USMLE Forums - ECFMG Forum

When I walked on this path the first time, I found candidate experiences on different forums, blogs and Facebook groups very useful, sometimes even more than the official information bulletins. I write my experience all down here, hoping it will help someone find their way.

First of all, I thank god that guided me to that way and helped me all along.

And for anyone who is interested in this track and read or heard how difficult the exams are or finding a residency is, I tell you don`t believe any of it. The USMLE exams are formulated for the average physician who can just study hard, make good use of their time, speak sound English and follow the rules. And about the residency positions, out of 24.000 residents who match every year, more than 40% are IMGs. If you can fix an above than average profile, I think you can make it to that 40%.

So, lets start.

Background

My name is Mostafa Elguindy. I am an Egyptian International Medical Graduate (IMG). I graduated from the Faculty of Medicine, Tanta University, Egypt, in the year 2005 with excellent degree with honor. After finishing my obligatory internship year, I started a 3 year residency training program in the department of cardiovascular medicine in Tanta University Hospitals, that was from April, 2007 to April, 2010. I was granted the Master of Science degree in cardiovascular medicine soon after, and was able to join the university teaching faculty in August, 2010 as an assistant lecturer (teaching assistant) in the department of cardiovascular medicine.

I was registered to the Ph.D. degree in cardiovascular medicine in the same facility in April 2011, but I decided to make a life-time career shift and to seek certification by the American Board of Cardiology. I read a lot about the required steps for such a challenge, and formulated my plan ahead.

Timeline

To seek certification by the American Board of Cardiology, I had this proposed timeline. I needed to get certified by the Educational Commission of Foreign Medical Graduates (ECFMG), that provide United States Medical Licensing Examination (USMLE) exams for IMGs, by the end of August the year before my planned match year, this means to pass the USMLE step 1 exam, USMLE step 2 CK exam and USMLE step 2 CS exam. Thu USMLE step 3 exam is not part of the certification and not mandatory on applying to programs as will be discussed later. Once certified, I will have to apply for a 3 years internal medicine residency training program accredited by the American College of Graduate Medical Education (ACGME), and to pass board certification exams, to be legible just after to apply for an accredited 3 years cardiovascular medicine subspecialty fellowship that will qualify my to the board exams and hopefully to the desired certification by the American Board of Cardiology. This would be 6 years ahead.

To apply for internal medicine residency, I shall register to the Electronic Residency Application System (ERAS) by July, and apply through it by September -after ECFMG certification-, the year before the match. Program directors interested in my profile will arrange for interviews from October to January. If the USMLE step 3 is planned -like explained later-, it shall be taken around early December. After the interviews season, both sides -myself and the program directors- will rank our matching preferences for the US main residency match, the National Residency Matching Program (NRMP) by February. The Main residency Match itself is held in the 3rd week of March. Matched applicants are informed by their matches, and start residency training by June/July. Three years after, I will do similar steps with the match for medical specialties to get the fellowship in cardiovascular medicine I am seeking.

For an American medical graduate (AMG), you can apply to the match with only your USMLE step 1 results then finish the rest of your exams later. For an IMG this might by formally possible, but actually if you apply before being ECFMG certified, then wait for no interviews or match. The US program directors are blind of any IMG that is not ECFMG certified. That is why everybody, like myself, was trying to get certified before ERAS season opening date. After you finish the 3 exams, the USMLE step 1, the USMLE step2 CK and the USMLE step 2 CS exams, your ECFMG certificate is issued, and you would be recognized by the program directors as ECFMG certified. The physical ECFMG certificate will arrive to your door step by mail around 2 weeks later.

For me, I knew that to apply for the match, it will never be before the 2013 match, and this means I would be 7 years old graduate when applying the year before. This was problematic as being an old graduate, especially as an IMG would lower my chances being matched. The second problem is that I took my decision to start on this track by July 2011, this means that to apply for the 2013 match, I will need to be ECFGM certified in August 2012, only 12 months ahead, and not only that but also with good scores to improve my IMG and old-grad profile.

From what I read in the different forums I came by, and from my experience now, ECFMG certification with good scores needs 18 months for a practicing physician -working by day, studying by night-, as long as they can properly handle their time. It may take up to 2 years or even more for a loser, and also can be done in 12 months for book worm or someone in a no-option situation, like I was.

Registering with the ECFMG

Initially you will register with the ECFMG for free and acquire a unique ECFMG number. You will need this number all the way to the start of your residency. Your name on registration must match EXACTLY the name on your English-letters ID used for exams, e.g. passport, to avoid hard times later.

