HOW THE PROFESSION IS ORGANIZED IN TEXAS
1. REGULATION OF PHYSICIANS IN TEXAS
As a physician trained outside the U.S., you will need to complete several steps in order to practice medicine in Texas. There are a number of organizations that regulate the licensing and practice of physicians in Texas.
The Texas Medical Board regulates the licensing and practice of physicians within the state. However, there is 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, which applies to all medical graduates in the U.S. The Educational Commission for Foreign Medical Graduates (ECFMG) certifies the qualifications of International Medical Graduates (IMGs). This certification requires you to take and pass Steps 1 and 2 of the United States Medical Licensure Examination (USMLE). These tests are discussed in further detail later in this guide.
After certification, you will need to return to training, compete for a multi-year graduate medical education program (a “residency”) and specialize. Competing successfully may mean that you choose to relocate to a new state and adopt a specialization different than what you practiced before immigrating.
After completing two years of residency in Texas or in another state and passing the last USMLE test (Step 3) and the Texas Medical Jurisprudence Exam, you are eligible to apply for a full Texas medical license. The next sections of this guide will look at each of these elements in detail.
2. EMPLOYMENT AS A PHYSICIAN IN TEXAS
It can be difficult and costly for an IMG to become licensed in the United States, but you can be successful. The Association of American Medical Colleges reports that, as of 2019, IMGs made up 23% of all residents and fellows in programs accredited by the Accreditation Council for Graduate Medical Education.
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 $2140,000 are common, while the best-paid specialties, such as anesthesiology, can easily pay $271,000.
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 more recent graduation. The competitive conditions that result can lead many IMGs to consider changing medical specialties in order to return to medical practice.
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. Primary care specialties such as family practice, internal medicine or obstetrics and gynecology also provide more residency opportunities, and there is high public demand for these doctors.
Texas 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—injury or loss to a patient caused by improper treatment. Texas allows a maximum of $250,000 in non-economic damages (compensation for pain, suffering, loss of consortium, disfigurement, and the like) per patient in a lawsuit. This “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 doctors and insurance companies at the expense of patients’ rights.
ELIGIBILITY FOR LICENSE TO PRACTICE MEDICINE IN TEXAS
This section explains 4 major steps that you need to complete before becoming licensed to practice medicine in Texas. They are:
I.Certification by ECFMG
III. Apply for a Physician-in-Training Permit
IV.Apply for a Texas Medical License
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 section will look at each step separately.
1. CERTIFICATION BY ECFMG
The Educational Commission for Foreign Medical Graduates (ECFMG) is the organization that certifies IMGs and qualifies you to compete for medical residency positions in U.S. teaching hospitals.
In order to qualify for ECFMG certification, your foreign medical school and program at the time of your graduation must be listed in the World Directory of Medical Schools, managed by the World Federation for Medical Education and Foundation for Advancement of International Medical Education and Research. The certification process can be broken down to the following steps:
- To begin, you will register through the Interactive Web Application (IWA) for a USMLE/ECFMG Identification Number and begin to build your profile. Be very careful to give accurate information from the beginning since changing your biographic information later in the process will require documentation and additional fees.
- Complete the Application for ECFMG Certification and submit it via IWA
- Then, a Certification of Identification Form (Form 186) will be created, which needs to be downloaded and notarized using NotaryCam.
- Apply for and take USMLE Step 1 and Step 2 exams through ECFMG. More information on these exams is provided later in this guide.
- You will also need to provide certain documentation related to your medical education credentials, including: certification from your medical school that you are a graduate, final medical school transcript (from your medical school), and your medical diploma.
- After passing Steps 1 and 2, and providing all documentation of your medical credentials to ECFMG, you can be approved for certification. You can check the status of your applications and test results at ECFMG’s On-line Applicant Status and Information System (OASIS).
After getting ECFMG certification, the next step towards a medical license is completing a medical residency or fellowship, also known as a Graduate Medical Education program (GME). These programs are accredited by the Accrediting Council on Graduate Medical Education (ACGME) and vary in length from 3 to 7 years depending on the specialty. Occasionally, a teaching hospital will accept IMGs as second-year residents; however, these are rare cases, and you should be prepared to go through a full residency program.
Finding a residency requires careful strategy, organization and initiative. Graduates of U.S. medical schools benefit from more established networks and familiar credentials. Since you will be competing with these U.S. graduates, you should dedicate time to developing job search skills and 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.
Although you may have already specialized in your previous country, you may consider being flexible about both the residency specialties and locations you will accept. You may increase your chances in obtaining a spot in residency programs that are:
- in medically underserved areas (rural and/or economically-depressed areas),
- in lower-earning specialties, or
- in specialties with more demanding work hours.
“The Match” is a standardized process most medical graduates participate in to obtain a residency program. This process involves online applications to multiple residency programs, followed by interviews with those programs, after which you rank your choices and the programs rank candidates. On “Match Day,” an algorithm is run to match programs to candidates after which you are bound to accept a placement with the residency program you match with (and vice versa). This section will discuss the match in detail.
