Finished Your Residency – What’s Next?

Faroque A. Khan, MD, MACPProfessor of MedicineState University of New York at Stony BrookACP Regent

All trainees in Internal Medicine, usually during their second year of training, have to decide on the future course of their training. Will they start practice after completing their three-year training? Will they pursue specialized fellowship? If so, how do they go about it, and what’s a good or “hot” fellowship?
As a Program Director and Chairman of Medicine, I had the opportunity to talk to and advise over 300 trainees, most of them IMGs. What follows is basically a summary of those discussions with some concrete take-home messages.
Q. Where do you intend to settle after completing your training?
A. I want to go back home.
The answer to this question gives a good indication of the choice of post-career pathway. For those who plan to return to their country of origin, it makes a lot of sense to pursue further specialized training – the reason being the scarcity of specialists. For example, when I visited Malaysia I was informed there were only three rheumatologists in the entire country of Malaysia. This type of situation is not unusual and, thus, any specialized skill an IMG acquires in the USA will be in great demand. Several of my former trainees, after completing their specialization in the USA, have returned to Pakistan, India, Jordan, Qatar, and Saudi Arabia and are making major contributions to the upgrading of health care in these countries.
A. I am determined to stay in the USA.
In this type of a scenario, my advice follows in the following format: The health care environment in the USA is changing rapidly. Solo practice is being replaced by group practices which, in turn, are being driven by Managed Care with heavy focus on cost containment. Many parts of the USA are facing a surplus of specialists. The fastest growing age group is above the age of 85. There is an explosion in information technology, and health systems are trying to incorporate these modalities to maximize efficiency and cut down on costs.
So, after studying the environment around you, one should make an intelligent choice about specialization based on what will be needed in 5-10 years, rather than what you may have desired while you were in medical school. Thus, if you choose to specialize, you might like to pick an area in an emerging field that is in great demand; ex, Informatics, Geriatrics, etc.
A. I have done enough training. I want to start a practice and make a living.
In this type of a scenario my advice would be to be flexible regarding geographic preference. Many of my trainees have settled in mid-western and southern states where, in addition to being able to start a practice, they have been “sponsored” for a permanent visa, as well.
To enhance one’s marketability, I would suggest getting additional competence in clinical skills that would be of use in an office setting, such as arthrocentesis, skin biopsy, hospice care, pharmacokinetics, women’s health, etc., etc. These can be obtained by taking additional CME courses. Organizations, such as ACP, offer them at national and regional meetings.
A. Dr. Khan, I really want to be a cardiologist.
I can’t begin to recall how often I have been asked about the prospects for Cardiology Fellowship, particularly by trainees from South Asia. Perhaps it’s related to the role models the trainees are exposed to as students, the “stature” of cardiologists in their home countries, and lack of the availability of other specialties particularly dependent on laboratory support such as immunology, oncology, rheumatology, etc.
One house officer even remarked, “My father insists I become a cardiologist. Any other specialty will be perceived as a failure.” This young man’s real interest and passion was in oncology.
I have always tried (not very successfully) to show the house officers the advantages and options of other specialties available in the USA.
A. How do I get into a good fellowship program?
Here again there are some practical steps that the trainee can take to enhance their prospects for entering into a highly competitive fellowship. One of the things that helps includes academic productivity during training. A house officer who has participated in ongoing research, such as presenting or publishing material at regional and/or national meetings considerably enhances their chances for fellowship, as does the support from key faculty members, particularly if they are from the same specialty, and more so if they make personal calls on behalf of the applicant.
Q. Does visa status change the prospects for fellowship?
A. The answer is yes and no.
Some programs do not accept H-1 or J-1 applicants, while other programs may prefer J-1 applicants. I recall once being successful in having one of my trainees placed in a highly competitive program in another state. One of his “selling” points was that he was a J-1 visa holder, and I was able to assure the Program Director that after completing his fellowship this candidate would return to his home country. He did just that! This candidate’s J-1 visa became an asset instead of a liability.
Q. I didn’t get the fellowship I was looking for. What should I do now?
A. Well, this doesn’t represent the end of the world.
Let’s move on and think of another field. I, personally, wanted to become a gastroenterologist. In fact, I was accepted by a very prestigious program. There was one problem. They didn’t have a salary to support me. After that rude awakening, I took the first opportunity that came my way, which was Pulmonary Medicine. I enjoyed the training in Pulmonary and my subsequent career.
Like everything in life, one doesn’t always get everything. Be prepared to make choices, accept alternatives, and move on.
Brief Bio:
Faroque Ahmad Khan is a graduate from Srinagar, Kashmir. He trained in Internal Medicine and Pulmonary Medicine, and was a Pulmonary Fellowship Program Director for 10 years, followed by Chairmanship of Medicine for 12 years. Dr. Khan was awarded Mastership in ACP in 1993, and in 1995 Dr. Khan was elected a Regent of ACP, being the first elected IMG Regent. Dr. Khan chaired the Credentials Committee and the Education Committee, and is a member of the International Subcommittee of ACP.

Spanish Speaking International Medical Graduates Applying for a Residency in the USA: Some Thoughts

Rodolfo A. Armas-Merino, MD, FACPProfessor of MedicineUniversity of Chile

If you are a Spanish-speaking International Graduate applying for a residency in the USA, may I tell you that you are in one of the most important moments of your life.
You are facing a moment of great perspectives. The most important incentives that we physicians may have are good conditions of life and professional work at a reasonable level. Good conditions of life means to live in a place and community where we would like to raise a family and reach an economical status that allows us to live without financial preoccupations. For our work, we want to be members of a friendly and efficient team that works at the best technical level.
It is not easy to have all these conditions in our Spanish speaking countries, due mainly to their economical limitations and, in particular, to the chronic and almost extreme poverty of our medicine. On the other hand, all these conditions are possible in the USA.
It is a fact that we belong to poor, underdeveloped or developing countries and that the USA has the highest living standard of the world. Even more, it is also a fact that the USA invests in medicine more money than any other country in the world. This makes our medicine so different from the North American one. So, I think that you are right in preparing to do your residency in the USA, learning their today’s medicine that for us is tomorrow’s.
But the great perspectives of this moment are not only related with medicine. If you are married, at this time of your life it will be an extremely important experience to live with your spouse away from pressures and mainly dedicated to your growing family.
You will be facing difficult days. Starting your life in a North American neighborhood and your work in a North American hospital, you will face differences from which you are accustomed. Habits and culture, language, religion, styles of life, food, timing of the day’s activities, scale of values, etc. will all be different. Worse than that, sometimes, maybe someone will be prejudiced against you. You will be forced to gain your own space. Progress in communications has been fantastic, but we are still different. I like differences. This world and our lives would be terribly boring if the differences between groups disappear. Difference means diversity, and diversity is strength.
But, in spite of all, you will be a weak minority and you will face difficult days.
Feel confident. Many physicians coming from our countries have been very successful in the USA. Why not you? If you have been successful in your country, why will you not be so in the USA? The USA is accustomed to incorporating foreigners coming from the most distant and different parts of the world, and the condition of being a foreigner seems to disappear after a few years.
You will adapt yourself to the differences and you will adopt and enjoy many of them. If you ever go back to your country, you will miss many of the “difficulties” you had when arriving in the USA. It is a common experience that the shock of returning is harder than the one you have at the moment of emigrating.
Remember that medicine is very important but not everything. We cannot renounce to our condition of human beings, with vocations and cultural interests. It is easy to understand that your residency will be very important and a great preoccupation, but do not forget that it is also the time to go on with your personal development. You will need to learn a tremendous amount of medical knowledge, but it is also true that you will be a better physician if you are also cultivated in humanities and arts. In the city where you will be doing your residency, I am sure you will find cultural activities, arts and opportunities for entertainment most probably better than in the country of your origin. Take advantage and enjoy them. Do not let them go by.
You will face decisions that will change your life and perhaps the life of other members of your family. Time runs fast and at the end of your residency, what? It will be time to return back home? Would it be better to go on with a residency in cardiology or nephrology or any other subspecialty? Remember that you must look for the best for you and for the rest of your family. Remember also that medicine is very important but not all in our life. The longer you stay, the stronger are the links to the USA and weaker the links to your country of origin. You may be sure that once you have finished your residency you will be more useful working in your country than staying in the USA.
It is worthwhile to remind you that there exists some moral compromise with your country of origin. In Spanish speaking countries usually education and mainly university education is strongly supported by the State. That means that we have obtained important levels of education thanks to the rest of our people. This does not mean that you are not free to do what you think is the right thing to do. It is your life and your life is only yours. But do not forget that you are in debt to other people. If you decide to stay in the USA, try to give back to your country and your people as much as possible. There are many ways you can do that: Helping patients, helping and receiving young physicians, lecturing back at home, etc. Certainly, if you want to, you will find how to do it.
You are in a unique moment of your life and in a unique moment of your career. This is a time of new experiences and for making great decisions. Be sure, this residency will be an agent of great changes in you. Certainly, changes for the better. Don’t loose this opportunity and be prepared to enjoy it.
Dr. Rodolfo A. Armas-Merino was ACP Governor for Chile from 1996-2000. He was awarded Mastership in the ACP in 2001 in recognition of his outstanding contributions in the field of human rights, medicine and ACP activities.

