How The Profession Is Organized In California
Regulation
EMPLOYMENT AS AN MD IN CALIFORNIA
It is difficult and costly for an International Medical Graduate (IMG) to become licensed in the United States, but you can be successful. The American Medical Association reports that there are 43,554 IMG resident physicians in the U.S. representing about 23% of the country’s practicing physicians.
According to the Bureau of Labor Statistics, physician salaries are some of the highest professional salaries in the U.S. Family practice often earns on the lower end of the scale where salaries of $190,000 are common, while the best-paid specialties, such as anesthesiology, can easily pay twice as much. Often, though, medical school graduates have a huge amount of debt to repay (U.S. medical school can easily cost $175,000!).
Debt is one big influence on a medical student’s choice of specialty. Other factors are an interest in ‘controllable lifestyle’ specialties (with normal office hours), desirable geographic regions, or prestige programs. U.S. medical graduates usually have advantages in competition for residency, including familiar medical schools, career services support, and recent graduation. The competitive conditions that result can lead many International Medical Graduates to consider changing medical specialties in order to return to medical practice.
Primary Care specialties such as family practice, internal medicine or Obstetrics and Gynecology provide more residency opportunities and there is high public demand for these doctors.
Generally speaking, demand for doctors is increasing due to an aging U.S. population and expanded treatment options. Certain healthcare reforms may also increase demand; if more people become insured, for example, providing them with regular medical care should create more doctor demand.
California’s laws around medical malpractice limit the amount of money you as a physician can be ordered to pay a patient if you are found guilty of malpractice – of injury or loss caused by improper treatment. California allows a maximum of $250,000 in non-medical damages (money given to a patient to compensate for pain, suffering, disfigurement, etc.). This limit, also called a ‘cap,’ is viewed as favorable to physicians and lowers their cost of doing business because it controls the cost of malpractice insurance, which can be very high in states without a cap. The subject of caps is a controversial subject in medicine, however, since many people argue that caps favor the doctor and insurance companies at the expense of patients’ rights.
Eligibility for Licensing
This section explains 4 major steps that you need to complete before becoming licensed to practice medicine in California. They are:
California effected changes to the laws surrounding physician and surgeon licensure in January 2020. Due to the changing nature of the regulations surrounding licensure, we recommend you visit the websites linked here for the most up-to-date and accurate information.
Each of these steps is complicated and involves a large investment of your time, money, and effort. They include foreign degree evaluation, multiple tests, and tough competition among doctors for placements. This topic will look at each one separately.
I. CERTIFICATION BY ECFMG
The Educational Commission for Foreign Medical Graduates (ECFMG) is the
organization that certifies International Medical Graduates and qualifies you to compete for
medical residency positions in U.S. teaching hospitals.
In order to qualify for ECFMG certification, your foreign medical school and program at
the time of your graduation must be listed in the World Directory of Medical Schools, managed by the World Federation for Medical Education and FAIMER Directory.
THE ECFMG CERTIFICATION PROCESS
- To begin the process, you will register through the Interactive Web Application for a USMLE/ECFMG Identification Number and begin to build your profile. Be very careful to give accurate information from the beginning since changing your biographic information later in the process will require documentation and additional fees.
- You will also need to submit a Certification of Identification Form (Form 186) which needs to be notarized using NotaryCam.
- You will need to apply for and take USMLE Step 1 and Step 2 exams in order to complete your ECFMG certification. You will apply to take these exams through ECFMG. More information on these exams is provided later in this guide.
- You will also need to provide certain documentation related to your medical education credentials, including: certification from your medical school that you are a graduate, final medical school transcript, and your medical diploma.
- After passing Steps 1 and 2, and providing all documentation of your medical credentials to ECFMG, you can be approved for certification. You can check the status of your applications and test results at OASIS (Online Applicant Status and Information System).
For more information, please read the ECFMG Information Booklet and the USMLE Bulletin of Information.
II. FIND A RESIDENCY
After getting ECFMG certification, the next step towards a medical license is completing a medical residency or fellowship, also known as a Graduate Medical Education program (GME). These programs are accredited by the Accrediting Council on Graduate Medical Education (ACGME) and vary in length from 3 to 7 years depending on the specialty. Occasionally a teaching hospital will accept IMGs as second-year residents; however these are rare cases and you should be prepared to go through a full residency program.
