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North Carolina Licensing Guides for Immigrant Physicians

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How the Profession is Organized in North Carolina

REGULATION OF MDS IN NORTH CAROLINA

The North Carolina Medical Board (Board) regulates the licensing and practice of physicians within the Commonwealth of North Carolina. Before you can apply for a license to practice medicine at the state level, however, there is a complex system of training and exams that applies at a national level to all medical graduates in the United States, including International Medical Graduates (IMGs), that you will need to complete.  A general overview of the process is outlined below and will be discussed in more detail in this guide. There are four pathways to licensure in North Carolina.  This guide will focus on Path One. Path One:  Application for a Full License (21 NCAC 32B .1303)
  1. Graduate from a medical school outside of the United States or Canada.
  2. Obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG).  This requirements for this certification will be discussed in more detail below.
  3. Take and pass Steps 1 and 2 of the United States Medical Licensure Examination (USMLE), both of which are also required for ECFMG certification.
  4. Complete two years of residency.
  5. Complete your profile with Federation Credentials Verification Service (FCVS) six months prior to submitting your application to the Board.
Path Two:  Expedited Application for a Full License (21 NCAC 32B .2001)
  1. Must have a specialty board-certification within the past 10 years, a full unrestricted license in the United States or Canada for at least five years, and been providing patient care for an average of at least 20 hours per week for at least two years.
Path Three:  Application for a Medical School Faculty License (21 NCAC 32B .1502)
  1. Limited one year licenses to practice medicine in an approved medical school in North Carolina.
Path Four: Application for a Volunteer License (21 NCAC 32B .1702)
  • Limited licenses to volunteer at indigent clinics for no more than 30 days per year.

EMPLOYMENT AS AN MD IN NORTH CAROLINA

It is difficult and costly for an IMG to become licensed in the United States, but you can be successful.  The American Medical Association reports that, in 2019, approximately 25% of practicing physicians in the United States were IMG physicians. According to the Bureau of Labor Statistics, physician salaries are some of the highest professional salaries in the United States.  For example, in 2020, the average wages for a family and general practitioner was around $214,370 per year, while the average wages for an anesthesiologist was around $271,440 per year. 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.  For example, if more people become insured and seek regular medical care, demand for physicians should increase. Many IMGs consider changing medical specialties in order to return to medical practice due to the competitive environment for securing residencies.  Choice of specialty can be influenced by a number of factors, including debt, an interest in “controllable lifestyle” specialties (e.g., with normal office hours), desirable geographic regions, or prestige programs.  U.S. medical graduates often have advantages in the competition for residency programs, including familiar medical schools, career services support, and recent graduation.  But certain specialties where there is high public demand—such as primary care specialties like family practice, internal medicine, and obstetrics and gynecology—may have more residency opportunities. One consideration for candidates planning to practice medicine in North Carolina is that North Carolina law limits the amount of money that can be recovered by a plaintiff from a doctor in certain medical malpractice actions.  In 2011, North Carolina limited the total recoverable amount of economic damages for negligence to $500,000. This amount adjusts for inflation every three years.  For example, the current limit is $562,338. This limit (“cap”) is seen by some as favorable to physicians, as it lowers their cost of doing business by controlling the cost of malpractice insurance, which can be very high in states without a cap.  But the cap is not without controversy, as some argue that the cap favors doctors and insurance companies at the expense of patients’ rights.  However, it should be noted that the cap does not apply to cases of disfigurement, loss of use of part of the body, permanent injury, or death.

Eligibility for License to Practice Medicine in North Carolina

This section explains the major steps for becoming licensed to practice medicine in North Carolina under Path One.  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.

CERTIFICATION BY ECFMG

The first step toward licensing is obtaining a certification from the Educational Commission for Foreign Medical Graduates, which will qualify you to compete for medical residency positions in U.S. teaching hospitals.  As of January 2023, 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 Federal for Medical Schools with a notation that it meets the requirements for ECFMG.  In the near future, to be eligible for ECFMG certification, your foreign medical school and program must be accredited by an accrediting agency recognized by either the World Federation for Medical Education or National Committee on Foreign Medical Education and Accreditation.  Starting in 2024, ECFMG will indicate which medical schools meet the new accreditation policy in the “Sponsor Notes” tab of the school’s listing in the World Directory of Medical Schools.

The Certification Process

  • To begin the process, register through the Interactive Web Application for a USMLE/ECFMG Identification Number and begin to build your profile.  Be very careful to enter accurate information, as changing your biographic information later in the process will require documentation and additional fees.
  • Submit a Certification of Identification Form (Form 186) which needs to be notarized using NotaryCam.
  • 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 in Section III of this guide, below.
  • Provide certain documentation related to your medical education credentials, including: a certification from your medical school that you are a graduate, a final medical school transcript, and your medical diploma.
  • Attain a satisfactory score on the Occupational English Test (OET) Medicine (minimum of 350 on the Listening, Reading, and Speaking sub-test, and a minimum score of 300 on the Writing sub-test, in one test administration).
  • Pass the clinical and communications skills requirement through one of the Pathways.
More information can be found in the ECFMG Information Booklet and the USMLE Bulletin of Information.