Strengths and Weaknesses of International Medical Graduates in US Programs: A Chairperson’s Perspective

Barbara L. Schuster, MD, MACPProfessor and ChairDepartment of Medicine, Wright State UniversityDayton, Ohio

The United States is a country of immigrants. The vitality and spirit brought by new Americans add texture to daily life. The diversity of cultures creates complexity and challenge for those in healthcare. International medical graduates (IMGs) bring a wealth of knowledge of disease not often seen in the United States in addition to knowledge of the belief systems of the cultures from which they come. Belief systems have significant impact on health and disease. Having diversity within the healthcare team, allows for improved care delivery within a multicultural environment.
The challenges of IMGs in postgraduate programs include: 1) biased perceptions of medical students, staff, attending physicians, and patients; 2) communication skills of the international physician; and 3) professional and social acculturation.
In general, patients are more comfortable with caretakers who are the same gender, race, and culture. In most areas of the United States, the international medical graduate faces an additional hurdle in building the patient physician relationship because of cultural bias. Different is often translated as inferior. A current guide to residency in the United States clearly warns US medical students to consider the number of international graduates in a program when making their own choices. It implies that a program with significant numbers of international graduates is inferior. Because of this bias, residency programs without IMGs are wary about accepting international graduates and programs with a majority of IMGs have more difficulty recruiting US graduates. In both cases, perceptions of the quality of the program become more powerful than the reality. These perceptions pervade both academic and community faculty and may obstruct the growth and improvement of residency programs.
The ability to communicate goes beyond the ability to speak and write English. Accents, slang terminology, street language, and idioms all influence the communication between physician and patients as well as hospital staff. Humor markedly differs between cultures and language is often the medium. Non-verbal communication through body language is a more sophisticated, yet powerful medium that obstructs or facilitates patient-physician interaction. The extent to which the international graduate can vary his/her own verbal and non-verbal responses, is accepting of feedback about his/her communication skills, and can accept patient differences, the more likely the international physician will be successful in transitioning to a comfortable working relationship.
The international educational system also differs markedly from that in the United States. In many countries, the hierarchical system of instruction is reflected in less questioning of the professors by learners vs the more Ôteam’ learning system in the United States. Transitioning to different educational expectations requires time, patience, and understanding of both the learners and the teachers. Interacting with medical students is one of the hallmarks of graduate education. Helping international graduates to understand the undergraduate medical education system and how to most appropriately interact with students is an additional challenge. US medical students can facilitate the acculturation of the international graduate, if the international graduate accepts the Ôgive and take’ style of education.
Academic physician leadership has the responsibility of setting standards for the education of students and residents and the care of patients. The challenge is to help each young physician to grow in all skill areas necessary to be an excellent physician. Educating international graduates who have chosen to immigrate to the United States or to return home after advanced training to upgrade the healthcare in their respective countries, requires leaders who understand their own biases, accept the responsibility for advancing medical care within the growing multicultural environment of the United States, and find interacting with learners most exhilarating.

Brief bio:
Barbara L. Schuster graduated from the University of Rochester School of Medicine, Rochester, New York. After completing internal medicine residency in Rochester in one of the first Primary Care internal medicine residencies in the country, she joined the faculty and subsequently worked in graduate medical education in Rochester until eventually becoming the Program Director for the Primary Care Internal Medicine residency and the Combined Internal Medicine/Pediatrics residency. She served as President of the Association of Program Directors in 1992-93 and was elected a Master of ACP in 1996. She was elected to the Board of Regents of the ACP in 1999 and has served on the Awards Committee, the Nominations Committee, and the Education Committee. Since September 1995, she has held the position of Chairperson of the Department of Internal Medicine at Wright State University School of Medicine, Dayton, Ohio.

Preparedness for Training

Tanveer P. Mir MD, FACPDirector of GeriatricsWyckoff Heights Medical Center, New YorkFormer Governor ACP Downstate III region, New York

Q. How will you prepare yourself for training in the United States?
A. By demonstrating good attitude.
A resident starting training on July First can encounter significant problems, if he or she has not undergone a formal period of orientation. With demonstration of good planning and self-organizational skills, an International Medical Graduate can start training in July with confidence. The basic ingredient of any success story in Medicine is a good attitude. A physician may demonstrate superior clinical skills, possess encyclopedic medical knowledge, but a poor attitude will prevent him or her from being successful. Attitude is a frequently discussed topic in resident evaluation forums. This personality trait combined with compassion and superior humanistic skills will lead to a better acceptance by the patients, of a physician who is not born or brought up in this country. A good attitude will lead to letters of commendation and superior evaluations from faculty that makes its way to the personal folder of the resident.

A. By demonstrating superior communication skills.
Communication is by far the most important component of a physician-patient relationship. Verbal and non-verbal communication, discussion with patients, families, faculty and seniors is very important for a resident in training and is perfected by practice alone. Some training programs provide formal role-playing sessions but observation of faculty and senior residents with experience is the best teaching tool.

A. By demonstrating a superior fund of Medical Knowledge.
A good fund of Medical knowledge is important for patient care. All residents are expected to read on a daily basis and during each rotation, they may be asked to present a topic or two. Access to medline and Internet is universally available, and all residents are expected to be well versed with these issues. Regularly scheduled tests and annual in-service examinations prepare residents for taking the Boards after completion of training.

A. Please say “I don’t know” and ask seniors when in doubt.
Residents are not expected to know everything in Medicine. Familiarization with institutional policies and procedures is important. It is acceptable to say “I don’t know” at any stage of training and seek help from senior residents and faculty. A resident who follows these basic guidelines will be successful in a training program. There is no prescription to being a good resident, but a good person always makes a good physician.

