.

USMLE Step 3 Part-1

The first exam is expected to focus on whether an examinee possesses the knowledge essential to the independent practice of medicine, including a comprehensive knowledge of both foundational science and clinical medicine.

USMLE Step 3 Part-2

The second exam will assess an examinee’s ability to apply knowledge in the context of patient management, including demonstration of comprehensive knowledge of health and disease, and their impact on patients. The second exam will also require a demonstration of evidence-based medicine and quantitative reasoning skills important to patient care and to life-long learning.

The redesigned examination changes announced by USMLE will include assessment of “a comprehensive knowledge of both foundational science and clinical medicine,” as well as “a demonstration of evidence-based medicine and quantitative reasoning skills important to patient care and to life-long learning.”

Over the next few years, Step 3 examinees will see a gradual increase in test items that assess knowledge of foundational science.

Starting 2013, Step 3 examinees will see an increase in the number of research abstract and pharmaceutical advertisement questions also.

5. 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.
StepMore Efficient Scenario Approximate Time & CostLess Efficient Scenario Approximate Time & Cost
1. Pursue ECFMG CertificationECFMG Registration

Tests
Study Courses
USMLE Step 1
USMLE Step 2 CK
USMLE Step 2 CS

Approx total $5,500 and 2.5 years
ECFMG Registration including translations

Tests (with retake)
Study Courses
USMLE Step 1
USMLE Step 2 CK
USMLE Step 2 CS

Approx total $7,000 and 4.5 years
2. Apply for Residency*FCVS Registration

Match Process

Research Programs

ERAS

NRMP

Travel and accommodations

Find Residency/GMT

Approx total $300
FCVS Registration

Match Process

Research Programs

ERAS

NRMP

Travel and accommodations

Find Residency/GMT

Approx total $300
3. Attend Residency Program3 years of Residency**

Residency License

Approx total $3,100 and 4 years
3 years of Residency**

Residency License

Approx total $6,200 and 5 years
4. Take Last Exam Required for LicensureUSMLE Step 3 exam

Unrestricted permanent license

Approx total $1,000
USMLE Step 3 exam

Unrestricted permanent license

Approx total $1,000
TotalMore Efficient Total
About $10,000 and 6.5 years of preparation
(Plus at least 3 years to finish your Residency)
Less Efficient Total
About $14,500 and 9.5 years of preparation
(Plus at least 3 years to finish your Residency)
Earnings Potential in First Year Licensed$150,000$150,000

Notes:
Costs shown do not include annual living expenses at all.
*Applying does not guarantee acceptance into a Residency
**Even though New Hampshire only requires 2 years of Graduate Medical Training which can be internship and/or Residency, Residencies are at least 3 years, depending on the specialty.

6. CONSIDER OTHER HEALTH CAREERS

Lower-level job opportunities as a first step towards the MD

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.
  • You will have an opportunity to network with U.S. healthcare professionals, which may prove useful when gathering Letters of Recommendation for your application.

You may immediately qualify for several hospital staff positions that 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 inquire if they have benefits such as paying for your tuition or schedule flexibility that will support your goals.

Physician Assistant, as an alternative to MD

Consider becoming a Physician’s Assistant as an alternative to pursuing the FMG conversion. You may be able to complete a PA degree and certification within 3-1/2 years and be in practice soon after with a very reasonable salary, as opposed to the 9-1/2 to 12-1/2 years it takes (including the 3 years of Residency) to become a U.S. MD. The likelihood of successfully completing all required components from being a Foreign Medical Graduate to becoming licensed in the U.S. is lower for people who are from another country (IMG), and lower still for those who have been out of school for several years. It is important to know up front that becoming a Physician’s Assistant is an excellent alternative for many IMGs who weigh the opportunity costs and low probability of success. Becoming a PA does require completion of a new degree in the U.S. and may initially appear more expensive, but it is able to be completed sooner, with the possibility of getting back to work with a reasonably high salary much more quickly than going through the U.S. physician’s licensing process.

See the two MD scenarios and compare to the two Hypothetical Scenarios for Physician’s Assistant Education. Please do not consider them as minimum or maximum scenarios, only as some potential scenarios out of many. Your personal perspective and experience will vary.

Links to both tables can be found in the New Hampshire Physician Assistant Licensing Guide.

