New Hampshire Licensing Guides for Immigrant Physical Therapists

Eligibility For Licensing: Process And Timeline

This section explains 4 major steps that you need to complete before becoming licensed to practice medicine in New Hampshire.

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. – IV.).

I. Certification by the Educational Commission for Foreign Medical Graduates, or ECFMG

The Educational Commission for Foreign Medical Graduates or ECFMG is the organization that certifies International Medical Graduates and qualifies you to compete for medical Residency positions in U.S. teaching hospitals. For you to enter the certification program, your foreign medical school and its program at the time of your graduation must be listed in a special directory managed by the Foundation for Advancement of International Medical Education and Research: the International Medical Education Directory. “https://imed.faimer.org/”

The ECFMG Certification process

• Your contact with the ECFMG Certification process starts when you register for a USMLE/ECFMG Identification Number and begin to build your profile. Be very careful to give accurate information from the beginning; if you need to fix any errors later in the process it will require documentation and can be expensive.
• ECFMG will not process any information until you submit an application for one of the United States Medical Licensure Exams (USMLE): either the Step 1 or the Step 2 Clinical Knowledge exam, or both. At this point you should also submit your medical credentials.
• Your file will grow to include test results and all required documentation. You need to meet all testing and documentation requirements to be approved for certification.

ECFMG offers these services through paper forms or an online system. The online system includes full application services in its Interactive Web Application (IWA). Another important online tool is the On-line Applicant Status and Information System (OASIS), which helps you collect important details about your profile and track the status of applications and test results.

Here are a few highlights of the required documentation and testing you will complete before receiving ECFMG Certification (this is not a complete list):

Medical education credentials:

• A certification statement or certification identification form from your medical school
• Final medical school transcript, including any transfer courses
• Medical diploma

Examinations:

• USMLE Step 1
• USMLE Step 2: this is a test taken in 2 parts, Clinical Knowledge and Clinical Skills (called “CK” and “CS”, respectively)
• Note: passing the TOEFL is no longer a requirement for Certification

Exam fees: $790 for Step 1, $790 for Step 2 CK, about $1,375 for Step 2 CS. Fees to prepare credentials vary.

Proof of Certification

ECFMG has a Certification Verification Service that you will use to send proof of your Certification to both medical licensing authorities and hospitals where you apply for Residency. Fee: $35

For more information, links to ECFMG and other websites can be found in the “Important Links” section at the end of this page. Testing information will be covered in more detail in the next topic: Tests (Section 4).

II. Register with the Federation Credentials Verification Service (FCVS)

The Office of the Professions requires all IMGs to register with the Federation Credentials Verification Service (FCVS.) The FCVS was created by the Federation of State Medical Boards (FSMB) to provide a centralized and uniform process for all state medical boards in the United States to obtain verified, primary source records of physicians’ core medical credentials obtained in the U.S. or abroad. The FSMB is a trusted source and guarantees your information will remain secure and confidential.

You have the option to fill out the application form online or send it in by mail. If you submit a hard copy and do not apply online, an extra fee of $50 will apply. On the application you will need to provide the FCVS with detailed information and photocopies of your personal information, medical education, clinical clerkships, postgraduate training, examination history, ECFMG Certification, and more. The FCVS will then contact the sources where you obtained your records and by such means verify your credentials. It is important that you do not try to obtain transcripts from third parties yourself. These will not be accepted by the FCVS. The FCVS will obtain the documentations regarding your credentials directly from the third parties.

The advantage of using FCVS is that once your credentials have been verified you will have a permanent lifetime record of all your core credentials, which on your request can be forwarded to any beneficiary. The FCVS charges a fee of $325 for the initial request, and $65 for additional requests. These fees are subject to change and surcharges may also apply. When you apply for your New Hampshire Physician License you will make such a request to be sent to the New Hampshire State Board of Medicine.

The application process for FCVS can be found online at www.fsmb.org.

III. Find and Complete a Post Graduate Medical Training/Residency

Now that you are certified with the ECFMG and have started your FCVS profile, finding a Post Graduate Medical Training Program (usually called Residency) is your next step.

For New Hampshire, you must apply for a New Hampshire Residency License ($50.00), which allows you to work under supervision in Post Graduate Medical Training/Residency.

For International Medical Graduates, the biggest obstacle to becoming a licensed physician in the U.S. can be to find a medical Residency program, also known as a Graduate Medical Education (GME) program. These programs are accredited by the Accrediting Council on Graduate Medical Education and vary in length from 3 to 7 years depending on the specialty. Occasionally hospitals will accept IMGs as second-year residents, however these are rare cases and you should be prepared to start at the beginning and go through a full program. Most Residencies are based at hospitals and affiliated with a medical school – but not necessarily located together.

New Hampshire has a small number of Residency training programs at Dartmouth Hitchcock Medical Center or Concord Hospital

Once you have accepted an offer to join a Graduate Medical Education Program for your Residency you may have to acquire a limited permit to practice medicine for the purpose of your Residency. In New Hampshire this is called a Residency License. Your new Residency program will inform you of their Residency License requirements.