When applying for the first step you will take, whatever it is as you can take them in whatever order, you will go through 23 questions by the ECFMG that will establish your profile at their records. Be honest and answer questions the right way. After you finish them and pay for the step exam fees, you will be given many forms you have to fill and send with your photo and copies of your credentials -or as requested on the most recent ECFMG information bulletin-. Of these forms, the form 186 was considered a problem back then because I needed to sign it from an American consulate official then from the dean of my faculty of medicine. But things went nicely, and after I did so I sent all requested documents by DHL to the ECFMG. They notified me by e-mail when they received my mail 6 days later, and 25 days after they e-mailed me again that my documents, including form 186, were accepted and that I am ready to start taking USMLE exams.

The ECFMG later contacted my medical school to verify my credentials, and the school answered back that they were accurate. The ECFMG sent me a mail on the address I put on my profile notifying me that my credentials have now been verified. I understood later that this means once I am ECFMG certified; now only I can rank my match preferences, later on, for the match.

USMLE step 2 CK

Starting with which step was the next question. I have been practicing at the bed side for 6 years, then, and when I saw the step 1 curriculum, I found it very difficult. To shift from your daily patient-centered practice and start studying medical genetics, immunology, anatomy and so on. Like hell I am. I then found the step 2 CK curriculum more close to the practicing mind. So, I took my decision to start with USMLE step 2 CK exam. I recommend for any one who has been in practice for some time to do the same.

Like I said before, once your documents, including form 186, are accepted by the ECFMG, you are legible to start taking the USMLE exams. I was e-mailed by the ECFMG that my examination permit is ready -which I will use for admission at test center-, and with a number to use to book an examination spot at the nearest Prometric center. Try to choose your exam date a good time earlier as you plan to finish studying, because it`s always busy up to a month or more ahead.

The step 2 CK curriculum consists mainly of 5 subjects with minor add-ons: Internal medicine (40% of the whole study material), Surgery, Pediatrics, OB-GYN and Psychiatry. The next question was the studying source, and from the forums I came by and from my experience now, I recommend the Kaplan lecture notes as a primary source. The notes are 1400 pages long and you may need to draft short notes out of them so that you can cover in the last few weeks before the exam. And for someone who cannot draft for themselves, I recommend the First Aid book after you finish studying the former to do the drafting job.

It coasted me 790 $ on applying for the exam, as I was already in the United States for a part time training program, and I started studying. It took me exactly 3 months and 3 weeks from the first page in the internal medicine notes to the exam day. I took 2 months and 2 weeks to cover the whole study material for a first time. I subscribed to the USMLE World online Q-bank for a month and later extended for 2 weeks, coasting 150 $ total. Then, it took me a bit less than a month to draft and revise while answering the Q-bank. The final week was the last revision with the marked and wrong questions.

My cumulative score on the USMLE World Q-bank was around 68 %. I took the USMLE World self-assessment exam 3 days before the exam and scored 241. I was ready.

I took the exam in the Prometric center in Washington, DC. I reached the center by 8:10 am. I had with me my passport, the examination permit and the confirmation notice by Prometric for the booked exam date. Admission was simple, we were assigned small lockers, examined by metal detectors -and as indicated in the step information bulletin- and I started the test before 9:00 am. I had downloaded the tutorial on the USMLE official site before so I added these 15 minutes to my break time. The USMLE World Q-bank had exactly the same interface as the official exam program and that made things much easier. The only notes that I may have is that there was no food or drinks at the center, that I didn`t know. I had to leave the center in the break time to a nearby CVS to get myself some candy bars and a drink. So, get all what you want and leave it in the locker before the exam times. I also I asked for a quite place to pray in the break, as I am a Muslim, and this was not available.

The exam was in 8 question blocks and it took 9 hours to finish. It was actually much difficult than the average of USMLE World Q-bank and the self-assessment exam, and I knew I won`t get that 241 anyway. I read before in forums of people saying the same thing, and on the contrary people saying how much easier the exam was. I don`t why do things look so differently like that.

I received my result 18 days after. I got 221; meaning 95 on the old now cancelled percentiles. I thanked god, it was not the best I wanted but it was above average for the internal medicine residency I am seeking.

USMLE step 2 CS

While I was studying for the USMLE step 2 CK exam, I started my research about the USMLE step 2 CS. I understood that it takes about 2 weeks to one month to prepare for it if you have just finished the USMLE step 2 CK exam and study material, so I decided to it the same way.