Some experienced foreign doctors may have developed relationships with hospitals or residency programs through personal or professional connections. You can look for a pre-match placement while also participating in the match process, but you must withdraw from the match program before its deadline (when rank lists close) if you have accepted a position “outside of the Match.” If you do not, you could be responsible to join more than one residency program and will have violated match rules. If you think a pre-match is likely, make sure to formally accept the offer and get documentation before the match deadline.
Every year, the match program follows the same timeline:
- September: Match “season” begins; candidates and programs accept match participation terms; applications and interviews occur
- February: candidates and residency programs can begin to enter rankings for each other
- Early-March: rank lists close
- Mid-March: matches are announced on Match Day
The match process can be broken down into 4 steps, which will be discussed in more detail below:
- Researching residency programs.
- Compiling documents and applying to programs.
- Phone and in-person interviews with residency programs.
- Ranking of schools by candidates, and vice versa, resulting in a match.
A. Researching Residency Programs
You should begin researching residency programs well before Match season begins in September. 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.
FREIDA is a searchable online 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.
TIP: 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. This guide assumes you are an IMG who already has permanent work authorization through permanent residency or refugee or asylee status.
B. Compiling Documents and Applications 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 September 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, the ECFMG serves as the designated Dean’s office and is your primary contact for assistance and information throughout the ERAS application process. The ERAS support service involves fees for processing documents, 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: $155 ECFMG token fee (to register and start your residency application); $80 USMLE transcript fee; $99 for ERAS (for up to 10 applications; additional applications incur additional fees) and $85 for NRMP (for ranking up to 20 programs; additional rankings incur additional fees).
You will need to submit Letters of Recommendation (LoR) from physicians familiar with your clinical abilities, medical knowledge and work ethic. 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 in a U.S clinical setting. Most programs ask for three LoRs, and all programs have a maximum of four LoRs. You may consider different LoRs for different specialties to make your application more competitive. 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 strengths 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.
C. Phone and In-Person Interviews With Residency Programs
Between September and February, you may receive invites to interview with residency programs you applied to. These interviews are a critical step in the process, so you should ensure you prepare well before interviewing. Research the program and develop your personal story of why you want to practice this specialty at this particular residency program.
You will be expected to travel to these interviews and pay for your own travel and accommodation. If you are able, you should target at least five interviews. When interviewing, think about how you will want to rank each program to optimize your chances of getting a successful 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 online in the NRMP. Residency programs will rank candidates in order of preference based on their applications and interviews. 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 early March and NRMP utilizes an algorithm to match candidates to programs based on their rankings. The algorithm is “applicant-proposing” and prioritizes candidates’ rankings over the programs’ rankings.
The resulting matches are announced during Match Week, which is in mid-March.
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. This means that there are many qualified candidates who do not receive a residency match. There are also some residency program openings that remain unfilled.
On the Monday prior to Match Day, you will be notified whether you have matched or not matched. On Match Day (always a Friday) you will find out which program you matched to.
If you are notified that you did not get a match, then you will have a chance to find a match through what is called the Supplemental Offer and Acceptance Program (SOAP). From Monday through Thursday, 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 SOAP positions.
If you are eligible for SOAP, you will receive a list of programs with remaining spots on Monday morning. You can apply to up to 45 unfilled programs. Be careful when you choose which programs to apply to, and make sure that the program accepts IMGs before applying. It is recommended that you apply to programs by Monday afternoon.
On Wednesday, programs will begin making offers to candidates. There are three rounds of offers from Wednesday to Thursday. If you receive an offer, you will have two hours to respond. You may receive multiple offers during the week, but you can only accept one offer.
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.
3. APPLY FOR A PHYSICIAN-IN-TRAINING PERMIT
If your residency or fellowship program is in Texas, you will need to obtain a special Physician-in-Training (PIT) Permit. The TMB suggests that you should allow at least 90 days to 120 days for processing of the application.
Once you have received acceptance to a Texas residency program, you may apply for a PIT Permit. You will need to provide your ECFMG certification number in your application.
When you have a valid PIT Permit, you may only practice medicine within your residency program. You may not moonlight outside of your residency program. Internal moonlighting (additional optional training within the residency program) is permitted if it occurs under the direction of a faculty member associated with the training program, is in compliance with the training requirements (including requirements for faculty supervision and work hour limitations), and is in the same specialty as the training program or approved by the program director as a training area related to the specialty.
The application fee for the PIT Permit for the length of Texas residency is $200. Some residency programs might reimburse their residents for this fee.
4. APPLY FOR A TEXAS MEDICAL LICENSE
You can apply for the full Texas medical license after you have completed two years of continuous and progressive graduate medical training through a residency program in the U.S. or Canada. You must also have passed all Steps of the USMLE and the Texas Medical Jurisprudence Examination, which are explained in detail in the Tests section.
