Medical education in the United States is provided differently than in Belgium. In the United States, students wishing to become doctors study first for four years, generally in programs referred to as “pre-medical study”. These “pre-med” programs are offered by over 500 colleges and universities. At the end of the four years, they receive the Bachelor degree which allows them to apply to medical school. The medical school program lasts four years: the two first years are devoted to the basic medical sciences and the last two years concentrate on clinical training including practical training in hospitals (clerkships). While there are hundreds of universities providing pre-medical education (for the first four-year cycle), there are only 124 medical schools (for the second four-year cycle).
For this reason, competition for admission to American medical school is very intense, even among American students, where, in general, only one application in two is accepted. This means that foreign students’ chances of being admitted to American medical schools are very slight indeed. It is estimated that 10,000 – 15,000 American students who were not admitted to American schools are studying medicine outside the United States. Foreign students are seldom admitted unless they have completed all of their premedical training in the United States. Transfer at an advanced level is practically impossible for non-Americans. A personal interview is usually required.
The Association of American Medical College has created an official guide to the medicine school application process here: https://students-residents.aamc.org/
To obtain the best qualified students from among all those who apply, each school of medicine has its own admissions committee which selects the candidates who may be admitted to that school. Specific criteria for selection vary from school to school, but in general all consider the following:
1. Academic background
2. Academic achievement
3. Performance on the Medical College Admission Test (MCAT)
4. Evidence of suitability for a career in medicine
5. Communication skills
6. Health status
7. Financial plans
8. Residence
Academic Background
It is strongly recommended that applicants from other countries who wish to study medicine in the United States complete their pre-medical college work in the United States. Applications should be made directly to the undergraduate colleges that customarily prepare students for medical school. To be considered for admission to a medical school, an applicant must usually have a baccalaureate degree. This “premedical” curriculum normally consists of: psychology, 2 years of biology, 1 year each of organic chemistry, inorganic chemistry, and physics, as well as English, calculus and mathematics. Many medical schools require additional specific courses. These are covered in the information on each school.
Academic Achievement
An outstanding academic record at the university level gives no assurance that the applicant can be admitted to a school of medicine, but grades are important indicators of ability to handle medical course work if one should be accepted. In general, students who have performed at the highest academic levels are given preference. Foreign applicants are expected to meet academic standards comparable with those applied to nationals on United States.
Medical College Admission Test
The Medical College Admission Test is a multiple-choice type examination designed to measure the applicant’s verbal ability, quantitative ability, general information, and scientific knowledge. Completion of this standardized test is required for admission to all medical schools in the United States. The exam is given several times a year at international testing sites. For more information concerning MCAT registration see here: https://www.aamc.org/students/applying/mcat/
Suitability for a Career in Medicine
Evaluation of an applicant’s suitability for a career in medicine is based only in part on academic performance. Motivation for the study and practice of medicine, emotional stability, interest and performance in areas other than the basic pre-medical requirements, extracurricular activity, specific career goals, and personal qualities are among the factors that are given consideration by admissions committees. Recommendations from the university or universities previously attended and, in most cases, a personal interview with the applicant by the admissions committee are also important.
Communication Skills
It is essential that applicants to medical schools in the United States be proficient in English. For foreign students, the school of medicine may require proficiency certification from a designated official agency in the applicant’s own country. Foreign applicants, who have attended a college or university in the United States or Canada, or in another English-speaking country, may be requested to present evidence of English language proficiency from the university.
Health Status
An applicant for admission to a school of medicine must be in good health. Before the applicant is accepted, the medical school may require a certified physical examination by some agency or physician designated by the school.
Financial Plans
Applicants from other countries should make detailed plans for financing their medical education in the United States and should understand that, prior to being admitted to a school of medicine, they will be called upon to state the source and amounts of the funds they have available to meet the necessary expenses. Assistance from U.S. federal and state governmental agencies is only available to medical students who are citizens of the United States. Foreign students find it extremely difficult to find funding for medical school in the U.S. Very few medical schools are able to offer financial aid to foreign students. Moreover, most state supported medical schools are required by law to give admission preference to residents of that state; certain others are required to give preference on a local, state, or regional basis. A growing number of privately supported schools are receiving partial support from their states in return for giving increased preference to their own residents.