Finding a residency requires careful strategy, organization, and initiative. Graduates of U.S. medical schools benefit from more established networks and familiar credentials. Since you will be competing with these U.S. graduates, you should dedicate time to developing job search skills and to such activities as:
- Building networks and identifying physician mentors currently practicing in your specialty by attending meetings and seeking volunteer opportunities.
- Creating error-free and persuasive presentation documents like American-style resumes or online profiles, emphasizing your special skills and achievements.
- Practicing for interviews by preparing answers to common questions and conducting research on your target programs.
Although you may have already specialized in your previous country, you may consider being flexible about both the residency specialties and locations you will accept. You may increase your chances in obtaining a spot in residency programs that are:
- in medically underserved areas (rural and/or economically-depressed areas),
- in lower-earning specialties, or
- in specialties with more demanding work hours
The Match
“The Match” is a standardized process most medical graduates participate in to obtain a residency program. This process involves online applications to multiple residency programs, followed by interviews with those programs, after which you rank your choices and the programs rank candidates. On “Match Day,” an algorithm is run to match programs to candidates after which you are bound to accept a placement with the residency program you match with (and vice versa). This section will discuss the match in detail.
Pre-match
Some experienced foreign doctors may have developed relationships with hospitals or residency programs through personal or professional connections. You can look for a pre-match placement while also participating in the match process, but you must withdraw from the match program before its deadline (when rank lists close) if you have accepted a position “outside of the match period.” If you do not, you could be responsible to join more than one residency program and will have violated match rules. If you think a pre-match is likely, make sure to formally accept the offer and get documentation before the match deadline.
Timeline
Every year, the match program follows the same timeline:
- August: Match “season” begins; candidates and programs accept match participation terms; applications and interviews occur
- January: candidates and residency programs can begin to enter rankings for each other
- Mid-February: rank lists close
- Mid-March: matches are announced on Match Day
You will apply to residency programs through the Electronic Residency Application Service (ERAS), and submit your rank list through the National Resident Matching Program (NRMP).
It can be broken down into 4 steps, which will be discussed in more detail below:
A. Researching residency programs.
B. Compiling documents and applying to programs.
C. Phone and in-person interviews with residency programs.
D. Ranking of schools by candidates, and vice versa, resulting in a match.
A. Researching Residency Programs
You should begin researching residency programs well before Match season begins in
August. You will need to do a lot of your own research to learn what residency programs interest you and which are more likely to favor your application.
FREIDA is a searchable online database managed by the American Medical Association.
It provides key information on participating residency programs. It is a good first place to look for programs that interest you.
TIP: Make sure that when you ask for advice, you tell people that you do not require visa
sponsorship. Many people assume that as an IMG, you require visa sponsorship. This can limit their thinking about what residency programs are available to you. Remember that this guide assumes you are an IMG who already has permanent work authorization through permanent residency or refugee or asylee status.
B. Applications to Programs
Once you have a list of residency programs you want to target and as soon as you are eligible to start the Match process (around August each year), you should use the Electronic Residency Application Service (ERAS) to collect and send applications and documentation to residency program directors.
For foreign medical graduates, ERAS is accessed through the Educational Commission for Foreign Medical Graduates (ECFMG). This service involves fees for processing, ordering exam transcripts, and sending applications online. You can pay extra to send applications to more residency programs, which can be a good investment to increase your chances of receiving requests for interviews.
You also need to open an account with the National Resident Matching Program (NRMP), agree to its terms, and provide all required information.
Fees: $99 (base rate) ERAS (for 10 applications, additional applications incur additional
fees) and $50 for NRMP (for ranking up to 150 programs; additional rankings incur additional fees).
You will need to submit Letters of Recommendation (LoR) from U.S. licensed physicians. The best way for IMGs to obtain positive LoRs is to work or volunteer in a hospital setting. Networking with U.S. healthcare professionals increases your chances of finding physicians willing to recommend your work. Most programs ask for three LoRs, and all programs have a maximum of four LoRs. You may consider different LoRs for different specialties to make your application more competitive. Your recommendations should come from physicians who know you in a working context; never ask a relative to write you a
recommendation.
You will also need to submit a personal statement, which you can tailor if applying to multiple program specialties. A personal statement should be 1-2 pages and should highlight your strengths as a candidate. It is always a good idea to ask someone to read over your personal statement for grammar, spelling, and sentence structure. Mistakes in your personal statement can reflect poorly on you as a candidate.
C. Phone and In-Person Interviews with Residency Programs
Between August and early November, you may receive invites to interview with residency programs you applied to. These interviews are a critical step in the process, so you should ensure you prepare well before interviewing. Research the program and develop your personal story of why you want to practice this specialty at this particular residency program.