7. BEYOND LICENSING

Complete Your Residency

The State of New Hampshire allows you to receive a license after you have completed a minimum of two years of Graduate Medical Training/Residency. At that time you are able to practice general medicine without supervision. However, general medicine is not a specialty. You must complete a Residency (at least 3 years) to be Board Eligible in any given specialty.

Join 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 New Hampshire 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:

The New Hampshire Medical Society: http://www.nhms.org/

National:

American Medical Association: http://www.ama-assn.org/

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

Licensing Mobility

The State of New Hampshire grants licensing to MDs by examination (the process described in this topic). A physician must independently meet all New Hampshire 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 New Hampshire and want to practice medicine in another state, you will need to research the legal requirements for that state.

Maintaining Your New Hampshire License

Your New Hampshire Physician License must be renewed every two years through the New Hampshire State Board of Medicine. To renew your license you must also have 100 hours of Continuing Education credits (as defined by the NHSBM). You should apply on or before June 30th every two years. Cost for license renewal is $350. You can submit your renewal online. Reinstatement is possible if your license expires, but additional application and fees are involved.

Why you may wish to consider becoming Board Certified

Medical specialty certification in the United States is a voluntary process. While medical licensure sets the minimum competency requirements to diagnose and treat patients, it is not specialty specific. Board certification demonstrates a physician’s exceptional expertise in a particular specialty and/or subspecialty of medical practice.

8. IMPORTANT LINKS

New Hampshire Licensing

The New Hampshire State Board of Medicine website has general licensing information on several regulated professions in the State of New Hampshire. http://www.nh.gov/medicine/physicians/

For general inquiries contact the New Hampshire State Board of Medicine, 2 Industrial Park Drive #8, Concord, NH 03301. Phone: (603) 271-1203. More ways to reach the NHSBM can be found at http://www.nh/medicine/contactus/htm

The laws, rules and regulations section provides additional information on the law that regulates Physician and Surgeon licensing for foreign-educated medical graduates. Most information can be read at http://www.nh.gov/medicine/laws/

Federation Credentials Verification Service (FCVS)

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. Click http://www.fsmb.org/pdf/FCVS_Physician_Brochure.pdf for an online brochure. All International Medical Graduates in the State of New Hampshire must use this service and sign up for a Physician Information Profile.

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

International Medical Education Directory

The International Medical Education Directory by the Foundation for Advancement of International Medical Education and Research is searchable online. It lists schools whose graduates (for specific years) are eligible to participate in the certification program. https://imed.faimer.org/

ECFMG Certification

The Educational Commission for Foreign Medical Graduates (ECFMG) provides certification for graduates of foreign medical schools to compete for Residency in the U.S. http://www.ecfmg.org/

You will register through them to take the USMLE Step 1 and 2 examinations. http://www.ecfmg.org/usmle/index.html

ECFMG also provides other online services. The ECFMG 2014 Bulletin has essential information to learn more about the ECFMG Certification process.

ECFMG Common Fees

Apply for USMLEs through the Interactive Web Application.

The IMG Advisors Network (IAN) is a free advising program for first-year resident IMGs.

Medical Residency – search and temporary licensing

https://freida.ama-assn.org/Freida/user/viewProgramSearch.do

FREIDA online is the AMA searchable database on Residency programs.

Electronic Residency Application Service (ERAS)

The National Resident Matching Program helps Residency candidates and programs match. http://www.nrmp.org/

United States Medical Licensing Exams (USMLEs):

Register for USMLE Step 3 through the Federation of State Medical Boards (FSMB). http://www.fsmb.org/

After you obtained all the USMLE examinations, fill out the Examination and Board Action History Report at:

Form (EBAHR) on the FSMB website: http://www.fsmb.org/transcripts.html

Test Preparation

National Boards of Medical Examiners, NBME, offers web-based self-assessments, descriptions and content outlines for all USMLE computer-based tests (Step 1, Step 2 CK, and Step 3). http://www.usmle.org/practice-materials/

Professional Associations

The New Hampshire Medical Society http://www.nhms.org/

American Medical Association (AMA) http://www.ama-assn.org/

Accreditation Council for Graduate Medical Education http://www.acgme.org

The American Osteopathic Association: http://www.osteopathic.org

Board Certification

A complete listing of all general specialty and subspecialty certificates recognized by the ABMS Member Boards: http://www.abms.org/Who_We_Help/Physicians/specialties.aspx