Application Procedure
Since the number of applicants always far exceeds the number of places available, many who meet the requirements set forth above may still find that they cannot gain admission to a school of medicine. Admissions committees select, on a competitive basis, only those who are considered most likely to succeed as medical students and physicians. The foreign applicant to a medical school in the United States must expect very severe competition.
Application is made either to individual schools directly or, where required, through the American Medical College Application Service (AMCAS). AMCAS is a centralized non-profit application processing service and does not render admissions decisions nor does it advise students where to submit applications. It provides a single application form which is sent by AMCAS to as many schools as the student specifies, each for a fee, and may considerably reduce the time and expenses necessary for multiple direct applications. At present, 105 medical schools participate in AMCAS. Information on AMCAS can be found at : www.aamc.org
Transfer from Foreign Medical Schools
If you wish to transfer from a non-U.S. medical school to a U.S. medical school, you should contact the individual medical schools directly. Advanced standing is rarely offered and the possibilities for admission are very limited.
Internships
Following the four-year basic program, the new physicians must undertake a one-year internship in a teaching hospital. During the internship the physicians concentrate on a chosen specialty under the supervision of a senior resident or department head.
Upon completion of the internship, physicians undertake a residency training program in their chosen specialty. The duration of the residency program may be two to four or more years, depending on the area of specialization.
Video: Cedric Van Dijck, Medical Internship at the Cleveland Clinic, Ohio:
Residency/Fellowship
If a doctor wishes to practice a medical specialty, the internship is followed by several additional years of training, generally as a hospital resident, or as a fellow. The resident assumes responsibility for the care of patients and participates in a training program within particular service or specialty in the hospital, involving bedside instruction, operating and delivery room instruction where indicated, teaching rounds, laboratory studies, conference seminars and lectures. The fellowship is usually a medical school appointment. It is similar to a hospital residency, but usually places more emphasis on teaching, laboratory, and research experience.
Each residency training program is organized and managed by a program director who oversees a staff responsible for education, training and supervision of the residents. Programs are offered by teaching hospitals, medical schools or medical institutes. There are two types of residency training programs:
1. Transitional Programs: Available for physicians interested in gaining experience is areas other than their specialty. These programs are offered for one year either at the beginning or end of the regular residency training program. Residents must also meet all requirements for their chosen specialty.
2. Categorical Programs: Meet the specific requirements for a chosen specialty. The length of time spent in residency, fellowship, or other specialized post-graduate training varies for the different medical specialties. In general, two to four years are considered essential, but a longer period may be necessary in some of the more highly specialized fields. In addition to approximately three years of residency training, the American doctor who seeks recognized specialist standing is also required to practice in his specialty for a prescribed number of years before qualifying for specialist certification. Lists of these programs and other information are given in the Directory of Graduate Medical Education Programs which is available for consultation in the Advising Centre. For information on possibilities for postgraduate training in medicine in the United States, ask to receive our handout on “Information for Graduates of Foreign Medical Schools”.
ECFMG Certification
Under rules established by the Accreditation Council for Graduate Medical Education (ACGME), an international medical school graduate must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) in order to be eligible for appointment to an accredited graduate medical education program in the United States.
To be eligible for certification by the ECFMG, Belgian medical doctors must:
1. Send one recent full-face color photograph and two copies of their diploma of Docteur en Médecine/Arts, together with official English translations and proof that they are registered to practice medicine in Belgium. Non‑Belgian graduates of Belgian medical schools need not be registered to practice medicine in Belgium.