You will be expected to travel to these interviews and pay for your own travel and accommodation. The typical U.S. medical school graduate will go on more than five interviews; if you are able, you should target more. When interviewing, think about how you will want to rank each program to optimize your chances of getting a successful match.
D. Ranking Lists Resulting in a Match
When you have completed interviews and visits to residency programs, you must rank your choices online in the NRMP. Residency programs will rank candidates in order of preference based on their applications and interviews. In ranking a candidate, a residency program is committing to accepting that candidate if the match is made, and vice versa. Do not rank a program unless you are prepared to commit to it!
Rank lists close in February and NRMP utilizes an algorithm to match candidates to programs based on their rankings. The algorithm prioritizes candidates’ rankings over the
program’s rankings.
The resulting matches are announced during Match week in mid-March.
Supplemental Offer and Acceptance Program (SOAP)
Matches can only be made when both a candidate and a residency program rank one another in the NRMP. This means that there are many qualified candidates who do not receive a residency match. There are also some residency program openings that remain unfilled.
On the Monday prior to Match Day, you will be notified whether you have matched or not matched. On Match Day (always a Friday) you will find out which program you matched to.
If you are notified that you did not get a match, then you will have a chance to find a match through what is called the Supplemental Offer and Acceptance Program (SOAP). From Monday through Thursday, programs with unfilled positions offer unmatched applicants remaining residency spots. The entire process is conducted through ERAS, so you will use the
same account during Match Week to apply to SOAP positions.
If you are eligible for SOAP, you will receive a list of programs with remaining spots on Monday morning. You can apply to up to 45 unfilled programs. Be careful when you choose which programs to apply to, and make sure that the program accepts IMGs before applying. It is recommended that you apply to programs by Monday afternoon.
On Wednesday, programs will begin making offers to candidates. There are three rounds of offers from Wednesday to Thursday. If you receive an offer, you will have two hours to respond. You may receive multiple offers during the week, but you can only accept one offer.
Unfortunately, SOAP is the last major opportunity you will have in a given year to compete for a large number of residency placements.
You will need to consider your options if you are not placed in a residency at this time. If you choose to go through the Match process again, you must make sure you take steps to keep your skills current and also to improve your appeal as a candidate.
III. APPLY FOR A POSTGRADUATE TRAINING LICENSE
Before January 2020 IMGs needed to obtain a special Postgraduate Training Authorization Letter before being allowed to practice medicine or obtain a physician license in California. However, after reforms to medical training by the California legislature, this is no longer required. You will still need to obtain a Postgraduate Training License (PTL) to practice medicine while in residency.
You may only apply for a Physician’s and Surgeon’s Certificate after completing 36 months of training in a residency program accredited by the ACGME or similar organizations in Canada. Before you can obtain that license, you will need to have a PTL in order to practice medicine while in training.
Once you have received acceptance to a California residency program, you may apply for a PTL. You must obtain a PTL within 180 days of beginning your residency program, which will be valid for about 39 months (required 36 months plus 90 days during which you must obtain your physician license).
There is a substantial amount of documentation you will need to provide in connection
with your PTL application, including your ECFMG certification, USMLE exam scores, medical school records, fingerprints and a fee of $491. You will need to get fingerprinting done at a LiveScan site in California.
The Medical Board of California has a helpful checklist with thorough instructions. Ensure you read these closely and include all required documentation when submitting your application.
While you have the PTL, you may only practice medicine in connection with your residency program (as an intern or resident) or as otherwise authorized by the program director of your residency, such as to moonlight outside of your residency program.
IV. APPLY FOR A CALIFORNIA PHYSICIAN LICENSE
You can apply for the California Physician’s and Surgeon’s License after you have completed three years of graduate medical training through a residency program in California or another state. You must also have passed the last Medical Licensure Exam, the USMLE Step 3, which is explained in detail in the Tests section.
If you are in residency in California, you will need to complete a transition application to the Medical Board to transition from your PTL to an unlimited license. This will involve transferring your USMLE Step 3 score and a certificate of completion of 36 months of ACGME training.
If you completed your residency outside California, you will have to fill out a complete application for a Physician and Surgeon’s License online through the Department of Consumer Affairs BreEZe Online Services website. You should review the instructions and checklist carefully to ensure you include all required documentation. Many of the requirements are the same as for the PTL, but you will also need to a certificate of completion of your ACGME postgraduate training.