Orientation and Acculturation

An International Medical Graduate (IMG) joining a residency program in the U.S. is expected to perform in the same fashion as a U.S.-born physician. Most International Medical Graduates meet the requirements for U.S. training, when accepted in a program. The United States Medical Licensure Examination parts I & II certify the Medical Knowledge of a candidate. The Clinical Skills Assessment (C.S.A.) formally assesses spoken English skills of the candidate, diagnostic and management skills, identification and interpretation of laboratory data, and performance in clinical encounters with standardized patients. Hence the E.C.F.M.G. certificate of today provides the basic Clinical skills to an International Medical Graduate for Residency training in the U.S.
Program Directors, faculty and peers expect residents to adapt to the system as soon as possible. Issues related to patient-physician relationship, verbal and non-verbal communication is as important as Medical Knowledge and clinical skills. Today’s physician work force in the U.S. represents diverse Cultural, Ethnic and Language backgrounds. It is expected that these factors not interfere in the training and education of residents. Issues related to difficult patients may present a challenge to a physician who is starting training in a new environment. Patient care issues at the end-of-life and death and dying are strongly determined by the patients’ belief-system and values. A physician from a different background may not be able to comprehend these cultural nuances. Hence provision of care at the end-of-life may be a difficulty that an IMG has to encounter in a new environment.
Several training programs in the U.S. and Canada offer orientation and acculturation programs to IMG’s entering training in the U.S. These programs are offered in the institution of training and last a few days to two weeks in duration. These sessions are offered in the last few days of June, prior to an IMG starting training. These orientation sessions are designed to teach residents’ basic communication and sociolinguistic techniques useful for negotiating the U.S. healthcare system. They are provided with a basic packet of information that covers most of the topics covered during the orientation period. Approach to difficult patients, how to obtain a Do Not Resuscitate and Autopsy consents are incorporated into these sessions. Medical record documentation and the legal, ethical and financial ramifications of the same are stressed throughout these sessions. The effect of structured and systematic cognitive thinking and evidence-based decision-making in patient care are stressed throughout the period of orientation. Formal instruction in questioning, attentive silence, eye contact, teaching, feed back, correcting, information giving, persuasion is provided with role-playing and video replays of actual patient encounters. Dress code, punctuality, promptness and decorum are an integral part of an orientation program. After completion of this period of Orientation, IMG’s are better at communicating with patients, faculty and nursing staff. They have a better understanding of the American Healthcare System and they are better equipped to handle delicate and often misinterpreted issues, that allow them to function better as healthcare providers. Bedside observation of seniors and faculty during patient encounters completes the required curriculum of most orientation programs.
Acculturation: Resident well being is a fundamental requirement and a social need for all incoming IMG’s . Orientation is the time when future residents arrive in a new country, acquire coping skills, and learn patient management skills through formal instruction. During this period of orientation, the IMG gets an opportunity to adapt to the U.S. culture and system. Enculturation occurs during formal and informal interaction with peers, medical, nursing, and secretarial staff. A pleasant social environment is conducive to learning. Hence the orientation and acculturation program prepares an IMG for a smooth July first transition.
At this time, all residency programs in the U.S. do not provide Orientation Programs. International Medical Graduates starting training in the U.S. must plan to arrive at least two-weeks prior to July Ist. in the town where they will train. This will give them an opportunity to complete paper work, seek accommodation, start a bank account, get a social-security number and identify means of transportation before starting training. This period of adjustment will prepare an IMG and identify problems related to day-to-day living. Waiting for the last minute to make all these arrangements may lead to additional stress and distractions when starting training. In addition if requested in advance, most program directors will welcome the arrival of a resident earlier than the stated start date and will approve of a few days of observation and attendance on rounds to a future resident.
To conclude, all IMG’s starting training must allow themselves a two-week orientation period. The problems related to a July transition will be fewer and overall the new residents will adapt well to their new roles. Last minute and late arrivals do not allow for this transition period, hence must be avoided.

Brief Bio:
Tanveer Mir MD,FACP is a graduate from the Medical College of Kashmir, India in 1981. In the U.S. she completed her training in Internal Medicine at Long Island Jewish Medical Center, New York in 1989. After completing a Chief Residency in Internal Medicine at Nassau University Medical Center, she stayed on as a faculty member. Dr. Mir was the Associate Program Director and Division Chief of Geriatrics at Nassau University Medical Center until 1999. Dr. Mir was affiliated with the State University of New York at Stony Brook. Currently Dr. Mir is the Director of Geriatrics at Wyckoff Heights Medical Center, an affiliate of the New York and Presbyterian Network.Dr. Mir is/was the Governor of the Downstate III region( New York) of the American College of Physicians. Dr. Mir is the current chairperson of the International Medical Graduate subcommittee of the NYACP-ASIM. Dr. Mir is also the co-editor of the International Medical Graduate website of the ACP-ASIM.

Immigration Law and International Medical Graduates

Reaz H. Jafri, Esq.
Jafri & Jafri, LLP
581 Middle Neck Road
Great Neck, N.Y. 11023
E-mail: reaz@msn.com
516-487-4592(tel)
516-487-9044 (fax)

THE CONTENTS OF THE ARTICLE HEREIN IS FOR INFORMATIONAL PURPOSES ONLY AND IS NOT INTENDED OR OFFERED AS LEGAL ADVICE, FOR WHICH AN ATTORNEY PRACTICING IN THE AREA OF IMMIGRATION LAW SHOULD BE CONSULTED.

Introduction
At the risk of leaving out much pertinent information, this article proposes to serve as a general overview of the erstwhile complex and complicated area of Immigration law as it concerns foreign physicians seeking to enter the U.S. for purposes of graduate medical education, clinical practice, teaching and/or research. This article will be limited to providing some operating definitions and proceed with a general discussion of the B-1, H-1B, O-1 and J-1 nonimmigrant visa categories. The article will then address the two-year foreign residence requirement that J-1 residents and fellows are subject to and mention the various waiver strategies thereof. This article will not discuss the various immigrant visa or “green card” options. Interested parties are invited to contact the author directly with their queries about immigrant visas or any other immigration-related matter

Definitions
An “alien” is any person not a citizen or national of the U.S. All visa holders, non-visa holders, and permanent residents (that is, green card holders) are classified as aliens. An immigrant is a person who is a lawful, permanent resident of the U.S. This classification does not include persons with temporary visas. A nonimmigrant is a person who has been issued a temporary visa by a U.S. consular officer (if abroad) or other authorized official (if in the U.S.).
An International Medical Graduate (IMG) is a person who has graduated from a medical school in an international state or who is otherwise qualified to practice medicine in an international state. To claim IMG status by virtue of having gone to medical school, an IMG must have graduated from a medical school that 1) is listed in the World Directory of Medical Schools published by the World Health Organization (www.who.org), and 2) is located outside the U.S., Canada, and Puerto Rico. All IMGs desiring to enter the U.S. to practice medicine must have passed parts I and II of the NBME examination or its equivalent (that is, VQE, FMGEMS, or the USMLE). Unless a Canadian medical school graduate is conferred a degree by a medical school that is accredited by the Liaison Committee for Medical Education (www.lcme.org), he or she is considered an IMG and is subject to all the requirements of an IMG. Examinations are waived for IMGs who 1) are of national or international renown in the field of medicine, 2) were licensed and practicing medicine in the U.S. before 9 January 1978, or 3) come to the U.S. to teach or to conduct research in which no direct patient care is involved.
The Educational Commission for Foreign Medical Graduates (ECFMG) (www.ecfmg.org) administers examinations to IMGs and determines whether they are qualified to enter an accredited residency or fellowship program in the U.S. The ECFMG website offers a tremendous amount of information about the USMLE, J-1 sponsorships and provides valuable links to other web resources.
The United States Medical Licensing Examination (www.usmle.org) was introduced in 1992 and replaced the National Board of Medical Examiners (NBME) examination, the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS), and the Federation Licensing Examination (FLEX). The USMLE is a three-step examination offered at various times during the year in selected locations throughout the U.S. and the world.