There are a number of exams you must take and pass to become licensed in Texas. The most common tests are called the United States Medical Licensing Examination (USMLE), and there are three tests you must take: Step 1, Step 2, and Step 3. In addition, applicants must pass the Texas Medical Jurisprudence Exam.
You will apply to take Steps 1 and 2 as part of your ECFMG certification. You will take Step 3 after you have started your residency. Steps 1 and 2 are given at Prometric test centers in the U.S. and abroad. Step 3 is offered in the U.S. only.
1. USMLE STEP 1
The USMLE Step 1 exam is a broad-based test that focuses on 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.
Note that for Step 1 exams taken on or after January 26, 2022, the score reporting will be pass/fail only. Score reports for Step 1 tests taken before January 26, 2022 still have a numeric score and pass/fail outcome.
The USMLE Step 1 is an 8-hour, multiple choice exam taken on a computer. There are up to 280 questions, some containing audio and video references. The exam covers general medical principles across systems and also at processes within organ systems. Questions come from traditional and interdisciplinary areas.
Traditional medical disciplines:
- Gross anatomy & embryology
- Behavioral sciences
- Histology & cell biology
2. USMLE STEP 2
Step 2 used to consist of two different tests, Clinical Knowledge and Clinical Skills. Step 2 Clinical Skills was an in-person simulated practice exam, given at only five testing centers in the country. During the COVID-19 pandemic, Step 2 Clinical Skills was suspended due to public health measures. The USMLE announced in January 2021 that it would not resume Step 2 Clinical Skills.
The USMLE Step 2 Clinical Knowledge (CK) exam is a 9-hour long computer exam consisting of up to 318 multiple-choice questions. It assesses whether you can apply medical knowledge and understanding of clinical science that is necessary for providing patient care. It includes emphasis on health promotion and disease prevention.
The test evaluates your knowledge in these content areas:
- Obstetrics and gynecology
Most Step 2 CK exam questions describe clinical situations and require that you provide a diagnosis, prognosis, indication of underlying mechanisms of disease and/or next steps in medical care.
3. USMLE STEP 3
The USMLE Step 3 is administered by the Federation of State Medical Boards (FSMB). The FSMB recommends applicants to take Step 3 after completing their first year of residency. You cannot take Step 3 until you have passed Step 1 and Step 2.
The USMLE Step 3 exam is a two-day computer-based exam. The two days cannot be more than 14 calendar days apart.
The first day of testing, known as Foundations of Independent Practice, consists of 232 multiple-choice questions divided into six 60-minute blocks. The second testing day, Advanced Clinical Medicine, begins with approximately 180 multiple-choice questions. The rest of the session is dedicated to 13 Clinical Case Simulations that each last 10 or 20 minutes each. The simulations involve real-time patient care scenarios.
The Step 3 fee is $895.
4. THE JP EXAM
The Texas Medical Jurisprudence Exam (JP Exam) covers Texas statutes relevant to the practice of medicine, including, but not limited to, eligibility requirements to be licensed, registration renewal requirements and procedures, continuing education requirements, scope of practice, investigations of complaints and enforcement procedures.
The passing score for the JP Exam is 75. You have unlimited attempts. The fee is $34.
5. TEST PREPARATION
The National Board of Medical Education (NBME) offers online self-assessments for the Step 1, Step 2 and Step 3 tests. There are also content outlines available for all USMLE tests. Other companies offer study programs. You should seriously consider taking a test preparation course if your self-assessments turn out unsatisfactory. Investing early in preparation will save you money on retakes!
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.
5. OTHER CAREERS AND CREDENTIALS
You may want to consider whether taking a transitional or lower level job in healthcare in the short-term can help you meet longer-term goals of licensing as a physician. 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 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.
1. COMPLETE YOUR RESIDENCY
The state of Texas allows you to receive a license after two consecutive years 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.
2. 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 Texas 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.
In June 2021, Texas passed a law to join the Interstate Medical Licensure Compact. Once the Compact licensing program is implemented in Texas, which is anticipated to be in early 2022, licensed physicians in Texas will be able to apply for licensure in other participating states in a more streamlined process. However, if you become licensed in Texas and would like to practice medicine in a non-participating state, you will need to research the legal requirements for that state.
4. MAINTAINING YOUR TEXAS LICENSE
Once the Texas Medical Board (TMB) has issued you an official license number, you will have 90 days to register and activate your license. Failure to register will result in penalty fees and, after one year, license cancellation.
Your Texas Medical License must be registered every two years (initial license will be either 12 or 24 months in length) through the TMB. Registrations are available online 60-90 days prior to your current expiration date.
Texas physicians need to complete at least 48 credits of continuing medical education (CME) for every 24-month registration period. It is a good idea to keep a record of your CME history in case you are audited. You should check the TMB website for details and consider joining a professional association that offers CME opportunities to members.
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 issues such as:
- FINANCES: 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 U.S.-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 IMGs 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.
- PAY ATTENTION TO DETAIL: all documents you submit either on paper or online are official so 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 of Texas 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 4 failures on any USMLE Step, 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.