Specialty training in the United States

If you are a physician that is interested in specialty training in the USA, you must first decide whether you wish to:

be a Clinical Observer in the USA (at a University Hospital or Private Clinic).

receive the official ACGME-Accredited residency training that leads to American-Board Certification.

The process differs significantly in these two situations.

A. In case you are interested in a Clinical Observership:

Clinical Observership in the United States can last for a period of a few weeks to several months, depending on the arrangement you make with the Hospital or Clinic. Usually you fill out the University Hospital application form and send your CV. Observation applications are almost always approved, even from top universities like Harvard Medical School. The process is usually very simple and once you have arranged the paperwork and visa (typically ESTA tourist visa), you will be able to attend for the length of time you have agreed with the university.

It is important to know that during the Clinical Observership:

You are not a licensed physician in the U.S.
You are not allowed clinical contact with patients
You are not allowed to participate in surgery
You do not have an official hospital position or salary.

Also, the costs of your stay are provided by you. It s important to mention that the observation may in the future be mentioned in your CV as “observation/observership in the Unites States” but is not considered residency specialty training and it’s not recognized as clinical training.

B. In case you wish to receive the official ACGME-recognized training (specialty) in the United States leading to American Board Certification in your specialty:

In this case the process is quite demanding and requires commitment as it usually takes several years and you will have to complete the following steps that apply equally to all U.S. medical students and physicians:

Step 1: Obtain the Medical Licensure Examinations (USMLE)

Unlike the EU countries that automatically license an EU doctor (directive 93/16) so that he/she can start residency training without an exam, this is not the case in the United States. Doctors with European medical degrees do not automatically receive a medical license to start a residency.

In order to be able to apply for residency training in the US, you must first achieve high scores on the USMLE (United States Medical Licensing Examination) so you can obtain a medical license in the U.S. The USMLE is a 4-part exam and certifies each physician’s total medical knowledge, critical thinking and application of this medical knowledge to clinical practice with a focus on safe and effective patient care. The Examination involves all subjects of Medicine.

USMLE Step 1: Examined in all Pre-clinical fields of Medicine such as Anatomy, Biochemistry, Microbiology, Microbiology, Pathology, Pathological Anatomy, Pharmacology, Physiology, Genetics, Immunology, Pathophysiology, Biophysics, Behavioral Sciences.
USMLE Step 2 CK: You are examined in all Clinical fields of Medicine like Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, Psychiatry, Epidemiology, Preventive Medicine.
USMLE Step 2 CS: Assesses examinees’ ability to apply the medical knowledge and skills necessary to provide care to the patient under observation, using standardized patient cases (actors) to test students and graduates on their ability to gather information from patients, perform physical examinations, and communicate their diagnosis to patients and colleagues.
USMLE Step 3: Step 3 is the final USMLE exam leading to the professional license. The exam syllabus is determined by committees composed of experts in their fields, both academic and non-academic, who are well-established in their fields. You are tested on whether you can cope as a physician of all basic clinical specialties in day-to-day clinical situations in the physician’s office, emergency room, operating room and intensive care unit.

The USMLE process is very time-consuming and it is recommended that you complete it with high scores as they are of great importance during the next step of the process (the application process), especially for highly competitive specialties.

Step 2: Specialty Application process

Once you have completed the USMLE you should start the Application process to the Academic Programs you are interested in. The process is called the Matching Program, takes about a year and is a highly competitive process, especially for the highly desirable specialties such as Plastic Surgery and Neurosurgery which have very few residency slots per state.