Residency Strategy, Competition and Presentation

Finding a Residency requires careful strategy, organization, and initiative. You need to develop U.S. style job search and presentation skills in order to compete at the same level as graduates of U.S. medical schools, who benefit from more established networks and familiar credentials.

You should dedicate time 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.

You will also increase your chances if you are flexible about both the residential specialties and locations you will accept. You are more likely to find Residency programs:

• In medically underserved areas (rural and/or economically-depressed areas),
• In lower-earning specialties, and
• In specialties with more demanding work hours

The Residency search process Part I: Pre-Match

If you have developed a special relationship with a Residency program through private or professional connections, you may be lucky enough to receive a Residency offer without having to compete in the standard process described in Part II: Matching.

This is a rare occurrence. However, some experienced foreign doctors may be in this position due to international cooperation over their careers or careful networking after resettling in the U.S.

You can look for a pre-match placement while also participating in the matching process (Part II), but you must withdraw from the match program before its deadline (when rank lists close). If you do not, you could be responsible to more than one Residency program and will have violated match rules. If you think a pre-match is likely, make sure to get documentation of the offer before the matching deadline.

The Residency search process Part II: Match

Matching is the process most medical school graduates go through to find a Residency program. There were about 26,392 first-year (PGY1) Residency positions available through the match in 2013. Since the 1980’s there has been a trend of more applicants than of positions offered through the match.

You will need to use two services in the Match process: the Electronic Residency Application Service (ERAS) to make applications, and the National Resident Matching Program (NRMP) to collect feedback from you and the programs you visit and turn it into a binding Match agreement for your Residency placement.

This annual process has a timeframe that is similar from year to year, however, you will need to confirm actual dates.

• 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

It can be broken down into 4 steps (a. – d.), which will be discussed in more detail below:

a. Researching Residency programs.

b. Compiling documents and applying to programs.

c. Interviewing with Residency programs.

d. Ranking of programs by candidates, and vice-versa, resulting in a match.

a. Researching Residency programs

You should begin this stage 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. Apply to as many as desired and remember you must travel to the interview and move to attend the Residency. Therefore, apply only to programs you would be interested in attending as you will be obligated to those you are matched with.

You can gather information in many ways, including:

• Networking in-person or online
• 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 residence or refugee or asylee status.
• Searching for official information on Residency programs
• FREIDA online is a searchable 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

b. Compiling documents and applying 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: $70 per Match season for ERAS and $50 for NRMP

Among the documents you will need to submit are 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. All programs have a maximum of 4 LoRs. You can get different LoRs for your application for various specialties, which means that you can make your application more personalized for each specialty. This can help you be more competitive when applying for a specialty different than the one you practiced in your home country. 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 assets 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.

By now, you should have taken the time to develop U.S.-style materials that market your education and experience. You should be comfortable talking about this information and providing clear examples of your skills based on your work and education history.

c. Interviewing with Residency Programs

You may be contacted by Residency programs for phone screenings or in-person interviews. Prepare yourself for these interactions because they are critical to your success. You should also have money saved for this purpose, because candidates for Residency normally pay their own expenses when visiting for in-person interviews. The typical U.S. medical school graduate will go on more than five interviews; if you are able, you should target more. Be sure to include a range of programs, not only your top choices, to improve your chances of a match.

d. Ranking of schools by candidates, and vice-versa, resulting in a match

When you have completed interviews and visits to Residency programs, you must rank your choices in the NRMP system. Residency programs will do the same, ranking their candidates in order of preference. 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 applies a software program to the ranked preferences. The resulting matches are announced during Match Week in mid-March.

The Residency search process part III: 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 system. This means that there are many candidates who do not receive a Residency match; there are also many Residency program openings that remain unfilled.

If you do not get a match when the first matches are announced, then you will still have a chance to find a match through what is now called the Match Week Supplemental Offer and Acceptance Program (SOAP – previously referred to as “scrambling”). During this first week, 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 unmatched positions. You will need to apply through ERAS to unmatched programs. Then, the programs will review the applicants and make offers. You will receive more than one offer during this week, but you may only say yes to one. Details for the process are below. This process has replaced “Scramble” and took effect in 2012.

All match applicants will receive notification from NRMP on the Friday before Match Week at 12 p.m. Eastern Standard Time (EST) indicating eligibility for SOAP. Unmatched candidates who qualify for SOAP will be given a list of unfilled programs at 12 p.m. EST on Monday of Match Week. You will then be able to apply for unfilled positions starting 2 p.m. EST on Monday of Match Week through ERAS. During this week, unfilled programs and unmatched candidates can communicate via ERAS. However, no match offers or agreements can be made until 12 p.m. EST on Wednesday of Match Week. Unfilled programs will be given seven opportunities over the next three days to offer matches to candidates. When an offer is made, candidates have just two hours to respond.