The Pathways

IMGs who wish to take part in the 2023 Match who need to meet the clinical and communication skills requirements for ECFMG Certification must apply to one of six Pathways.
  • Pathway 1 – Already Licensed to Practice Medicine in Another Country
  • Pathway 2 – Already Passed an Objective Structured Clinical Examination (OSCE) for Medical Licensure Administered by an Acceptable Medical School
  • Pathway 3 – Medical School Accredited by Agency Recognized by World Federation for Medical Education (WFME)
  • Pathway 4 – Medical School Accredited by Agency that Has Received a Determination of Comparability by National Committee on Foreign Medical Education and Accreditation (NCFMEA)
  • Pathway 5 – Medical School Issues Degree Jointly with a U.S. Medical School Accredited by Liaison Committee on Medical Education (LCME)
Pathway 6 – Evaluation of Clinical Patient Encounters by Licensed Physicians

RESIDENCY

After obtaining your ECFMG certification, the next step toward a medical license is completing a medical residency or fellowship, also known as a Graduate Medical Education (GME) program.  These programs are accredited by the Accrediting Council on Graduate Medical Education (ACMGE) 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.

Residency Strategy:  Competition and Presentation

Finding a residency requires careful strategy, organization, and initiative.  Graduates of U.S. medical schools benefit from access to established networks and familiar credentials.  Since you will be competing with U.S. graduates for the same residency programs, you should dedicate time to developing job search skills and to activities such 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 résumés or online profiles that emphasize your special skills and achievements; and
  • 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 also 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 (e.g., 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.  It can be broken down into the following steps, which will be discussed in more detail below:
  • Researching residency programs;
  • Compiling documents and applying to programs;
  • Interviewing by phone, virtually, and in-person with residency programs; and
  • Ranking of schools by candidates (and vice versa), resulting in a match.
“The Match” process generally follows the same timeline each year.
  • September:  Match “season” begins.  Candidates and programs accept participation terms, and applications and interviews occur.
  • Early-February:  Candidates and residency programs can begin to enter rankings for each other.
  • Early-March:  Rank lists close.
  • Mid-March:  Matches are announced on Match Day.
NOTE:  Some experienced foreign doctors who have developed relationships with hospitals or residency programs through personal or professional connections may be able to “pre-match” and avoid the general match process.  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.”  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.

Researching Residency Programs

You should begin researching residency programs well before match season begins in September.  You 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.  This guide assumes you are an IMG who already has permanent work authorization through permanent residency or refugee or asylum status.

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 September 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 ECFMG.  The ERAS support services through ECFMG involve fees for processing documents, 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 separately register for a match by opening an account with the National Resident Matching Program (NRMP), agreeing to its terms, and providing all required information. You will need to submit Letters of Recommendation (LoR) from physicians familiar with your clinical abilities, medical knowledge, and work ethic.  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.

Phone and In-Person Interviews with Residency Programs

Between September and early February, 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 accommodations.  If you are able, you should target at least 5 interviews.  When interviewing, think about how you will want to rank each program to optimize your chances of getting a successful match.

Rank 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 also 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 early March and NRMP utilizes an algorithm to match candidates to programs based on their rankings.  The algorithm prioritizes the candidate’s 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 will be many qualified candidates who do not receive a residency match.  There will also be 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 still 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 four rounds of offers on Thursday.  If you receive an offer, you will have two hours to respond.  You may receive multiple offers, 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.

Temporary License

Once you have accepted an offer to join a GME program for your residency, you will need to apply for a temporary license to practice medicine for the purposes of your residency.  If your residency is in North Carolina, you must apply for a resident’s training license from the Board of Medicine. You should apply for a resident training license immediately upon notification of appointment for postgraduate clinical training.  To apply, you will need to submit your completed application for a training license, the associated fee, and an original copy of your ECFMG certificate. More information on how to apply for the temporary license is available from the North Carolina Board of Medicine.

APPLY FOR A NORTH CAROLINA PHYSICIAN LICENSE

To practice medicine in North Carolina after your residency, you will need a full and unrestricted license.  You are eligible to apply for an unrestricted license in North Carolina after you have completed two years of your residency and have taken and passed USMLE Step 3. Applications for an unrestricted license are accepted exclusively online through the Board of Medicine.  The process takes an average of five months, so you will need to plan accordingly.  Once an application has been started, you will have 12 months to complete the application. More information on the application process, as well as a checklist of documents and information that will need to be submitted, is available from the Board of Medicine.

LIMITED PROFESSORIAL LICENSES

North Carolina issues renewable one year limited licenses to IMGs to practice medicine in an approved medical school or college in North Carolina as a professor or fellow.  To apply for a professorial license, you will need to submit evidence of authorization to practice medicine in a foreign country, ECFMG certification (or its equivalent), and a recommendation from the dean of the accredited medical school in North Carolina where you will be practicing in a limited capacity.

