International medical graduate
An international medical graduate (IMG), earlier known as a foreign medical graduate (FMG), is a physician who has graduated from a medical school outside of the country where he or she intends to practice. Generally, the medical school of graduation is one listed in the International Medical Education Directory (IMED) as accredited by the Foundation for Advancement of International Medical Education and Research or the World Health Organization.
Medical schools around the world vary in education standards, curricula, and evaluation methods. Reason why many countries have their own certification program, equivalent to the ECFMG in the United States. The purpose of ECFMG Certification is to assess the readiness of international medical graduates to enter clinical specialty training programs as resident physicians and fellowship programs in the United States.
License requirements by country
The requirements to obtain a license to practice varies by country and often by state or province.
IMGs who wish to be licensed in Australia must apply to the Australian Medical Council (AMC) to arrange an appropriate assessment pathway. The standard pathway involves an IMG sitting a series of assessments, including AMC MCQ Exam and AMC clinical exam. AMC MCQ Exam consists of 150 MCQs organized through computer adaptive scoring.
For AMC clinical exam, a candidate is required to pass 12 out of 16 cases including one compulsory case in each of Gyne and pediatrics.
Australia is in the process of establishing a national registration process for all the doctors under Medical Board of Australia.
In 2010 the Minister for Health and Ageing (Australia) launched an Inquiry process into registration and accreditation processes for international medical graduates which reported in 2012.
Several organizations have put pressure on the government such as the Association For Access to Health Care Services, and Association of International Physicians and Surgeons of Ontario. Bill 97, Increasing Access to Qualified Health Professionals for Ontarians Act, was passed in 2008, requiring the College of Physicians and Surgeons to provide adequate numbers of doctors by issuing transitional licenses. However, the college has not complied with the law.
In addition to undergoing the regular licencing process as required of all Canadian medical school graduates, IMGs must pass the LMCC Evaluating Examination. IMGs in Canada also have a harder time getting into residency programs compared to Canadian graduates — only ten percent of IMG applicants get a position.
Graduates of United States M.D. programs are not considered IMGs and are thus exempt from the Evaluating Examination; graduates of U.S. osteopathic medical schools are considered IMGs.
Graduates of Canadian M.D. programs are not considered IMGs in the United States.
The main pathway for IMGs who wish to be licensed as physicians in the United States is to complete a U.S. residency hospital program. The general method to apply for residency programs is through the National Resident Matching Program (abbreviated NRMP, also called "the Match"). To participate in the NRMP, an IMG is required to have an ECFMG certification by the "rank order list certification deadline" time (usually in February of the year of the match). To acquire an ECFMG certification, the main requirements are:
- Completion of USMLE Step 1, USMLE Step 2 Clinical Knowledge and USMLE Step 2 Clinical Skills
- A medical diploma of medical education taken at an institution registered in the International Medical Education Directory (IMED)
In comparison, regular graduates from medical schools in the United States and Canada need to complete USMLE Steps 1 and 2 as well, but can participate in the NRMP while still doing their final year of medical school before acquiring their medical diplomas. In effect, taking regular administrative delays into account, and with residency programs starting around July, there is a gap of at least half a year for IMGs between graduation from medical school and beginning of a residency program.
One study came to the result that almost half of IMGs were unsuccessful in their first attempts in the pursuit of a U.S. residency position, and three-quarters began a residency after five years. It also indicated that IMGs were considerably older when they first applied for a residency position than are most U.S. medical graduates, with mean age of IMGs when the ECFMG certificate was issued being 31.3 years, with a standard deviation of 5.6 years.
All applicants to residency programs in California need a Postgraduate Training Authorization Letter (PTAL), colloquially called a "California Letter". Obtainment of a PTAL requires graduation from a medical school listed by the Medical Board of California, which is more stringent than the International Medical Education Directory. It also requires a having a Social Security number.
Origin by country
|Country of medical school||Percentage of IMGs||Total number (2007)|
Source: 2007 AMA Masterfile
Quality of care
One study examining quality of care by international medical graduates is noted as follows. "One-quarter of practicing physicians in the United States are graduates of international medical schools. The quality of care provided by doctors educated abroad has been the subject of ongoing concern. Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates"..
- "IMG guides: Applying to the Australian Medical Council". Australian Medical Council. 27 February 2012. Retrieved 7 June 2014.
- "Assessments & examinations: Standard pathway". Australian Medical Council. 27 February 2012. Retrieved 7 June 2014.
- "Inquiry into Registration Processes and Support for Overseas Trained Doctors". Parliament of Australia. Retrieved 2 June 2014.
- readersdigest.ca - Why Is Canada Shutting Out Doctors?: "In 2003, 625 international graduates competed. Only 67—about ten percent—found a position"
- "Evaluating Examination: Apply". Medical Council of Canada. Retrieved 2010-04-16.
- "Frequently Asked Questions: 1. What Is ECFMG Certification?". 2010 ECFMG Information Booklet. Educational Commission for Foreign Medical Graduates. Retrieved 2010-04-16.
Medical schools outside the United States and Canada vary in their educational standards and curricula. The purpose of ECFMG Certification is to assess whether graduates of these schools are ready to enter U.S. residency and fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).
- nrmp.org > Independent Applicants Updated 09/08/2010.
- nrmp.org > 2012 Main Match Schedule Updated 05/19/2011
- ecfmg.org > Medical Education Credentials Last update: September 15, 2010
- nrmp.org > U.S. Seniors > Registering with the NRMP Updated August 2010
- Participation in U.S. Graduate Medical Education by Graduates of International Medical Schools By Jolly, Paul PhD; Boulet, John PhD; Garrison, Gwen PhD; Signer, Mona M. MPH. Posted: 05/23/2011; Academic Medicine. 2011;86(5):559-564.
- Postgraduate Training Authorization Letter (PTAL) or “California Letter”, Educational Commission for Foreign Medical Graduates. Last updated June 4, 2013.
- University of California, Los Angeles - PTAL, Updated January 2011
- The Medical Board of California - Physicians and Surgeons. Retrieved May 2014.
- "IMGs by Country of Origin". American Medical Association. Retrieved 7 June 2014.
- Norcini 2010, pp. 1467