AMBOSS IMG Insights

Expert insights for AMBOSS IMGs
on COVID-19-related disruptions
to the USMLE Process

ECFMG Certification of IMGs applying for 2021 Match

Last updated June 19th, 2020

Until recently, all IMGs were required to have completed all USMLE Step exams (1, 2-CK, and -CS) to obtain ECFMG certification. This certification is a prerequisite to enter residency or fellowship programs in the U.S. The NBME’s announcement that the Step 2 CS exam was being suspended for 12–18 months had left the IMGs, who would still need ECFMG certification to apply for the NRMP Match in 2021-22, in limbo.

In response to this situation, the ECFMG has recently announced some encouraging new changes to the ECFMG Certification process, ensuring that qualified IMGs can participate in the 2021 Match.

Here is all you need to know about these changes and how we think they could affect you:

WHAT ARE THESE CHANGES?


As a follow-up to their initial statement about ensuring “the ability of qualified IMGs to pursue and participate in U.S. GME without interruption”, the certification commission finally revealed their response to the suspension of the Step 2 Clinical Skills (CS) examinations on June 17, 2020.

They have announced five new, alternate options (or “pathways”), which will allow qualified IMGs that have been unable to take Step 2 CS due to the suspension to meet the clinical skills  requirements for ECFMG Certification and, hence, participate in the upcoming Match.


Applicable only to a specific set of aspirants:

Before delving into the details of the new pathways, it is worth pointing out that these changes are only applicable to the IMGs applying to MATCH for the 2021 season (i.e. those applying in the year 2020, for a residency program starting in Jul.–Aug. 2021).

Although the Step 2 CS suspension might also affect those aiming for the 2022 Match, the ECFMG has not yet announced any measures for those aspirants. The body states that they will announce the process for 2022 (and beyond) soon. We, at AMBOSS IMG-Insights, will keep you updated about the same.

Prerequisites:

Additionally, it is worth noting that all IMGs appearing for the 2021 Match will need to fulfill the following requirements:

  • Eligibility limitations: Certification via these new pathways can only be acquired by the IMGs that meet all of the following conditions:
    • Have not already passed Step 2 CS and/or are already certified by ECFMG
    • Are not barred
      • by the ECFMG from pursuing certification
      • by USMLE from taking a Step exam from Aug 1, 2020 to Jan 31, 2021
    • Have not failed any USMLE Step exam two or more times
    • Have appeared for (or registered) at least one Step exam since January 1, 2018
  • Compulsory additional English proficiency assessment: Regardless of which pathway an IMG utilizes for ECFMG certification, they will need to pass an additional English proficiency assessment. All IMGs need to take this test, regardless of citizenship. The details of this language assessment have not yet been clarified by the ECFMG and are likely to be announced soon.

WHICH PATHWAY CAN YOU APPLY UNDER?


Pathway 1

Already Licensed to Practice Medicine in Another Country

You are eligible for this pathway if you meet both the following conditions:

– you have been licensed to practice medicine (without restrictions) in any country, at any point in time after January 2015. That license need not be currently valid.

– if that license has never been subject to disciplinary action.



Pathway 2

Already Passed a Standardized Clinical Skills Exam for Medical Licensure

You are eligible for this pathway if:

– you have already successfully cleared (or will have cleared before certification) a clinical skills exam in English. The exams accepted by the ECFMG include:

    • PLAB Part 2 (UK)
    • MCCQE Part 2–NAC (Canada)
    • AMC Part 2–Clinical (Australia)
    • NZREX Clinical (New Zealand)
    • PRES Level 3 (Ireland)


Pathway 3

Medical School Accredited by Agency Recognized by World Federation for Medical Education (WFME)

You are eligible for this pathway if you meet all of the following requirements:

– you have graduated after Jan. 1, 2018

– from a medical school that is currently accredited by an agency recognized by WFME.

– possess some documentation/attestation from your medical school that you possess satisfactory clinical skills



Pathway 4


Medical School Participates in U.S. Federal Student Loan Program

You are eligible for this pathway if you meet all of the following requirements:

– you have graduated after Jan. 1, 2018

– from a medical school that currently participates in the U.S. Federal Student Loan Program.

– possess some documentation/attestation from your medical school that you possess satisfactory clinical skills



Pathway 5

Medical School Issues Degree Jointly with a U.S. Medical School Accredited by Liaison Committee on Medical Education (LCME)

You are eligible for this pathway if you meet all of the following requirements:

– you have graduated after Jan. 1, 2018

– from either Weill-Cornell (Qatar) or Duke-NUS(Singapore).