I paid for the exam about 3 months ahead from my expected date and while I was studying for the USMLE step 2 CK exam. I knew from what I read that the examination spots are limited and are busy for more than 2 months ahead. I was living near Washington, DC, so I choose the closest USMLE step 2CS testing center in Philadelphia, PA out of the 5 centers available in the US. I read a lot and was told by many that this is the hardest center for IMGs with worst 1st time passing chances. But I made my mind that I am studying the same way and tested in a standardized way, so what`s the deal? If I shall pass in Atlanta, Houston, Chicago, or Les Angeles, I shall pass here.

It coasted my 1375 $ when applying for the exam. If you are outside the states, you will be issued a visa letter that will help you when applying for the B1 visa to enter the United States for the exam. When I was booking for the exam date for the first time, I didn`t find any empty spot even close to my desired date. The site, accessed via the ECFMG portal, has a great service to e-mail you once an examination spot becomes vacant in a time slot pre-determined by you. I received the e-mails instantly on my mobile phone and used this service to change my exam date for may be 7 times -for free- before I came to my final exam date. I don`t remember the time cut before the exam date after which changing the date gets paid for -check the latest USMLE step 2 CS information bulletin-.

The book I choose base on all forums surveys was the First Aid for the USMLE step 2 CS exam, it was great in content and just enough sized. After I took my USMLE step 2 CK exam and after 2 break days, I started studying. The study manner for this exam is so different than the former, and it felt first like I was down with my pace. Later, you will take to it and adjust your timing. From the official USMLE site, I downloaded and watched the USMLE step 2 CS exam date orientation video and saved the sample patient note page on my desktop. I also found many YouTube channels useful to review basic clinical examination, like mdofola, oscetube and others. I had no study partner, I was afraid this might compromise my tight time schedule. I read case histories and did patient encounter simulations on my own, expecting patient replies. This is very important, even the door knocks, and the way you speak, react, move, turn and write down your sheet to make your mind for the exam environment. Mange your time to make the introduction and taking the history in a little more than 5 minutes, do the examination in a little bit less then do the closure in final 2 minutes, making 15 minutes total. Never underestimate the introduction and the closure as every thing counts. I then tested my keyboard skills on the sample patient note. You would have 10 minutes to write down your note, so train for it.

It took me exactly 16 days to prepare for the exam. I studied initially in 9 days, reviewed in 5 days and packed things up in the final 2 days.

On the exam day, do not dress casually, as advised. Be more formal; wear a tie and long sleeves. I took my white coat and my stethoscope with me, along with the examination permit, the confirmation notice, and my passport. I had booked a train ticket for the exam date, at 5:30 am with AMTRAK to be in Philadelphia by 7:20 am. I found no bus service to Philadelphia that early, that would be much cheaper but takes around 3 hours. Try to book your ticket more than 15 days ahead as it is also much cheaper (40% less). You don`t need a business class ticket even if you intend to study or review anything in the way as the train was so quite with very few passengers that early. I arrived at 30th street station in Philadelphia on time. It took me 20 minutes of soft walking to reach the exam center. I had a lot of time, so I didn`t use the underground.

At the exam center, admission with easy with the required documents. I was upstairs in the center by 7:50 am and we waited till 8:10 until everybody was there. They started with a simple introduction about the staff and the day time schedule. The staff members were so friendly. They checked we had ordinary stethoscopes and untagged coats, and then we were admitted to the locked exam arena. We were seated on numbered desks and shown the official exam videos then left to see a sample exam room with all the equipments to try. We were then shown where the bathrooms are and directed to the lockers to leave our things, that won`t be available till after the exam. If you have got some food with you, you will leave it on the desk.

We started the exam exactly at 9:00 am. Due to confidentiality issues, I cannot speak more about the exam content. All what I can say is that the First Aid book, the revision videos on YouTube, the orientation video and simulated patient encounters were all great and just enough. I was satisfied with my performance. There was a launch in the long break, but bring some candies and a drink if you wish. We finished the exam before the evening turn; I think after 3:00 pm and left the center before 4:00 pm with an attendance confirmation. That was from another door, and after the evening turn candidates were admitted.

I had the all day in Philadelphia before I go back to Washington, DC, on a bus I booked at 10:00 pm. Plan for some fun ahead, you deserve it my boy after the 2 exams this month. I had planned myself a trip to the Independence hall and national historic park. I used the underground SEPTA service and it was horrible, one of the worst I have ever seen in my life. I took my launch, a real one and toured the city. I came back to 30th street station again where the bus stops are, and back to the nation`s capital.