Tests

There are a number of tests that you must take in order to become licensed in North Carolina, known as the United States Medical Licensure Examinations (USMLE).  This sequence of tests includes Step 1, Step 2, and Step 3.

USMLE

Step 1

The USMLE Step 1 exam is a broad-based test that focuses on the basic sciences used in medicine.  The exam is an 8-hour exam taken on a computer, and it includes up to 280 multiple choice questions.  The exam covers general medical principles across systems, processes within organ systems, as well as physician tasks and competencies. 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 the basic topics covered in Step 1 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 Step 1 and will not interview candidates with lower results.
  • Once you pass Step 1, you cannot retake it, even if your score was lower than desired.
Note that USMLE Step 1 scoring transitions to reporting pass/fail outcomes only for tests taken on or after January 26, 2022.  Thus, if you took Step 1 on or after January 26, 2022, you will not receive both a numeric score and a pass/fail outcome.

Step 2

The USMLE Step 2 Clinical Knowledge (CK) exam assesses your ability to apply medical knowledge, skills, and understanding of clinical science to provide patient care.  The exam emphasizes health promotion and disease prevention.  The exam is a one-day examination administered over 9 hours on a computer.  It covers areas including medicine, surgery, pediatrics, obstetrics and gynecology, and psychiatry. Most Step 2 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.

Step 3

The USMLE Step 3 exam is the final exam you will need to take before being eligible for an unrestricted medical license.  The exam focuses on your ability to apply medical knowledge and understanding of biomedical and clinical science.  The exam is a two-day examination.  The first day focuses on 232 multiple choice questions, while the second day includes 180 multiple choice questions and 13 case simulations.  The simulations involve real-time patient care scenarios where the candidate will prescribed medications or procedures and the patient’s condition will evolve.

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 steps of the USMLE, and many companies 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!  Note that the total number of attempts allowed per Step is four.

OCCUPATIONAL ENGLISH TEST (OET) – MEDICINE

To meet the communication skills requirement for ECFMG Certification, you will need to take the OET Medicine test.  If you are taking the OET Medicine after April 1, 2022, you will need to obtain a minimum score of 350 on the Listening, Reading, and Speaking sub-tests, and a minimum score of 300 on the Writing sub-test, in one test administration. More information on the OET Medicine is available on the OET website.

Time and Costs

The licensing process is both long and expensive.  There are many factors that will determine how long and costly your own process will be.  They include, but are not limited to:
  • 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 lower-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.
  • More energy to focus on studying.
  • 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 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

COMPLETING YOUR RESIDENCY

North Carolina allows you to receive a license after two years of medical residency.  At that time, you are able to practice general medicine without supervision.  Most doctors choose to complete their residency programs, but you will 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.  Their websites may offer useful orientation about the licensing and examination process.  They often provide continuing education to members as well.

LICENSE MOBILITY

North Carolina grants licensing to MDs by examination (as described in this guide). A physician must independently meet all North Carolina requirements for licensing.  The national exams and the mobility of the resident experience help make licensing in other states a relatively easy process.  But if you become licensed in North Carolina and want to practice in another state, you will need to research the legal requirements for that other state.

MAINTAINING YOUR NORTH CAROLINA LICENSE

Licenses must be renewed within 30 days of the license holder’s birthday every year.  The North Carolina Department of Health Professions will send a License Renewal Notice approximately 60 days before your license is set to expire, so be certain to keep your contact information up-to-date.  If you let your license expire, you will have a much more complicated process to restore the license. Upon renewing your license for the first time, you will begin your first three-year continuing medical education (CME) cycle.  Every three years, you must state that you have met the 60-hour Continuing Education requirement.  You will need to keep the information on file in case you are audited.  There are many opportunities to earn these hours, and a variety of activities count.  You will need to research the exact requirements and distribution of hours.  Joining a professional association can give you access to professional development and keep you updated on this and other requirements for maintaining your license.

Tips

PLANNING

Becoming a licensed MD in the U.S. is a difficult, long, expensive, and competitive process.  You will need a clear and realistic plan to succeed.  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 this long process.
  • Preparation:  you will need to invest resources in test preparation to pass your examinations.  For residency, you will have to prepare U.S.-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 obtained U.S. licenses.  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.

COMPLETE CREDENTIALS

Invest the time and money early to get complete educational and professional credentials for your foreign degree evaluation process.  Follow up carefully with institutions where you studied and practiced medicine to ensure they send documents in the required format.

PAY ATTENTION TO DETAIL

All documents you submit either on paper or online are official.  Take your time to fill them out carefully.  For example, make sure your name and other information are used in exactly the same way on each document.  Mistakes in these types of 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 Board and testing organizations.

INVEST IN TEST PREPARATION

Your ability to pass your exams at the first sitting can be a very important factor in your appeal to residency programs.  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.  In addition, you can only take each of the Steps a maximum of four times.

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 cultural gaps and target your presentation to a U.S. audience.  Many well-qualified people do not find a residency because they are unable to successfully prove their value over other candidates to residency programs.  Consider this an opportunity to make your international experience a selling factor in this process.

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