Nonimmigrant Visas
B-1 (Temporary Visitor for Business)B-1 visas are available to (1) IMGs or international medical students (IMS) who are coming to the U.S. to take an elective course at an American medical school or hospital that is part of their formal medical education, (2) IMGs who come to the U.S. to observe medical practices, to consult with other physicians on the practice of medicine, or both, and (3) IMGs desirous of coming to the U.S to interview for GME positions. A B-1 nonimmigrant may not work in the U.S. and cannot participate in any patient care. Generally, a person may not remain in the U.S. with a B-1 for more than one year.

H-1B (Temporary Worker)
The H-1B is the most preferred visa by IMGs and, if offered by a GME program, can often be used to attract the most qualified candidates. An H-1B enrolled in a GME program may engage in any medical activity provided the he or she (1) has passed all parts of the USMLE (or its equivalent) or is a graduate of a U.S. medical school, (2) has established competency in oral and written English, (3) is fully licensed to practice medicine in a foreign state, and (4) is otherwise authorized to practice in the state of intended employment.
If an IMG has not passed the necessary examinations, he or she may still enter the U.S. under the “researcher/teacher” classification, which specifies that the employer must certify that any patient care will be incidental to the IMG’s research. After coming to the U.S. and passing the necessary examinations, a “researcher/teacher” IMG may legally change his or her H-1B classification to “medical resident.”
The H-1B visa can be granted for a maximum of 6 years. As of the date of this article, IMGs who will be employed in a research or GME capacity by (i) institutions of higher education, (ii) their related or affiliated non-profit entities, (iii) nonprofit research organizations, or (iv) governmental research organizations are exempt from the number of H-1Bs that may be granted annually (195,000 for fiscal year 2001). Once a petition filed by an employer is approved, the IMG (other than citizens of Canada) must apply for an H-1B visa at a U.S. consulate. If the IMG is in the U.S. under some other visa status (such as B-1/B-2, F-1, and so forth) the IMG’s status may be adjusted to H-1B in the U.S.

J-1 (Exchange Visitor)
Administered by ECFMG, the J-1 visa is the most common visa for IMGs. To qualify for certification and sponsorship by ECFMG, an IMG must have passed Steps 1 and 2 of the USMLE, have a contract for a position in a “matched” program accredited by the Accreditation Council for Graduate Medical Education (www.nrmp.aamc.org/nrmp) and have demonstrated competency in oral and written English. A J-1 may engage in direct patient care.

J-1 Waivers
Many J-1s are subject to a two-year foreign residence requirement upon the completion of their training. This rule is strictly enforced wherein the J-1 visa holder must return to his or her country for at least 2 years before being allowed to re-enter the United States in another visa category. Many J-1 visa holders, however, try to have the 2-year rule waived. Not surprisingly, this is difficult. The following are the only statutory grounds for an IMG to obtain a waiver of the 2-year foreign residence requirements:
Pursuant to a recommendation by an interested federal agency or a state department of health to the INS
Upon the issuance of a “No Objection” letter from the J-1’s home country (not applicable to IMGs who were issued J-1s for GME purposes)
Upon a showing that the J-1 will face persecution upon returning to his or her home country
Upon a showing that a U.S. citizen or permanent resident spouse and/or child would face “exceptional hardship” were the J-1 required to fulfill the 2-year foreign residence requirement
J-1s are required to work in federally Designated Health Professional Shortage Areas to be eligible for a waiver. The agencies that most frequently act as interested federal agencies are the U.S. Department of Agriculture and the Appalachian Regional Commission. In addition to USDA and ARC, other federal agencies, most notably the U.S. Health and Human Services Administration, can act as an interested agency. Finally, each state is empowered to recommend up to 20 waivers. Each agency had its own waiver application guidelines and should be consulted on a case-by-case basis.

O-1 (Alien with Extraordinary Ability)
Given the difficulty of J-1 waivers, IMGs and their employers often look to the O-1, which is the only relevant visa that a J-1 who is subject to the foreign residence requirement can apply for. To qualify for O-1 status, one must demonstrate sustained national or international acclaim and recognition for achievements in the field of expertise. This is established by receipt of nationally or internationally recognized prizes or awards, membership in associations field which require outstanding achievements of their members, published material in professional publications or major media about the alien concerning the alien’s work in the field, participation on a panel, or individually, as a judge of the work of others in the field, scientific, scholarly, or business-related contributions of major significance in the field, authorship of scholarly articles in the field in professional journals or other major media, employment in a critical or essential capacity for organizations and establishments that have a distinguished reputation, high salary or other remuneration commanded by the alien for services and other comparable evidence. There is no explicit statutory limitation on the period of stay for an O-1.

Helpful links:
http://www.state.gov/www/services.html
http://www.ins.usdoj.gov/graphics/index.htm

Reference Letter Outlines

Laurie Ward MD, FACPChief, Division of General MedicineNassau University Medical CenterAssistant Professor of MedicineSUNY-HSC at Stony Brook

Letters of recommendation are a very important part of your application for residency training programs. Programs will tell you how many letters they require. Do not submit more letters than are requested. The maximum number that can be submitted through ERAS (Electronic Residency Application Service) is 4. You must also submit a Dean’s Letter requested from the medical school from which you graduated if this is available. This does not count as one of your letters of recommendation. If your medical school does not provide Dean’s Letters, you can indicate that on your application.
Since many of the deans of international medical schools might not know the kind of information that has to be provided in the Dean’s Letter, it is advisable that you provide them with a template of the type of information that is generally expected. These components are: personal background information, statement regarding academic evaluations and research experience, extracurricular activities, interpersonal skills, communication skills and personality descriptions.
If the Dean’s letter is not in English, submit a translated version to ERAS. It is not necessary to provide a copy of the document in the original language. However you made be asked to provide your original documents if program directors ask of them.
When requesting letters, it is best to ask “Would you feel comfortable writing me a strong letter of recommendation?” rather than “Will you write me a letter of recommendation?” The first approach may allow you to eliminate people who do not feel they can write a letter that will help you. It is considered to be better, though not necessary, to waive your rights to see the letter of recommendation. These letters are considered to be a more honest reflection of the authors’ opinions of you and, therefore, carry more weight.
If you have done a rotation in an American institution and have interacted with someone who you feel can write you a good letter, ask them to do so. Don’t wait until it is time to apply, as letters written in close proximity to the clinical experience tend to be more detailed and personal. Such letters are especially helpful if they come from the institution to which you are applying.
The best people to ask for letters are the most senior faculty who has worked with you enough to comment on your abilities. It is especially helpful if this person is from the institution to which you are applying. Do not ask for letters from residents or fellows. Although they may know you the best, these are not considered to be adequate letters of recommendation.
It is best to request a letter from a faculty member/physician who has directly supervised you in a clinical experience so that he/she can comment on your abilities from a personal point of view. In general, letters that can comment on your work ethic, motivation, dedication, communication skills will be at least as useful as those about your medical knowledge or test scores, if not more so.
In order to assist the physician in writing your letter, provide them with a copy of your CV and personal statement.
For ERAS programs, one letter is submitted addressed to “Dear Program Director”. Information about submission of letters can be obtained from the ECFMG website. All documents should be identified by identification stickers sent with you’re an instruction manual. If you do not have stickers, identify each document with 1) your name 2) your USMLE number and 3) what the document is (Dean’s Letter? Letter of Recommendation? etc). For non-ERAS programs, provide the letter writer with the names and addresses of the programs to which you are applying as well as address labels whenever possible.
Allow sufficient time for the letters to be written and submitted. Generally 4-6 weeks in advance is sufficient. Do follow up with the faculty to members to insure that the letters have been submitted. Reminders may be necessary but don’t be a pest
Educational Commission for Foreign Medical Graduates: www.ecfmg.org
Brief bio:
Laurie Ward is a graduate of the University of Pittsburgh Medical School. She trained in Internal Medicine and Nephrology. She was the director of primary care at Nassau County Medical Center and is now Chief of the Division of General Medicine at Nassau University Medical Center. Dr. Ward was awarded fellowship in the ACP in 1997.