I received my test result 2 months after, as the USMLE step 2 CS test score reporting is predetermined on longer intervals than both other tests. It was a straight first time PASS and I was all delighted.

USMLE step 1

Then, came the epic conclusion. Once upon a time, actually 4 months ago, I thought it would be quite impossible to study the basic science stuff of the USMLE step 1. Now, and with only this exam standing between me and applying to the match, and after I came to understanding the USMLE study material and question format, and after I was satisfied with me previous 2 exams -though hadn`t received USMLE step 2 CS result yet-, I was ready to start.

I found out it was not that hard like I once thought, not at all. The USMLE step 1 curriculum consists of 7 books: Physiology, Anatomy and Histology, Microbiology and Immunology, Pathology, Pharmacology, Biochemistry/Molecular biology and Medical Genetics, and Behavioral Sciences. The content looks massive in the beginning and would actually take much longer time to cover, but on drafting it won`t look that large. Not mentioning how easy and actually basic I found it. Start with whatever sequence you prefer, it won`t matter in the end. The source I finally came to was the Kaplan lecture notes, and they were remarkably great. I would say now that more than 95% of the exam questions came by my sight on the USMLE step 1 Kaplan notes. But take care, the books are about 2600 pages overall. Again, if you`re not good at drafting, refer back to the First Aid book after you finish studying.

Over all, it took me about 8 months from the first page in the physiology book to the exam date. This was more than twice than the USMLE step 2 CK, but actually by that time I was back to Egypt and to my full time job, so that counts in the calculation. It took about 5 months and 3 weeks to cover everything for the first time. I subscribed to the USMLE World Q-bank for 2 months for 145 $, and again the questions were remarkably helping. I started revision while answering the Q-bank and it took me less than 40 days to cover things back again. I took a leave from work for the final 2 weeks to cover everything for a 3rd time while answering the wrong and marked questions. The last 3 days for only rapid scanning of the drafts. Due to my bad experience with the USMLE World self-assessment exam with the USMLE step 2 CK exam and due to the lack of time, I did not do it that time. My cumulative score on the USMLE World Q-bank was 72%. I was ready.

It coasted a bit more than 900 $ to book for the exam, as I was outside the United States this time. When I was booking for it, I found no empty spots around my desired date in the Cairo Prometric center at AMEDEAST, Cairo. It was all busy 3 months ahead. I even booked initially in Dubai, UAE then Beirut, Lebanon but finally back to Cairo after I caught an empty spot from a changing candidate. There was no service to inform with newly empty spots -like with the USMLE step 2 CS site- so I had to check the site for availability every now and then. The ERAS post office opening date was delayed for the first time to September, 15 this 2013 match season. And like I said before, everyone was trying to be ECFMG certified before the date. So again, book your spot as early as possible especially for centers outside the United States with large candidate numbers and limited exam spots.

On the exam date, I took my passport, my examination permit and confirmation notice. I slept the night in Cairo and arrived at the center at 8:10 am. The staff members were friendly, and the same that happened in the Washington, DC center happened but the orientation was in Arabic as all the candidates that day were Egyptians and Arabs. One of the candidates was denied admission as his passport has expired and he didn`t have a current English-letters ID in replacement. The staff even asked for the national Arabic ID plus a current credit card in English, matching the name on the examination permit, to admit him but he didn`t have the latter. So, be prepared with your documents. I was the last one admitted, about 9:15 am, as they started with USMLE step 2 CK candidates and I was the only USMLE step 1 candidate present. Again, the same checks, adding finger print checks, then the lockers.

The exam took 8 hours overall. I added the tutorial time to my break time, and is gave me a comfortable 1 hour of break time to distribute between the 7 question blocks. Strangely, the exam was much easier than expected -compared to my USMLE step 2 CK experience-, and don`t ask me why. I prepared for my breaks with some snacks. I finished by 5 pm in the afternoon. It was such a relief.

I knew that the USMLE step 1 score was the most important determinant used by program directors to filter applicants applying to programs (others include graduation year, USMLE step 2 CK score, Visa status, and the CV). By early September and on applying, AMGs usually have only their USMLE step 1 scores available. So, program directors will use this score to filter IMGs applying to a program in comparison to AMG applicants.

I received my score report exactly 3 weeks later, after I had established my ERAS profile and was ready to apply. I scored 228. The official conversion tables are not available anymore at usmle.org as the old percentiles are now history, but I remember well that for the USMLE step 1 scores, the 95th percentile was at 227. So, I was there.