– possess some documentation/attestation from your medical school that you possess satisfactory clinical skills.

WHAT DOES THIS MEAN FOR IMGs?


Positive, for the majority:

For the most part, we think that this is a positive move from the ECFMG for the IMG community. With the Step 2 CS suspension, the ECFMG had to shoulder a very difficult responsibility–of coming up with a solution that balances the opposing factors of providing as many IMGs as possible a chance to get the certification, without jeopardizing the confidence that residency directors could place in that certification (with regards to the clinical and communicative skills of the certified candidate).

The currently provided options cast a wide net and allow the majority of IMG candidates to prove their clinical and communicative competence, via an easily available option PLUS the language assessment test.

  • Most IMGs, who have already graduated, would be covered by pathways 1 and 3.
  • Those ineligible for pathways 1, 3, 4, and 5, could possibly circumvent that by appearing for an alternative CS exam near their home (for example, US-IMGs could try appearing for the Canadian NAC exam).

Extremely unfortunate, for some:

That having been said, the new pathways leave certain sections of IMGs in a very tenuous situation, regarding their ECFMG certification and application for the upcoming Match cycle.

Candidates that graduated before 2018 from medical schools that do not meet any of the criteria in pathways 3, 4, or 5, AND never got licensed to practice in their graduation-country seem to have no recourse, if they would like to appear for this year’s match. However, we do believe that it might not be time to despair just yet. Please read our thoughts below.

OUR THOUGHTS ON THIS


For the IMGs that meet the criteria for one of the pathways:

We hope that you are feeling some relief that your progress towards US residency has not been thwarted by situations that you had no control over! Please know that we sent a few heartfelt high-fives your way, when we read that announcement.

It is definitely an advantage that you don’t have to now deal with the burden of travel and associated expenses of the classical CS exam. The language assessment exam is also likely to be a less stressful exam to take, as it won’t be held in a foreign setting.

However, please bear in mind that we don’t yet definitively know which particular language exam it will be. The ECFMG has not specified any details about whether it will be TOEFL or IELTS or some other exam altogether.

For those who don’t meet any of the criteria for any of the pathways:

Although this situation seems extremely dire, at first consideration, we do think that it may not be time to abandon the American Residency dream just yet. First of all, we still do not definitively know if being able to continue with  the residency process without Step 2 CS is as clear an advantage as it may appear (see our summary and advice, below, for further context).

 


To summarize:

It is definitely a positive move that ensures that most (if not all) the IMGs, who had originally planned to appear for Match 2021, will get the opportunity to do so. However, the implications of these changes on the actual Match outcomes will only become entirely clear after the interviews in 2021.

Unless the NRMP and NBME come out with statements explaining how this could impact the interview-call decisions of residency administrators, it is almost impossible to predict whether the program directors would consider certification by these alternate pathways to be as dependable as the classical process, and how this affects their decisions on which candidates to shortlist for interviews.

That being said, we do expect most PDs to be considerate of the fact that most IMG candidates applying this way were victims of the prevailing global circumstances and, hence, to make adequate leeway for them.

WHAT SHOULD YOU DO?


If you meet the criteria for one of the pathways:

Ensure that you are eligible(see above) + clear the Steps 1 and 2CK before September 2020 + pass the language assessment test that the ECFMG prescribes.

Following this, you can pick up your ECFMG certification and apply for the 2021 NRMP Match, when ERAS opens in Sept. 2020.

 


If you don’t meet any of the criteria for any of the pathways:

We really suggest that you first explore the possibility of appearing for one of the alternative clinical skills exams (pathway 2). The ECFMG has specified a non-exhaustive list that “includes” (and does not “consist of”) six example exams. This could mean that if you have a clinical skills exam being held in your country in English, there might be an opportunity that it could also be considered by the ECFMG. We encourage you to write to the ECFMG and explore if this is possible.  Even if not, it may still be worth contacting the commission, via tweets and public forums, to make yourself heard and seen as a significant proportion of competent (but unlucky) IMGs.
The ECFMG has not yet finalized its stand on the coming year’s certification process (when the Step 2 CS might still be suspended). Mounting pressure from masses of affected students, especially, on publicly visible platforms, could very well force the emergence of a new pathway next year that considers the situation of this subset.

In the eventuality that this happens, you may even want to consider delaying your Match application to next year and take the time to enhance your CV further. Admittedly, delaying residency by one year has significant life consequences for a lot of you, (and we–at AMBOSS–want to assert that we are extremely aware and empathetic to those concerns), we do want to iterate that the current situation is not set in stone.