How to Write a C.V.

Annabeth BorgRetired Medical SecretaryE-Mail: Annabethb@Yahoo.com

Generally, your curriculum vita (C.V.) is the first contact you may have with a prospective program director. Therefore, you would surely want a C.V. that does more than simply impart information about your personal history, and educational and professional qualifications and achievements. Strive for a CV that establishes a favorable image of your professionalism in the mind of the reader. It should emphasize your areas of strength, and create an interest about you sufficient to result in a personal interview. Make your C.V. work for you!
There are several phases in creating an effective C.V.
Compile all potentially useful information and organize those items under appropriate categories. Be sure the information you choose clearly communicates a sense of professionalism, competence, and enthusiasm.
Select only the most pertinent information. Keep the level of information concise and, at the same time, as comprehensive as possible. Bear in mind that your C.V. is your “advertisement” for an interview!
Finally – review and revise the document. As important as the information provided, your C.V. should be edited for proper grammar, correct spelling and appropriate punctuation. To further convey your professional image to the reader, use quality paper, ink, and equipment. Inferior materials or illegible photocopies say to the reader, “You are not important to me.”
The following is a sample format of a C.V.
1. Contact Information
2. Personal Data
3. Educational Background
4. Employment Experience
5. Professional Affiliations and Honors
6. Publications, Presentations and Other Activities
7. References
Contact Information
This information is always located at the top of the first page. It should include your name (avoid nicknames), address, telephone and other contact numbers (fax, e-mail). Be sure to spell out words like Street, Avenue, North, etc. If your current address is not your permanent address, indicate your current-address information under a heading marked “Present”, followed by your permanent-address information under a heading marked “Permanent.”
Personal Data
This is a professional document, so disclosure of information regarding age, marital status, children, and health is a matter of choice. Some recipients expect this information, and it is a common practice to provide it.
Educational Background
The information in this section is usually given with the most recent training listed first. The order in which you present this information is your choice — be it date first, degree first, or perhaps institution first. Whichever your preference, keep your entries consistent.
Employment Experience
Begin by separating your part-time employment entries from your full-time employment entries, and list them under appropriate subheadings. This avoids any misunderstanding by the reader. The list of your employment experience generally starts with your current employment. Be sure to provide the date of your employment, your job title, and your employer’s name and address. You may choose to include major duties, successes and achievements, research interests, committee assignments, etc. It is important, however, to keep all entries uniform. Avoid providing a lot of information on your recent entries, but giving less information on later entries. A subheading for certification or license status may be included at the end of this section. Indicate certificate/license numbers and the dates issued.
Professional Affiliations and Honors
This section should include your current membership in professional organizations. Include any significant appointments and/or elections to positions or committees, indicating the appropriate date for each position listed. Indicate any significant activities completed under your leadership. Honors from professional, educational or related organizations should also be shown under this section. Keep your comments brief in describing these items. This will avoid the risk of creating an unfavorable impression of exaggeration on your part by the reader.
Publications, Presentations and Other Activities
This is an area considered to be the perfect opportunity to list your professional accomplishments. The following subheadings may be listed in this section: publications, presentations, invited lectures, abstracts, research activities, community service and leisure interests to name a few. When listing your publications, give full bibliographic entries so the reader can easily find them.
RefrencesPlace this information at the end of your document. Include the following information in each entry: name, position, address, and telephone number.
Some Points to Consider
The information and advice given are no guarantee that your C.V. will open all doors for you. It offers a start in preparing an effective document – one that shows clarity, consistency, and an organized format. Your C.V. should be easy to read, leaving no confusion in the reader’s mind as to what it is he is reading. Here are some points that will help you produce a document with impact.
Your C.V. will be read by people who do not know you, so you must present your information in the clearest, most concise fashion possible. These people will be responsible for developing a list of recommended candidates, probably in a limited amount of time, so your document must be precise and specific at the first reading.
Accurate presentation of your qualifications is imperative. Be specific – for instance, under:Educational Background – include your major, year degree was received, name of degree, complete name of institution (no abbreviations) and its location.Employment History – leave NO gaps in the total number of years worked (account for every year); distinguish between part-time and full-time work; use separate headings for entries such as: military service, volunteer activities, leave of absence (explain).Professional Activities – cite current memberships; clearly date all former activities and memberships.Publications – clarify your role in group efforts; distinguish between refereed and nonrefereed articles; use separate headings for different types of publications (journal articles, books, chapters in books, abstracts, etc.)
Consistency is crucial. It reflects good organization and appearance and is vital to fast readers. Be consistent under all categories of your C.V. Do not provide information in one entry and fail to do so in other entries within the same category.
Do not make double entries. This does not strengthen your C.V. and may be unfavorably viewed as “padding” by the reader.
Stay chronologically consistent when presenting information. If you elect to present the most current information first, stay with that order through all sections. This makes your document easier to read and avoids confusion on the part of the reader.
There is no magic number for the maximum number of pages considered ideal for an effective C.V. However, it is generally accepted that a two-to-four page C.V. should communicate the essential background details for a young professional.
It bears repeating — be clear, consistent and organized. If your C.V. is hard to read or an entry projects a suspicious aura, your entire document may be discounted or even rejected.
It is helpful to have the final version of your document proofread by: a) a professional friend who knows you (able to spot significant information left out or is confusing as presented). b) a professional who does not know you (able to read your C.V. critically as a person learning about you for the first time – a status similar to your eventual readers). c) a personnel officer, dean or department head (experienced in reviewing this kind of material).
Print your C.V. on standard 8 _” x 11″ white paper; print on one side only; be sure the print on all copies is clear and easy to read; all pages should be clean of smudges and streaks. A single staple in the upper left-hand corner is a simple and sufficient method for securing the pages.

Individuals are faced with many choices when writing a C.V. The methods used to develop this document are varied, but the goal is the same — a curriculum vitae that will impress and convince the reader that you are the person they seek. I hope the advice offered here will help you to develop that kind of C.V. My best wishes for success in all your endeavors.
Brief Bio:
Annabeth Borg, now retired, has had more than 26 years of secretarial experience that involved working in several fields. Her early background included working for the New York State government and in the private legal sector prior to taking a 12-year hiatus to raise a family. After rejoining the work force, she worked briefly in private industry, followed by 21 years as a medical secretary at the Nassau County Medical Center in East Meadow, NY. During most of that period she served as secretary to the Chairman and Program Director of the Department of Medicine. In this capacity, Annabeth became familiar with, amongst other things, the hiring process for new house staff, both American graduates and international medical graduates. There were approximately 100 house staff in the Department of Medicine. Annabeth estimates that she assisted in the recruitment of between 500-600 house staff during her tenure at the hospital.