Tests
There are a number of exams you must take and pass to become licensed in California. The tests are called United States Medical Licensure Examinations (USMLE) and there are three tests you must take: Step 1, Step 2, and Step 3.
You will apply to take Steps 1 and 2 as part of your ECFMG Certification. You will take Step 3 after you have started your residency. All USMLEs are given at Prometric test centers in the U.S. and abroad.
USMLE Step 1
The USMLE Step 1 exam is a broad-based test that emphasizes the basic sciences used in medicine. Most U.S. medical school students take Step 1 in their second year of medical school and study intensely for it.
While you may not have had to return to these basic topics for many years, there are several reasons why you should take test preparation for Step 1 very seriously:
- Residency programs tend to use Step 1 scores as a predictor of performance in a residency program or specific specialty.
- Many residency programs have established a minimum score for the Step 1 and will not interview candidates with lower results.
Once you pass the Step 1 you cannot retake it, even if your score was lower than you desired.
USMLE Step 1 is an 8-hour, multiple-choice exam taken by computer. There are approximately 280 questions, some containing audio, and video references.
The exam looks at general medical principles across systems and also at processes within organ systems. Questions come from traditional and interdisciplinary areas.
Traditional medical disciplines:
- Anatomy
- Behavioral sciences
- Biochemistry
- Microbiology
- Pathology
- Pharmacology
- Physiology
Interdisciplinary subjects:
- Genetics
- Aging
- Immunology
- Nutrition
- Molecular biology
- Cell Biology
Fees: The Step 1 exam costs $975
USMLE Step 2
Step 2 used to consist of two different tests, Clinical Knowledge and Clinical Skills. Step 2 Clinical Skills was an in-person simulated practice exam, given at only five testing centers in the country. During the COVID-19 pandemic, Step 2 Clinical Skills was suspended due to public health measures. The USMLE announced in January 2021 that it would not resume Step 2 Clinical Skills.
The USMLE Step 2 Clinical Knowledge exam is a 9-hour long exam consisting of 318 multiple-choice questions given by computer. It assesses whether you can apply medical knowledge and understanding of clinical science that is necessary for providing patient care. It emphasizes health promotion and disease prevention.
The test looks at your knowledge in these content areas:
- Internal medicine
- Obstetrics and Gynecology
- Pediatrics
- Preventive medicine
- Psychiatry
- Surgery
- Other areas relevant to the provision of patient care
Most Step 2 CK exams describe clinical situations and require that you provide a diagnosis, prognosis, indication of underlying mechanisms of disease, and/or next steps in medical care.
Fees: The Step 2 CK exam costs $975
USMLE Step 3
The USMLE Step 3 is the final exam you will need to take before being eligible for your Physician License. Step 3 is administered by the Federation of State Medical Boards (FSMB). In some states, you cannot take Step 3 until you have completed one year of your residency; this is not the law in California, although many people still wait to take Step 3 after their first year. You cannot take Step 3 until you have passed Step 1 and Step 2.
The USMLE Step 3 exam is a two-day computer-based exam, which lasts 8 hours each day. The entire first day consists of 232 multiple-choice questions divided into six blocks of 38-39 questions.
The second day begins with 3 hours with 180 multiple-choice questions. The rest of the session is dedicated to 13 Clinical Case Simulations that last 10-20 minutes each. The simulations involve real-time patient care scenarios. The candidate must prescribe medications or procedures and the patient’s condition will evolve.
Fees: The Step 3 exam costs $895
TEST PREPARATION
The National Board of Medical Education (NBME) offers online self-assessments for the Step 1, Step 2, and Step 3 tests. There are also content outlines available for all USMLEs. There are also other companies that offer study programs. You should seriously consider taking a test preparation course if your self-assessments are weak. Investing early in preparation will save you money on retakes! Also, note that there is a 6-attempt limit on any USMLE Step or Step
Component, including incomplete attempts.
Time and Costs
Your progress through the licensing process will certainly be both long and expensive. Still, many factors will ultimately determine how long and costly your own process will be. Just some of these include:
- The completeness of your credentials and the speed of their collection and assessment.
- Your performance on all steps of the USMLE.
- How flexible you are about residency types and locations.
- Your efficiency and effectiveness in the residency search process.
- Your free time and how much money you have to spend.
Other Careers and Credentials
You may want to consider whether taking a transitional or entry-level job in healthcare in the short term can help you meet longer-term goals of licensing as an MD. Working in healthcare in a different capacity and with fewer responsibilities may offer you some advantages:
- Your employer may pay for some costs associated with licensing.