The process works as follows:

In each round, programs rank the candidates and give Residency slot offers to their top candidates. As the rounds continue, programs continue to offer spots to the remaining candidates in order of their preference for candidates. Candidates may receive more than one offer during SOAP. These offers are sent at 3 p.m. Wednesday, 9 a.m., 12 p.m. and 3 p.m. EST on both Thursday and Friday, for a total of seven rounds. SOAP concludes at 5 p.m. EST on Friday of Match Week. All placements are finalized by 5 p.m. EST on Friday of Match Week.

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.

Residency, Year One

Once you have accepted an offer to join a Graduate Medical Education Program for your Residency you may have to acquire a limited permit to practice medicine for the purpose of your Residency. In New Hampshire this is called a Residency License. Please check with the hospital in question to find out what their Residency requirements are.

The New Hampshire State Board of Medicine will accredit your Residency, if it is approved by the Accreditation Council for Graduate Medical Education (ACGME) and if it meets the minimum length of 2 years. If you decide to do your Residency in another state, make sure you research specific state or individual hospital requirements to practice during your Residency. You need to make sure you obtain the necessary authorization of the hospital and state in which you wish to practice your Residency.

IV. Take Exam and Apply for a New Hampshire Physician License
Once in the 1st year of Residency in New Hampshire, you may apply for the Exam. Examination candidates who wish to take USMLE Step 3 in New Hampshire shall apply directly to the Federation of State Medical Boards (FSMB).

Candidates for USMLE Step 3 shall:

• Have graduated from a medical school accredited by the LCME or have completed their medical education from an institution located outside the United States and have such studies confirmed by the ECFMG;
• Have begun the first academic year of postgraduate medical training at an institution accredited by the ACGME, the Royal College of Physicians and Surgeons of Canada (RCPSC) or the American Osteopathic Association (AOA); and
• Have passed USMLE Step 1, 2 (CK) and Step 2 (CS) or one of the acceptable combinations of examinations noted in Med 303.01(b). See website: http://www.gencourt.state.nh.us/rules/state_agencies/med100-600.html

Requirements for the NH State Physician License:

• Education: The NHSBM will assess whether your international medical education meets the requirements set by them. One of these requirements is that you must have completed at least 2 years of college prior to entering medical school.
• Examinations: To receive your license you need to have completed all 3 Steps of the USMLE examinations and be ECFMG certified. More information about these examinations will be provided in “Tests” Section 4.
• Experience: The NHSBM requires all IMGs to successfully complete a minimum of 2 years of postgraduate medical training (usually called Residency) in any U.S. State.
• Registration with FCVS: To receive your license, your completed FCVS Physician’s Information Profile needs to be forwarded to the New Hampshire State Board of Medicine (NHSBM) to show that your medical credentials are verified.

It is important to time your application well in accordance with the examination schedule provided by the Federation of State Medical Board (FSMB). The FSMB oversees the USMLE Step 3 exam and you will have to register with them at www.fsmb.org to partake in this examination. You will need to file the physician’s license application form with the New Hampshire State Board of Medicine at least 3 months before you wish to take the exam. Be sure to check any registration deadlines that may apply on the FSMB website. When you have registered with the FSMB you receive your Scheduling Permit for USMLE Step 3 that you will then use to schedule an appointment with Prometric. You will find links to these services in “Links” Section 9.

Summary of how to apply for the USMLE Step 3 examination:

1. Register for the USMLE Step 3 exam with the FSMB.
2. Schedule an appointment to sit the exam with Prometric.

Similar to the Step 1 and 2 exams, you will need biometric information to identify yourself during the Step 3 exam. This is part of the Biometric Identity Management System program (BIMS). All the USMLE exams use biometrics as part of the test procedures. During the exam it is common that you will be asked to provide your fingerprint during check-in, breaks and check-out for identification purposes. Go to the BIMS website for further details. See “Important Links” Section 9.

Once your application is approved, you will have a 105-day eligibility period to take the examination. 90-day extensions are commonly granted if an eligibility extension request form is filed with the FSMB no later than ten days after the 105-day eligibility period expires. The extension fee is $65. For further details, consult the USMLE section of the Federation website.

How to apply for your NH State Physician’s License Application:

• Go to the NHSBM website: http://www.nh.gov/medicine/physicians/
• Click on the “New online application process for medical and osteopathic physicians link and follow the instructions for completing the application online. The New Hampshire application fee is $300.
• You must also complete the FVCS.

If you wish to have a paper application, you must submit a request to the NHSBM in writing. You must still complete the FVCS online.

Notify the FCVS and Office of the Professions once you have completed your Residency and have passed the Step 3 examination to finalize your application and obtain the physician’s license. To do so, fill out the Examination and Board Action History Report Form on the FSMB website, and the FSMB will then forward a certification of your exam results directly to the NHSBM.