So, we would like to repeat – it is not the time to be feeling completely deflated, just yet!

 


General advice for all IMGs, regardless of eligibility:

1. Do not let your clinical and communicative skills rust. You can make sure that you learn the most effective examination and communication skills by using the Step 2 CS preparatory module that is included with your AMBOSS access. Practice patient cases with AMBOSS

2. Make sure you remain on top of developments. The situation might continue to evolve, with further clarifications and alterations by the ECFMG or NBME. You need to stay on top of these changes to make the best decision for your residency path. To help you do this, we have established an IMG Insights channel. You can easily subscribe to it via the form on the right.

3. Do not stress. If you need guidance at this difficult time, we encourage you to sign up for a call with an AMBOSS counsellor. Our advisors provide 1-1 guidance on study strategy, which resources to use, and how to best prepare for your dream score. This service is free of cost for a limited time.

4. Try your best to supercharge your CV.  Every international medical student is facing this situation with you. Even with the new allowances to get certified, we still cannot predict whether the program directors would consider certification by these alternate pathways to be as dependable as the classical process.  In such a situation, the program directors will be keen to see your response to this challenge–so, take every research-, volunteering-, presentation-opportunity you can get, to make your CV stand out among other applicants!

 

Best of luck and stay safe,

Dr. Colaço from the AMBOSS IMG Insights team

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Step 2 CS cancellation and its effect on IMGs

Last updated: June 1st, 2020

The recently announced suspension of the Step 2 CS examination is the latest among many recent changes to the standard USMLE process. At AMBOSS, we realise that this announcement raises concerns that no previous generation of International Medical Graduates (IMGs) have had to face before. Here is all you need to know about this announcement and how we think this could affect you:

WHAT IS THE CHANGE?


On May 26, 2020, the NBME officially announced that they will suspend administering the Step 2 Clinical Skills (CS) examination for the next 12 to 18 months (i.e. till May 2021 or Nov 2021), in light of the COVID-19 pandemic. Refunds will be provided to everyone who couldn’t take the Step 2 CS because of suspensions during the pandemic.

WHY IS THIS SO RELEVANT TO IMGs?


While, on the face of it, it may appear that this move decreases one step in the journey towards obtaining a U.S. Residency position, the effects of this move does raise some serious concerns for IMGs because of the following implications:

  • Although the Step 2CS has been cancelled, ECFMG certification, which is a prerequisite to enter residency or fellowship programs in the U.S., is not.
  • With the Step 2 CS cancelled for the upcoming year, the established “normal” way of obtaining ECFMG certification has been disrupted: Without a Step 2 CS result, an IMG does not meet the examination requirements for ECFMG Certification, which comprise passing all the three requisite Steps (1, 2CK, and 2CS). Without this certification, technically, he/she cannot, strictly speaking, participate in the 2021 National Resident Matching Program (“the Match”) to enter U.S. programs of graduate medical education (GME).

WHAT NOW?


The ECFMG has released a response to this situation confirming their commitment to preserve “the ability of qualified IMGs to pursue and participate in U.S. GME without interruption.”

The agency claims that they are exploring alternatives to Step 2 CS, which the IMGs can appear for and claim their ECFMG certification. This would allow the IMGs to apply for the Match 2021.

There is no further information provided by the ECFMG on the nature of this “alternative” exam or when it will be announced.

WHAT DO WE THINK?


Despite the uncertainty of the situation, we do think it makes no sense to panic yet. The annual IMG intakes via the Match contribute a very significant proportion of doctors to the U.S. healthcare system. The current lack of a contiguous path for IMGs into US residency would severely affect this contribution. The added demands of the pandemic are only likely to make this need stronger.

Undoubtedly, considering the nature and risk of COVID-19, the execution of Step 2 CS is a high-risk exercise in these times, and its cancellation is justified in the interest of the safety of candidates, mock patients, and examiners. However, in what manner it will be replaced and how much value would such a replacement hold in the eyes of program directors are important considerations.

A new exam, exclusively for IMGs?

Since the US medical graduates do not need to be ECFMG certified to apply for the Match (and with this development, not even a Step 2 CS PASS result, anymore), the need for a probable alternate exam (that tests a candidate’s communication and clinical skills) applies exclusively to IMGs and their need to be ECFMG certified.