2. Pass the medical science examination: Currently, the examinations administered for this purpose are the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (Step 2 CK). The ECFMG also accepts certain former medical science exams to fulfill this requirement. See the ECFMG Information Booklet for more information. (www.ecfmg.org)
3. Pass the Clinical Skills Assessment, including an assessment of spoken English proficiency. The USMLE Step 2 Clinical Skills (Step 2 CS) is the exam currently administered that satisfies this requirement. Applicants who have both passed the former ECFMG Clinical Skills Assessment (CSA) and achieved a score acceptable to the ECFMG on an English language proficiency test (such as the TOEFL or the former ECFMG English test) can use these passing performances to fulfill this requirement. See the ECFMG Information Booklet for details. The Step 2 CS also has a distinct, separately scored subcomponent that assesses spoken English proficiency. Complete information at: www.ecfmg.org
Doctors who meet the conditions specified above will receive, within two to three weeks, from the ECFMG a Standard ECFMG Certificate.
PLEASE NOTE: Foreign doctors who accept research posts, defined as “observation, consultation, teaching or research” in US hospitals and who will thus have no direct contact with patients are not required to be ECFMG‑certified, and therefore are not required to take the USMLE.
United States Medical Licensing Examination (USMLE)
The USMLE Step 1 and Step 2 examinations have been designed and developed to assess knowledge in the basic medical and clinical sciences respectively. Foreign medical graduates may take Step 1 and Step 2 in selected centers throughout the world. Currently, foreign medical graduates may take the examinations in 12 locations in Europe, but not in Belgium.
Both Step 1 and Step 2 are in the multiple‑choice format and are given only in English. These two tests as well as Step 3 are given twice a year. Registration forms and information booklets are available from www.usmle.org.
Medical students may take Step 1, Step 2 CK, and Step 2 CS in any sequence, provided they have completed their basic sciences medical school curriculum or if they have completed at least two years in a medical school. Belgian students should probably wait to take any part until after they have completed the first year of the “doctorate.” For purposes of ECFMG certification, Steps 1, 2 CK and 2CS must be passed successfully within a seven year period.
STEP 1: A one‑day, multiple choice, computer-based exam that assesses whether you understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. Step 1 ensures mastery of not only the sciences that provide a foundation for the safe and competent practice of medicine in the present, but also the scientific principles required for maintenance of competence through lifelong learning.
STEP 2 Clinical Knowledge (CK): A one-day, multiple choice, computer-based exam that assesses whether you can apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention. Step 2 CK ensures that due attention is devoted to principles of clinical sciences and basic patient-centered skills that provide the foundation for the safe and competent practice of medicine.
Step 2 Clinical Skills (CS): is a one-day exam that consists of simulated clinical encounters. Step 2 CS is only given in the United States, in Atlanta, Chicago, Houston, Los Angeles, or Philadelphia.
For more details on the examinations, see www.usmle.org
Hospital Residencies and Fellowships
Once a doctor has passed the USMLE Steps 1 and 2, he/she may apply for positions in American hospitals.
There are no formal restrictions, overall or by program, limiting the number of international medical graduates that enter into accredited residency programs. However, certain specialties and programs within those specialties vary in their competitiveness.
Electronic Residency Application Service (ERAS)
There are currently two methods of applying to U.S. residency programs: submitting an electronic application using the Electronic Residency Application Service (ERAS) and submitting a paper application. Most medical specialties participate in ERAS. See the following web site for a list of the participating hospitals: www.aamc.org/eras or www.ecfmg.org/eras.
All applicants for residency positions, regardless of the method of application, should contact residency program directors for specific requirements and deadlines. Applicants should also register with the National Resident Matching Program (NRMP).
National Resident Matching Program (NRMP)
Almost all graduates of United States and Canadian medical schools obtain appointments in United States hospitals through the National Resident Matching Program (NRMP). Foreign medical graduates are not required to participate in this program but are permitted to do so if they have passed all the exams necessary for ECFMG certification prior to the “match” and if they expect to receive an Interim ECFMG Certificate no later than the starting date of the graduate training program for which they are applying.
The NRMP matches applicants with available positions in residency programs. Applicants submit to the NRMP a list of residency programs in order of preference. The programs listed are those programs to which they have applied (via ERAS or traditional paper applications). Program directors also submit to the NRMP ranked lists of the applicants they prefer for positions in their programs.
The matching is carried out in March, for programs that usually start about July 1. Since many U.S. hospitals look to the National Resident Matching Program for all of their trainees, and do not appoint anyone who does not participate in the program, many foreign medical graduates consider it desirable to participate.