Physician Licensing Boards

AlabamaMedical Licensure Commission
State of AlabamaPO Box 887Montgomery, AL 36101334-242-4153

AlaskaOccupational LicensingDepartment of Commerce and Economic DevelopmentPO Box 110806Juneau, AK 99811-0806907-465-2541

ArizonaArizona Board of Medical Examiners1651 E. Morten, Suite 210Phoenix, AZ 85043602-225-3751

Arkansas
Arkansas State Medical Board2100 Riverfront Dr., # 200Little Rock, AR 72202
501-296-1802

California
Medical Board of California1426 Howe Ave., Suite 52Sacramento, CA 95826-3236
916-263-2499

Colorado
Board of Medical Examiners1560 Broadway, Suite 1300Denver, CO 80202
303-894-7690

Connecticut
Connecticut Dept. of Public HealthLicensing, Applications &Endorsements ofPhysicians and Surgeons150 Washington St.Hartford, CT 06106
203-566-5296

Delaware
Board of Medical PracticeState of DelawarePO Box 1401 Cannon Bldg., # 203Dover, DE 19903
302-739-4522
DC
DC Board of Medicine614 H St., NW Room 108Washington, DC 20001
202-727-5365

Florida
Department of Business and Professional RegulationDivision of Technology, Licensure and TestingNorthwood Center1940 N. Monroe St.Tallahassee, Fl 32399-2206
904-488-8860

Georgia
Georgia State Medical Board166 Prior St., SWAtlanta, GA 30303
404-656-3913

Hawaii
Board of Medical ExaminersAttn: Executive OfficesPO Box 3469Honolulu, HI 96801
808-586-2708

Idaho
Idaho State Board of MedicinePO Box 83720Boise, ID 83720-0058
208-334-2822

Illinois
Illinois Department of Professional Regulation320 W. Washington, 3rd FloorSpringfield, IL 62786
217-785-0820

Indiana
Health Professions Bureau402 W. Washington St.,Rm. 41Indianapolis, IN 46204
317-233-4409

Iowa
Iowa Department of Public HealthDivision of Planning and Administration321 E. 12th St.Lucas Bldg., 4th FloorDes Moines, IA 50319-0075
515-281-4258

Kansas
Kansas Board of Healing Arts235 S. Topeka Blvd.Topeka, KS 66603-3068
913-296-7413

Kentucky
Kentucky Board of Medical Licensure310 Whittington Pkwy., # 1BLouisville, KY 40222
502-429-8046

Louisiana
Louisiana State Board of Medical Examiners630 Camp St.PO Box 30250New Orleans, LA 70190
504-524-6763 x225

Maine
Maine Board of Licensure & Regulation in Medicine137 State House StationAugusta, ME 04333
207-287-3601

Maryland
Board of Physician Quality Assurance4201 Patterson Ave.Baltimore, MD 21215
410-764-4705

Massachusetts
Board of MedicineCommonwealth of Massachusetts10 West St., 3rd FloorBoston, MA 02111
617-727-3086 x359

Michigan
Office of Health ServicesPO Box 30018611 W. OttawaLansing, MI 48933
517-335-0930

Minnesota
Minnesota Board of Medical Practice2829 University Ave SE, Suite 400Minneapolis, MN 55414
612-617-2130

Mississippi
Mississippi Board of Medical Licensure2688-D Insurance Center Dr.Jackson, MS 39216
601-354-6645

Missouri
Missouri Board of Healing ArtsPO Box 4Jefferson City, MO 65102
314-751-0098

Montana
Board of Medical ExaminerState of Montana11 North JacksonPO Box 200513Helene, MT 59620-0513
406-444-4000

Nebraska
Professional & Occupational Licensure DivisionDepartment of HealthPO Box 95007Lincoln, NE 68509
402-471-2115

Nevada
Nevada State Board of Medical ExaminersPO Box 7238Reno, NV 89510
702-688-2559

New Hampshire
Board of Registration in MedicineState of New Hampshire2 Industrial Park Dr., # 8Concord, NH 03301-8520
603-271-1203

New Jersey
State of New JerseyDivision of Consumer AffairsCentralized Licensing CN 152Trenton, NJ 08625
609-826-7100

New Mexico
New Mexico Board of Medical Examiners491 Old Santa Fe TrailLamy Building, 2nd FloorSanta Fe, NM 87501
505-827-5022

New York
New York State Education DepartmentDiv. of Professional LicensingCultural Education CenterAlbany, NY 12230
518-474-3830

North Carolina
North Carolina Board of Medical ExaminersPO Box 20007Raleigh, NC 27619
919-828-1212

North Dakota
North Dakota State Board of Medical Examiners418 E. Broadway, Suite 12Bismarck, ND 58501
701-223-9485

Ohio
State Medical Board of Ohio77 S. High St., 40th FloorColumbus, OH 43266-0315
614-466-3934

Oklahoma
Dept of Medical Licensure5104 N Francis, Suite COklahoma City, OK 73118
405-848-2189

Oregon
Board of Medical Examiners1500 S.W. First AveSuite 620Portland, OR 97201
503-229-5770

Pennsylvania
Pennsylvania State Board of MedicineCommissioner’s OfficePO Box 2649Harrisburg, PA 17105-2649
717-787-2381

Puerto Rico Board of Medical ExaminersPO Box 3969San Juan, PR 00908 809-782-8989
Rhode IslandBoard of Medical Licensure and DisciplineDepartment of HealthThree Capitol Hill, Room 205Providence, RI 02908-5097 401-277-3855
South CarolinaLLR Board of Medical ExaminersPO Box 11289Columbia, SC 29211-1289 803-737-9300

South DakotaSouth Dakota State Medical Association1323 S. Minnesota Ave.Sioux Falls, SD 57105-0685 605-334-8343

TennesseeTennessee Medical Board283 Plus Mark Blvd.Nashville, TN 37247-1010 615-367-6231

TexasTexas State Board of Medical ExaminersPO Box 1491341812 Center Creek Dr., # 300Austin, TX 78714-9134 512-834-7728

UtahDepartment of Occupational and Professional LicensurePO Box 45805Salt Lake City, UT 84145-0805 801-530-6633

VermontVermont Board of Medical PracticeState of Vermont109 State St.Montpelier, VT 05609-1106 802-828-2673

VirginiaDepartment of Health ProfessionsCommonwealth of Virginia6606 W. Broad St., 4th FloorRichmond, VA 23230-1717 804-662-9900

WashingtonDepartment of HealthMedical QAC1300 SE Quince St.Olympia, WA 98504-7866 360-586-8934

West VirginiaWest Virginia Department of Health101 Dee Dr.Charleston, WV 25301 304-558-2921

WisconsinDepartment of Regulation and LicensingOffice of RenewalPO Box 8935Madison, WI 53708 608-266-2112

WyomingWyoming Board of Medicine211 W. 19th St., 2nd FloorCheyenne, WY 82002 307-778-7053

ArizonaBoard of Osteopathic Examiners in Medicine and Surgery9535 East Doubletree Ranch RoadScottsdale, AZ 85258-5539(480) 657-7703

CaliforniaOsteopathic Medical Board2720 Gateway Oaks Dr., Suite 350Sacramento, CA 95833-3500(916) 263-3100www.docboard.org

FloridaBoard of Osteopathic Medicine2020 Capital Circle, SE, BIN #C06Tallahassee, FL 32399-3253(street address: Northwood Centre, 1940 N. Monroe St., 32399-0757)(850) 488-0595

MaineBoard of Osteopathic Licensure142 State House StationAugusta, ME 04333-0142(207) 287-2480(207) 287-3015

MichiganBoard of Osteopathic Medicine and SurgeryP.O. Box 30670Lansing, Ml 48909-7518(Street address: 611 W. Ottawa St, 1st floor, 48933(517)373-6873(517) 373-2179 Faxwww.cis.state.mi.us