The day I received the score report for my finale step for ECFMG certification, the USMLE step 1 score report, The ECFMG updated my ECFMG status at the Applicant Document Tracking System (ADTS) at MyERAS site. I read a notice at my OASIS account at the ECFMG portal that I will receive my physical certificate by mail within 15 days from today. The day after, my ECFMG certificate was formally issued at OASIS, so now I would be recognized as certified by program to which I shall apply.

Now, ECFMG certified, I was ready for the match.

Application

I won`t go in detail hear about the match experience as I have just applied to programs via ERAS and don`t yet know what to come. I will just tell about my experience to that point.

ERAS:
The registration started on July, 1st with tokens acquired from the ECFMG OASIS portal starting June, 26 for 100 $. The token is a unique number used for one time registration to MyERAS. On registration, I was assigned an AAMC number to participate in the match. You have all the time to prepare your application till the ERAS post office opening date more than 2 months ahead, so take your time. Starting this year, for the 2013 match, documents like Letters of recommendation (LORs), medical school transcripts, photo, California letter -for IMG applicants to the California state programs-, and the medical school performance evaluation (MSPE) can be scanned and uploaded directly to MyERAS through your OASIS portal at the ECFMG. For myself, I had no US LORs but 4 good ones from my 7 years of practice in Egypt. I also had no MSPE at my faculty back home in Egypt, and on the miscellaneous tab in the MyERAS application I checked No for the question if I am going to provide one.

I would just recommend one thing, be realistic on applying to programs. Don`t apply only to high-ranking university positions with lower than average scores. And it`s always better to put back-up programs when applying. Also, research well the programs you`re applying for. For my experience, after I initially prepared my program list to apply, I discovered that 60 % of them do not provide H1b visa, that I am aiming for, at all. Many of them also had a 3 year or 5 year graduation year cut-off, that will not go with me. The FRIEDA service at the American medical association (AMA) site provides great insight to program specifics. Refer finally to program web sites for more details.

NRMP:
I registered early in September with my AAMC number , for 50 $ and prepared my profile. The NRMP is a separate entity from ERAS and you shall register to both separately. I shall rank my matching preferences through the NRMP next February I hope.

USMLE step 3:
This test is not mandatory while applying for the match, and is required by most programs to be passed in the first 6 months of the residency program. But, I thought to take it now. IMGs applying to residencies in the United States are granted a J1 visa (exchange visitor) via the ECFMG to join their matched residency programs. After this visa expires, e.g. after the residency program 3-4 years according to the program, you have to go back to you home country for 2 years before you can ever visit the United States again. Some candidates manage to get waivers to extend their stay (research: travel.state.gov/visa). For someone who intends to apply for a subspecialty fellowship, I cannot risk it. The alternative to the J1 visa is the H1b visa. It needs me, once ECFMG certified, to apply to the USMLE step 3 in one of the 12 states that do not require a prior graduate medical education, as most others do. The USMLE step 3 study material is the same for USMLE step 2 CK exam, using the same books, but focusing more on treatments, communication skills and so on. The test results are required before the end of January by most programs providing an H1b visa. This means you need to take the test in early December as results will be available in 4-8 weeks. The match year USMLE step 3 cycle opens by October, 1st and closes by the end of next August. Once application is accepted, you have only 90 days to take the test with the eligibility period starting automatically on accepting the application. So I intend to apply in early October/November, and hope to make it.

Finally

I hope this experience be of value to newbie candidates. And I hope everyone shares his experiences on the different forums to help ourselves with this long, somehow complicated process.

Whatever comes out of this, like I don`t know now, I know I did great. I never thought a year ago that I would make to ECFMG certification and be applying to the 2013 match, that I am doing now. It was a hell of a year, but this was a job well-done. Again, thank god.

Mostafa Elguindy
Tanta. September 20, 2012

Recommended sites and links:

- ECFMG:
http://www.ecfmg.org/

- ECFMG yearly information bulletin:
http://www.ecfmg.org/2013ib/

- USMLE:
http://www.usmle.org/

- USMLE information bulletin:
http://www.usmle.org/bulletin/

- ERAS:
https://www.aamc.org/services/eras/
year manual available on registration

- NRMP:
http://www.nrmp.org/
year manual available on registration

- Road map to Residency: from application to the match and beyond. 2nd edition:
https://members.aamc.org/eweb/upload...cy%202ndEd.pdf

- USMLE forums:
http://www.usmle-forums.com/

- Though primitive, and mainly for Egyptian candidates, this helped me on initial registration to ECFMG:
http://dvd4arab.maktoob.com/f772/1299936.html

- For the Facebook note:
http://www.facebook.com/notes/mostaf...06857506036486

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