Three days prior to release of the general Match results, applicants find out whether or not they have matched to a program, although they do not learn the specific program to which they have matched. The following day, the list of unfilled programs is available to unmatched NRMP registrants on the NRMP web site at www.nrmp.org.
Before signing a contract with a hospital for residency training, candidates should carefully consider the following criteria:
1. duration of employment;
2. salary: good programs do not always guarantee a high salary;
3. allowance for housing and food;
4. insurance: Is the resident expected to pay for professional liability insurance or is this covered by the hospital?
5. health insurance: Does the hospital provide insurance for the resident and his/her family?;
6. hours of duty and details of work responsibilities;
7. vacation days and other benefits; and
8. program content including duration and sequence of specified assignments to clinical, laboratory or ambulatory care facilities.
Clerkships for Foreign Medical Students
Foreign medical students may apply to American medical schools for advanced clinical clerkships or clinical elective programs. However, foreign medical students will be admitted on a space‑available basis, since American medical schools give preference for positions in clinical electives to students from their own schools. Private medical schools are more likely to accept foreign medical students than are state universities. Clinical clerkships may normally be for a maximum of three months. Foreign medical students must also have malpractice (liability) insurance and be enrolled in their own institution in order to be considered for admission.
For medical students seeking clerkships in U.S. medical schools during their studies, there are no specific test requirements. The USMLE is not required, nor do they have to have ECFMG visa sponsorship. However, it may be useful, but not necessary, to pass Step 1 of the USMLE. Students doing clerkships of this type travel to the U.S. on F‑1 or J‑1 visas issued by the U.S. medical school.
VISAS
Candidates for hospital residency or fellowship programs normally receive visa sponsorship through the ECFMG. They receive Exchange Visitor (J‑1) visas which are valid for the time necessary to complete the training. To be eligible for ECFMG sponsorship, foreign doctors must have:
1. passed USMLE Step 1 and Steps 2 CK and 2 CS or the former VQE, NBME Part I and Part II or FMGEMS;
2. a valid Standard ECFMG Certificate and
3. a contract for a position in a training program. Application for visa sponsorship is made by the hospital providing the training, not the individual.
4. provided a statement of need from the Ministry of Health of the country of nationality. This statement must provide written assurance that the country needs specialists in the area in which the Exchange Visitor will receive training.
Please note that visa requirements and procedures are subject to change. For updated information, please see www.ecfmg.org/evsp.
Practicing Medicine in the United States
Foreign medical doctors who wish to practice medicine in the United States should request information about visa requirements at the American Consulate, Boulevard du Régent 25 Regentlaan, 1000 Brussels, Belgium or 22 Boulevard Em. Servais, Luxembourg City, G.D. Since immigration and labor certification regulations may change, it is best to request current information from the American Consul.
Candidates may find specific licensure requirements for each state on this website: https://www.fsmb.org. No diploma, whether American or foreign, entitles the bearer to practice medicine in the U.S. Each of the 50 states and each territory has authority to grant or withhold licenses to practice medicine within its borders. It is expected that all licensing authorities in the United States will accept USMLE Steps 1, 2, and 3 results for licensure purposes, which has been established as the single exam for licensure in the United States.
USMLE Step 3 assesses biomedical and clinical knowledge considered essential for the unsupervised practice of medicine and is organized along two principal dimensions: physician tasks and clinical encounter situations. Step 3 is given only in the United States, and is administered by the individual licensing authorities in each state. Eligibility requirements for taking Step 3, application deadlines, fees, test center locations, and other information on Step 3, can be obtained from the individual state medical board in which you wish to be licensed or from www.usmle.org
Answers to general questions about the practice of medicine in the United States may be found at www.ama-assn.org.
Scholarships for Medical Research
If they qualify as research scholars, Belgian/Luxembourg medical doctors may apply for partial Fulbright scholarships for medical research from the Commission for Educational Exchange. See Grants for Post-Doctoral Research. Candidates for research normally do not need ECFMG certification.