It is difficult to predict what this alternate test would comprise. We foresee one of the following three situations playing out-

  1. The replacement exam is either a virtually conducted “tele-simulated consultation” clinical examination, or a closely regulated OSCE-style exam, held at physical locations in individual countries: Both these outcomes could benefit the IMGs, in the sense that both could fulfil the role of the CS–i.e., establishing an IMG candidate’s competence at clinical communication–without the burden of travel and associated expenses of the classical CS exam. It is also likely to be a less stressful exam to take, as it won’t be held in a foreign setting. However, the disadvantage is that the replacement exam itself may not be as standardized as an NBME-administered Step 2 CS. This could cause the residency and program directors  to doubt the dependability of the such an “unknown, unstandardized” exam’s results. This could possibly cause directors to prefer older USMGs or those IMGs who have passed a classical CS exam, over those who have ECFMG certification by passing the replacement exam.
  2. The replacement could be a standardized communication exam, like the TOEFL or IELTS: We find this to be an unlikely (but not impossible) outcome, as it would disregard the primary purpose of Step 2 CS–i.e., to ascertain not just the simple communicative ability but also the clinical skills of the candidate.However, the ease of implementing such existing standardized exams on a large scale makes this the easiest executable option for the ECFMG, in terms of logistics.
  3. ECFMG waives the need for Step 2 CS to obtain certification: Although, this does seem like the most helpful solution at the moment, this could well turn out to be a move that hurts IMGs more than benefiting them–unless the people that decide which candidate gets called for interviews (ACGME, the program directors, and hospitals) clearly agree and publicly announce that they will not consider the lack of a Step 2 CS as a criterion to judge the eligibility of an applicant. Such an agreement could be difficult to arrive at because, without a standardized test that they trust, the decision makers will have no reliable way to judge the competence of a candidate. If this does happen, we do expect the NRMP and NBME to come out with statements explaining how this should impact the interview-call decisions of residency administrators.

SO, WHAT SHOULD YOU DO?


Despite the uncertainty of the situation, we do think it makes no sense to panic yet. The fact remains that IMGs make up a significant proportion of the US medical workforce (up to 8000 or nearly 22% of the Residents admitted every year are IMGs, according to NRMP Match Data). The added demands of the pandemic are only likely to make this need stronger. Therefore, an evolution of the current situation is inevitable and a solution would need to be reached to make sure that the system doesn’t suffer the consequences of a severe shortfall of doctors. No matter what the nature of the coming changes turns out to be, based on the currently available knowledge, we suggest the following to all our IMGs:

  1. Do not let your clinical and communicative skills rust. Regardless of what the outcome will be, as long as there is any replacement exam of any nature, you will need to be on top of your CS game to do well at it. This means continuing preparing your clinical skills, as you would’ve if this was not a worldwide pandemic that has sunk our lives in uncertainty. Regardless of whether you were actively preparing for the Step 2CS or not, you can make sure that you learn the most effective examination and communication skills by using the Step 2 CS preparatory module that is included with your AMBOSS access. Practice patient cases with AMBOSS.
  2. Make sure you remain on top of developments, so that you can optimize your preparations accordingly. To help you do this, we have established an IMG Insights channel. You can easily subscribe to it via the form on the right. If you are subscribed already, please watch your emails–we will keep you posted on how this develops and important insights about it.
  3. Do not stress. Remember, that this is a global situation that is unavoidable. Even if the Step 2 CS were to have occurred normally, it would have led to problems related to visa and international travel because of the pandemic. All you can do right now, is be as prepared as you can with the exact skill sets that the NBME tries to test by means of its exams.If you need study prep guidance at this difficult time, we encourage you to sign up for a call with an AMBOSS counsellor. Our advisors provide 1-1 guidance on study strategy, which resources to use and how to best prepare for your dream score. This service is free of cost for a limited time.
  4. Use this as an opportunity to enhance your CV. Never has it been easier to attend international conferences and paper presentations, what with all conferences moving online, obliterating the need for visa and travel expenses. Reach out to your post-graduate seniors and lecturers in hospitals and colleges, ask to help them in their research projects, and try to get more publications under your belt. You can even volunteer to work at local healthcare centres, specialty departments of your choice residency, and not-for-profit organisations to add value to your clinical experience. Every single medical student is facing this situation with you. The program directors will be keen to see your response to this challenge–make it an opportunity to make your CV stand out among other applicants!

Best of luck and stay safe,

Dr. Colaço from the AMBOSS IMG Insights team

Register here to stay updated on all similar IMG-specific expert insights published by the AMBOSS IMG Insights team.


 

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