During the application process:

You send a notification to the University Hospitals that you are interested in their Training Program. Many universities will ask for your CV and USMLE results as they may have many applications and they usually use these 2 tools in order to make their initial selection. If they approve your initial letter, they will send you their own separate application for a specialty position.
You fill out the applications for all the programs they send an application. Important in the applications are : Degree grades, letters of recommendation, possible clinical experience in the U.S. as a student, possible research or publications but most importantly the results on the USMLE steps exam since it is considered the most predictable and consistent factor for American Residency Specialty Training Programs.
If a University Hospital believes that a specific applicant may meet the acceptance requirements, the candidate is invited for an Interview and introduction to the Training Program. An applicant that has a good chance of obtaining a Residency Training position, will usually receive interview invitations from at least 8-10 training programmes.
Interview: This is a very important step in the application process is a detailed assessment of the candidate and whether he/she is a good fit for the specific Training Program. Almost all Clinical Professors, Attendings and key members of the Education Program interview the candidate and candidates often spend a full day or two days at the University Hospital of interest.
After the interviews are completed you fill out the Matching Program Application which is a numerical Preference List that both the applicants and the education programs complete. All lists are then electronically merged and a mathematical algorithm is used in order to generate the Match Results, i.e. “the Match”; whether a physician was accepted for Training and to which program he/she was accepted.
The Match day (results day) : This day is very important for medical students in the US (and for medical students applying from other countries) as the results of all algorithms are released and the Hospitals where all physicians will be located for the next several years is determined. This is very important since often many physicians choose to continue their academic and professional careers in the same location where they specialized.

The admissions process for non-American applicants is extremely difficult and great weight should be given to the application in order to have a chance of receiving an interview and admission to a residency program.

Step 3: The specialty

If you are accepted, you begin your Residency Training which has a duration of 4 to 8 years, depending on the specialty. It is important to know that there are very strict training program requirements in order for a physician to continue and complete his/her multi-year clinical Residency Training as he/she is constantly evaluated on many aspects of clinical medicine. Specifically, he/she is evaluated for his/her clinical knowledge through annual “in-service” exams and through annual oral exams in clinical cases. In addition, he/she is continually evaluated by all faculty in the training program for his technical and surgical skills, for the prevention and management of potential complications, and for methods of safe assimilation of new surgical techniques. The Professors and Attendings each year make an overall decision as to whether or not each Trainee/Resident will continue with his/her residency the following year. It is quite common for physicians who begin Residency in a specific Training Program to not meet the requirements for continuation of Residency Training and to have to change medical specialties.

Step 4: Subspecialty

Should you wish to obtain Subspecialty Training (Fellowship Training), you will need to follow the Matching Program process above once again. Specifically, you will have to apply again, submit your annual Residency Training exam results, submit appropriate letters of recommendation and again undergo the interviews processes. During “Match Day” you find out if you have been accepted into a Subspecialty Fellowship Training Program.

Step 5: American Board Certification

After a Physician successfully completes the required Residency/Specialization Training (a specific minimum number of years and experience is required for each Medical Specialty), he/she applies for the American Board Certification specialty exam (American Board Certification). The Board Application has detailed information about the physician’s clinical experience and knowledge by the Program Director of the Training Program. Specific prerequisites and criteria must be met for the candidate’s application to be accepted and in many cases the application is not accepted as the candidate may need additional experience or training in order to be admitted for the Board Examination.

If the Board Application is accepted, the candidate will have to complete the following steps:

Written examination in the entire range of the Medical Specialty
Oral examinations on hypothetical clinical cases of the Medical Specialty
Clinical Case Assesment: A thorough evaluation of the candidate’s Clinical Cases is carried out after he/she has started working. In other words, an evaluation is made of the actual surgical results on real patients during the first years of practice of the surgical candidate. In order to complete this step, the candidate must provide the entire official medical record from the hospital where he/she is working (signed by the hospital’s medical records) together with photographs, x-rays and anything relevant to each case in which he/she will be examined.

In case the candidate passes the Examinations and the Clinical Case Assesments, he/she will be awarded the American-Board Certification in his/her specialty (in Plastic Surgery, an average of 3 to 4 physicians become American-Board-Certified annually in each U.S. state).

Step 6: Continuous Certification

In order to maintain the American Board Certification, designation, every Board-Certified physician must compulsorily participate in the Continuous Certification (CC) Program / Maintenance of Certification (MOC) Program. During this Program, the Board tests his/her knowledge by annual examinations and periodically reviews his/her clinical approaches and real-life surgical cases. Additionally each physician must demonstrate that he/she is participating in Continuing Medical Education (CME) by completing a specific minimum annual number of Continuing Medical Education (CME credits).

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