NevadaState Board of Osteopathic Medicine2950 E. Flamingo Rd., Suite E-3Las Vegas, NV 89121-5208(702) 732-2147

New MexicoBoard of Osteopathic MedicalExaminersP.O. Box 25101Santa Fe, NM 87504(Street address; 2055 S. Pacheco, Suite 400)(505) 476-7120www.state.nm.us/rld

OklahomaState Board of Osteopathic Examiners4848 N. Lincoln Blvd, Suite 100Oklahoma City, OK 73105-3321(405) 528-8625www.docboard.org

PennsylvaniaState Board of OsteopathicMedicineP.O. Box 2649Harrisburg, PA 17105-2649(street address: 124 Pine St., 17101)(717) 783-4858www.dos.state.pa.us

TennesseeBoard of Osteopathic Examiners425 5th Ave. North1st Floor, Cordell Hull Building Nashville, TN 37247-1010 (37219 Fed Ex zip code)(615) 532-4384(888) 310-4650www.state.tn.us/health

VermontBoard of Osteopathic Physicians and Surgeons26 Terrace Street, Drawer 09 Montpelier, VT 05609-1106(802) 828-2373 (802) 828-2465 Faxwww.sec.state.vt.us

WashingtonState Board of Osteopathic Medicine and SurgeryP.O Box 47870Olympia, WA 98504-7866(Street address: 1300 SE Quince Street, 98501)(360) 236-4943(360) 586-0745 Faxwww.doh.wa.gov

West VirginiaBoard of Osteopathy334 Penco Rd.Weirton, WV 26062(304) 723-4638(304) 723-2877 Fax
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Writing a CV that brings Interviews

Reprinted by permission of MEDICAL ECONOMICS.

An expert tells how to make that all-important first impression in your resume and cover letter.

By William G. LeBoeuf, M.D.

A cynical pharmacist once told me he would not be surprised to learn that doctors submit curriculum vitae scribbled on paper towels. In five years as a physician recruiter, I have not seen anything that bad, but it’s been close.
Many doctors produce unreadable, novella-length scrawls. Others type the documents and keep them shorter, but correct them with a pencil. Then there are those who update a neat CV by stapling a scrap of paper to it. Would any of these people appear for job interviews in a T-shirt, patched jeans, and sneakers? Or even in a nice suit, but with an outlandish necktie and haircut?
Since your CV and cover letter make that all-important first impression, they should be prepared as carefully as possible. Other well-qualified people probably responded to the same advertisement, so your application is in competition.
It’s important to realize that the purpose of your CV and letter is simply to get you an interview, not to land you the job. I cannot write yours for you, but here are some suggestions on how to produce an effective CV and cover letter.
Make them look professional. Printing is overkill, though not unwelcome. It’s fine if your CV and letter are word-processed, then printed on a laser, ink-jet, daisy wheel, or a near-letter-quality dot matrix printer. Even a clean-printing typewriter will suffice.
In many cases, applications are put through a copier for members of a committee. If you use anything but black print on white paper, the copies are likely to be in shades of gray.
Have a clear heading. Center the heading at the top and include your full name, degree, address, phone number, and board status. Many people don’t like to reveal their address and phone number, but a CV is no place to be coy.
Outline logically. The first category below the top heading should be “Education.” Just say where and when you earned your M.D. Omit honors and embellishments. Below your medical education, list your undergraduate degree, date, and institution. But no extra detail. Nobody cares if you were leader of the Future Physicians Club. And forget high school. Some job applicants think the fact they were a high school valedictorian will help them land a $200,000-a-year position 20 years later.
Under “Postgraduate,” you should list fellowships, residencies, and internships, with the most recent first.
Even though it appears at the top of the CV, the next heading should be “Certification.” After that comes “License.” Indicate the states in which you hold a license, and the dates of expiration. This is critical information to the prospective employer, but is frequently omitted.
The next category should be “Experience,” and here you should include all the positions you’ve held, beginning with the current or most recent.
Follow chronological order. A resume should read like a diary-brief descriptions of where you’ve been and what you’ve done since medical school. Don’t leave gaps. If you spent 18 months bumming around Europe, account for the time as “sabbatical” or “personal leave.” The employer can ask for details during the interview. But leaving a gap only invites speculation that you’re hiding something.
Rewrite an out-of-date CV. Scribbling in or stapling on a change looks unprofessional.
Just give the facts. If you’re a general practitioner, describe yourself as “in the general practice of medicine,” and don’t say you’re in family practice. If you’re board-eligible, say so even though your residency was several years ago. I recall one physician who described himself as “board-qualified,” a meaningless term that only invites suspicion.
Be brief. A CV should be no more than three pages. I saw one from a teaching physician that included 37 pages of published papers. Selection-committee members usually aren’t interested in extensive lists of publications. Furthermore, no secretary is going to photocopy dozens of pages per CV, and your last fellowship may be on one of the pages that get tossed.
If publishing is an important aspect of your experience, you could include a “Papers published” heading and state, for instance, “Fifty-six papers published from 1985 to 1991. Citations furnished on request.”
Keep it relevant. Don’t include a narrative of your life: “I was born a poor but honest farm boy…,” for example. Don’t list hobbies, athletic achievements, military experience (beyond the dates of your service, if any), etc. If you’re a marathon runner, you might find a way to mention it in the cover letter you send to a sports medicine practice. But use this kind of information judiciously. And always reserve it for the cover letter, never the CV.
Write a good cover letter. A well-prepared CV should be a simple, concise listing of your qualifications. It should be non-specific enough that you can send it to any prospective employer. Your cover letter, in contrast, should be tailored to each job opening. The letter is the best way to separate yourself from others chasing the same job. So rewrite and edit until it’s clean and polished.
Investigate. The typical medical-journal ad doesn’t tell you much. But if there’s a phone number, call it and try to speak with a decision-maker, perhaps the medical director. Since this isn’t always possible, you may have to settle for an office manager or secretary.
First, ask the person to verify the qualifications listed in the ad. Then, try to learn what kind of patients they see, and how many on an average day. What procedures are done in the office? What percentage of the business is Medicare, Medicaid, HMO, PPO? And so on.
Jot down people’s names and anything you’ve learned about them. The secretary, for example, may tell you that the director is out sailing. That doesn’t help much with the cover letter, but it could prove useful during an interview.
Address the specific job. You may learn that the practice wants a doctor who can handle any patient who comes through the door. On the other hand, the employer may be primarily interested in a physician who’s tops at detecting a grade I heart murmur and reading ECGs. Your cover letters for these two jobs should be very different.
Say when you’ll be available. The letter should clearly state when you’re available to speak on the phone, be interviewed, and start work. Don’t be afraid to list good and bad times to be reached, or to specify that you shouldn’t be called at work. Note specific days, or parts of days, when you can be interviewed. Mention an upcoming vacation or trip out of town that you’ve scheduled for the near future. If you’re a homeowner, married, or have children in school, it’s important to mention when you could start in a new area.
Lifestyle preferences. If your primary reason for seeking the job is to get to a particular part of the country, to find a better climate, or for cultural reasons, say so in the cover letter. If you’re in a small town and prefer a city, or vice versa, point that out.
Physicians are trained to be positive and to be tenacious fact-gatherers. If you apply that training to your job search, and add clear writing, there’s no reason you can’t succeed.