- You can focus more energy on studying.
- You will have a chance to adapt to the U.S. healthcare system and workplace culture in a lower-pressure environment.
- An opportunity to network with U.S. healthcare professionals, which may prove more useful when gathering Letters of Recommendation for your application.
You may immediately qualify for several hospital staff positions which require little or no additional training, such as Certified Nurse Assistant or Phlebotomy Technician. Some immigrant professionals find jobs as healthcare educators or use language skills as medical interpreters.
You should be honest with your employer about your long-term plans and be sure that they have benefits such as paying for your tuition or schedule flexibility that will support your goals.
Beyond Licensing
Complete Your Residency
The state of California allows you to receive a license after your first year of medical residency. At that time, you are able to practice general medicine without supervision. Of course, most doctors choose to complete their residency programs, but you also have the option of working unsupervised in your free time and may hold part-time jobs in clinics or other healthcare environments.
Joining a Professional Medical Association
State and national associations for physicians provide opportunities for professional development and networking. They also help set acceptable working conditions for the profession and give information and opinions on policy in California and across the U.S. Their websites may offer useful orientation to medical candidates about the licensing and examination process, including test preparation. They often provide Continuing Education to members as well.
Licensing Mobility
The state of California grants licensing to MDs either by examination (the process described in this topic), by acceptance of examination, or by endorsement. A physician must independently meet all California requirements for licensing. The national exams and the mobility of the resident experience do help make licensing in other states a relatively easy
process. If you become licensed in California and want to practice medicine in another state, you will need to research the legal requirements for that state.
Maintaining Your California License
Your California Physician License must be renewed every two years through the Medical Board of California. Your license will expire on the last day of your birthday month. You are responsible to renew your license even if you do not receive a notice from the Medical Board of California; you can renew online or through the mail. The cost to renew on time as of April 2021 was $808. Be careful: if you let your license expire, you will be fined and you may have disciplinary action taken against you.
Every time you renew your license you must state that you have met a 50-hour Continuing Medical Education requirement or CME. You need to keep the information on file in case you are audited. There are many opportunities to earn these hours, but special rules apply. You should check the Medical Board website for details or consider joining a professional association that offers CME opportunities to members.
Tips
Planning
You need a clear and realistic plan to succeed in becoming a licensed MD in the US; it is too difficult, long, expensive, and competitive a process to do inefficiently. Take the time to develop a strategy for issues such as:
- Finances: You will need significant savings, a loan, or a job that helps pay for the long process.
- Preparation: you will need to invest resources in test preparation to pass your examinations; for residency, you will have to prepare US-style marketing materials, perfect your interview and presentation skills, research your target programs, and prepare to participate in SOAP if you are not matched with a program.
- Network: you will need to rebuild a professional network. It can help to find work in a lower-ranking healthcare position in a hospital if you use the opportunity to actively identify mentors among specialists in your field and International Medical Graduates who have successfully licensed. These contacts can not only help you with advice but become sources of letters of recommendation for your residency process.
- Flexibility: you will be more likely to find a residency if you are flexible about geography, program quality, and specialty type.
Consider these final pieces of advice!
Pay Attention to Detail: all documents you submit either on paper or online are official: take your time to fill them out carefully and make sure your name and other information are used in exactly the same way on each document. Mistakes in these simple details are a common source of delays and complications in the licensing process.
Get Your Questions Answered: be your own advocate throughout the licensing process. Seek clarification about questions and concerns directly from official sources. Organize your questions and ask for assistance; email can be your most effective means of communication with the State and testing organizations.
Invest in Test Preparation: your ability to pass your exams in the first sitting can be a very important factor in your appeal during the residency process. The results from the USMLE Step 1 exam are often used by Graduate Medical Programs, as
predictors of general success or of performance in a specialty area. If you have 6 failures on any USMLE Step or Step Component, you will be ineligible to make another attempt.
Market Yourself American Style: being able to market yourself in a way that appeals to U.S. residency programs can play a deciding factor in your success. You may need outside guidance to assess what parts of your education and experience you should highlight, and how to present them and yourself to potential programs. You must learn how to overcome any cultural gaps and target your presentation to a U.S. audience. Many people, who are well-qualified, do not find a residency because they are unable to successfully prove their value over other candidates to residency programs. Consider this an opportunity not to play down your international experience, but rather to make it a selling factor in this process.