Training All Over Again

Training All Over Again
Ashok M. Karnik
Attending Pulmonologist
Nassau University Medical Center
Clinical Associate
Professor of Medicine
SUNY Stony Brook, NY

A large number of physicians from various countries arrive in the US each year to receive further training. This is a diverse group of individuals, with different socio-cultural backgrounds, varying standards of medical education and a vast range of previous experiences. This transition, however, from a foreign medical graduate (“FMG”) to a successful physician practicing medicine in the US, is not easy. Given below are areas where difficulties are often encountered. Differences between foreign medical education, hospital practices and socio-cultural patterns and those of the US are highlighted. Suggestions are made which would hopefully make the transition smooth and painless.
Medical Education and Examinations: In most of the medical schools in India, Pakistan, Bangladesh and Middle East, the medical education emulates that in the UK. There is greater emphasis on clinical approach; the students learn to pick up subtle physical signs and are fond of diagnosing various syndromes by exotic eponyms. Because of lack of availability of advanced technologies in smaller hospitals, some students are not very familiar with investigational tools such as CT scans, MRI and angiographies. They may not have seen cases with diseases such as sarcoidosis, collagen vascular diseases, and pulmonary embolism etc.- either due to a truly lower incidence of some of these conditions or because of lack of recognition and diagnosis.
While both systems, the American and the British, have their strong and weak points, a successful resident would be one who is able to combine the good points of both systems. By using the “best of both worlds”, and using tact and discretion while presenting cases on the rounds or in conferences, he/she might eventually turn out to be a better resident than an average one. For example, on the rounds, the resident might present the case lucidly with all the physical signs and arrive at a good differential diagnosis, but should avoid using various eponyms for signs and syndromes. The resident should familiarize himself/herself as soon as possible with the various investigations and conditions that he/she is not familiar with. Residents from some countries tend to ‘talk like a book’ because of the ‘rote system’ of education they have gone through. He/she must apply his ‘book knowledge’ to a particular case under discussion rather than quote a list of causes or diagnose a fancy but far-fetched syndrome. The resident must remember that ‘it is better to be wrong for the right reasons rather than to be right for the wrong reasons’.
In the American system, the students are allowed to be involved in the work-up and management of cases, whereas in most of the other countries, they do not get hands-on experience till they become interns. During residency, however, they get an opportunity to do many more investigations. The experience vastly varies due to the prevalence pattern of various diseases. Further variability arises from the availability/non-availability of various investigations and the differences in the legal atmosphere in different countries. For example, in the US, an average intern may perform numerous arterial blood gases and place many central lines, but may not get a chance to do special investigations such as liver biopsy, kidney biopsy, bone marrow aspiration etc. till he/she does a fellowship in that particular specialty. On the other hand, a resident from an average medical school in India may not have done arterial punctures or placed any central lines and may have never seen a Swan-Ganz catheter, but he/she may have done some liver and renal biopsies and may have aspirated a few bone marrows.
The examination pattern in USA differs from other countries. The various ‘board examinations’ in the US consist of multiple-choice questions (MCQs), whereas most of the medical schools in the Indian sub-continent have essay type examinations. Clinical evaluations, in which the students and residents are allotted short and long cases, are an integral component of the examinations. While ignorance is quickly revealed by the MCQ, it can by masked by a verbose essay. However, the MCQ is rather rigid, gives you a fixed number of options, and sometimes two options may be equally correct in real life. The foreign graduates need to quickly adapt to the multiple choice-type of examination, which requires application of the book knowledge to a hypothetical clinical scenario. The best way to prepare is to do as many MCQs as possible from various sources such as Harrison’s and Cecil’s Review of Internal Medicine and MKSAP.
Although there is no escape from the various examinations, the FMGs who have passed examinations such as MRCP or have obtained experience in hospitals in the UK can often receive some exemptions from the required number of years for residency. Usually MRCP gives you a credit for one year, and one-half year of credit is given for each year of residency done in the UK. The Chairman needs to write a strong letter of recommendation, and an application for the exemption should be made at the earliest. FMGs must understand that there are three ‘tracks’ and the requirements for each are different. To become ‘board eligible’, the requirements for the completion of residency have to be fulfilled with or without any exemptions; for appointment to the position of an ‘Attending’, one must be board eligible/certified and a permanent resident of the US; for an academic appointment, the individual has to meet the criteria laid down by the University for various positions such as ‘ Tutor’, ‘Assistant Professor’, ‘Associate Professor’ or ‘Professor’. Most of the FMGs follow the usual steps such as completion of residency, passing boards, getting an ‘attending’ appointment in a hospital and then an academic appointment with the university to which the hospital is affiliated. Occasionally, an experienced and senior FMG, however, may be able to telescope the whole process in 1-2 years. He/she may obtain exemptions based on previous experience and get a direct academic appointment based on previous publications and fellowships in various US Colleges such as FACP or FCCP.
Working in a US Hospital: There are many differences between the pattern of rounds and working and the atmosphere in US hospitals and hospitals in foreign countries. A resident has to mold himself/herself to these very quickly and assimilate in the rest of the residency pool. A few examples: the ‘ morning report’, starting at 8 am or even earlier, is a tradition almost unique to US hospitals. Terms and practices such as ‘DNR’, ‘withdrawal of various life-support systems’, ‘health-care proxy’, and ‘living will’ may be unheard of in some countries and in remote hospitals, mainly because these issues do not come up in view of the type of social and family fabric of those countries. The agencies and concepts such as ‘ACGME’, ‘JCAHO’, ‘Quality Control’, ‘Risk Management’, ‘IPRO’, ‘Utilization Review’ etc do not exist. The degree and the accuracy of documentation required to defend oneself in a litigious atmosphere does not even cross the mind of an average physician who is providing much-needed service in an ill-equipped clinic in a remote area.
The FMGs also face a cultural shock when they start working in a US hospital. Calling a nurse “Sister” in a US hospital would produce either no response from the nurse or a sarcastic one. Calling a senior resident or an attending ” Sir” may be interpreted as a sign of submissiveness. Remaining silent on the ward rounds and waiting till you are asked a question, may be misinterpreted as a sign of ‘ignorance’ or an inability to participate in discussion. These are manifestations of a polite upbringing or the cultural background of a person but some virtues, when overdone, may place a person at a disadvantage. While some of these qualities may be so deeply ingrained that a person cannot change his/her personality altogether, a smart resident would make astute observations and adapt quickly.
Many residents, in their own countries, have passed their post-graduate examinations, equivalent to American ‘Boards’; many have been on senior positions prior to coming to USA. These physicians leave the shores of their homeland for further education, training and experience. Rarely, they are here because of circumstances beyond their control. In any case, it is heart-wrenching to have to swallow one’s pride and take orders from a senior resident who may be half their age; to start preparing for USMLE or Boards all over again or take night duties when the brain and body are not as vigorous as when the resident was 15 or 20 years younger. It is admirable that a vast majority of these ‘old’ first-year residents not only make it but also achieve academic, financial, and social success. The older foreign graduate should use his experience and clinical judgment to solve clinical problems and yet keep an open mind and learn newer techniques from his younger American colleague. He should not take an occasional brusque remark personally and should consider it to be part of cultural difference or impatience of a younger person. His maturity would help him see the things in correct perspective. Perhaps the secret of success of older FMGs is a constant reminder to themselves about their ultimate goal, their maturity, tolerance and persistence and a strong will to succeed. If you find yourself in such a situation remind yourself that “Today is the tomorrow that we worried about yesterday” and that there is always light at the end of the tunnel.
Author Bio:
Ashok M. Karnik is a graduate of King George’s Medical College, Lucknow, India. He received his training in India, England and the US. Besides the US, he has worked in four other countries. Currently he works as an attending pulmonologist at Nassau University Medical Center and is a Clinical Associate Professor of Medicine at SUNY, Stony Brook. He serves as Director of Pulmonary Care Unit and Pulmonary Function Laboratories.