How the Profession is Organized in D.C.
Regulation
As a physician educated outside the U.S., you will need to complete a number of steps in order to practice medicine in Washington, D.C. There are a number of organizations that regulate the practice of physicians in Washington, D.C.
The District of Columbia Board of Medicine regulates the licensing and practice of physicians within the District. However, there is a complex system of training and exams at the national level that you need to go through before you can apply for a license at the District level, which applies to all medical graduates in the U.S. The Educational Commission for Foreign Medical Graduates (ECFMG) certifies the qualifications of International Medical Graduates (also referred to as IMGs).
ECFMG certification is a requirement for IMGs to enter residency or fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME), take Step 3 of the three-step United States Medical Licensing Examination (USMLE), and obtain an unrestricted license to practice medicine in the U.S. ECFMG certification also requires you to satisfy certain examination requirements (medical science examination requirement, clinical skills requirement, and communication skills requirement), which are discussed in further detail later in this guide.
After certification, you will need to return to training and compete for a multi-year graduate medical education program (a “residency”) and specialization. Competing successfully may mean that you choose to relocate to a new state and adopt a specialization different than what you practiced before immigrating. The District’s Board of Medicine requires all applicants educated outside of the U.S. and Canada to complete three (3) years of postgraduate clinical training in a program accredited by the ACGME, the Licentiate of the Medical Council of Canada (LMCC), or American Osteopathic Association (AOA).
EMPLOYMENT AS AN MD IN WASHINGTON D.C
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 IMGs make up 25% of licensed U.S. doctors.
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 $200,000 are common in the District, while the best-paid specialties, such as anesthesiology, can easily pay $250,000 in the District. Often, though, medical school graduates have a huge amount of debt to repay (U.S. medical school can easily cost $55,000 per year!).
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.
Some states have laws that limit the amount of money you as a physician can be ordered to pay a patient if you are found liable for malpractice – of injury or loss caused by improper treatment. 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 District has no such cap on malpractice liability.
Eligibility for Licensing
This section explains 4 major steps that you need to complete before becoming licensed to practice medicine in Washington, D.C. They are:
I.Certification by ECFMG
II.Residency
III. Apply for Postgraduate Training License
IV.Apply for Washington, D.C. Physician License
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 section 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 the Foundation for Advancement of International Medical Education and Research.
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 Clinical Knowledge 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 CK, 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. 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 generally follows the same timeline:
- September 1: 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
- Early March: 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).
Steps
The match program can be broken down into 4 steps, which will be discussed in more detail below:
- Researching residency programs.
- Compiling documents and applying to programs.
- Phone and in-person interviews with residency programs.
- 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 September. 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 September 1 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. There are fees involved 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 open an account with the National Resident Matching Program (NRMP), agree to its terms, and provide all required information.
Fees: $85 standard NRMP registration fee, which includes the listing of up to 20 unique program codes on the primary rank order list and up to 20 unique program codes on all supplemental rank order lists combined. For each program code ranked over 20, NRMP charged an extra rank fee of $30 per program code up to the maximum of 300 ranks. For rank order lists with 100 or more ranks, certain additional charges apply.
You will need to submit Letters of Recommendation (LoR) from 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 about one page long 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 September 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. 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 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 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
All postgraduate physician residents practicing in District hospitals and their affiliated academic training institutions must apply to the D.C. Board of Medicine for a medical training license (MTL) prior to their program onsite start date. The MTL is a limited license and practice is solely limited to the training program institution listed on the application. It is issued for a maximum of one year. The MTL application is available here and provides a helpful document checklist indicating the supporting documents required by the D.C. Board of Medicine. There is a $100 fee associated with applying for an MTL. You must also mail a copy of your MTL application to your GME office, which will serve as the liaison between you and the D.C. Board of Medicine.
As a foreign medical school-trained physician who will be enrolled in a postgraduate clinical training residency program in the District, you will need a Type I(B) MTL. Prior to the beginning of each training year, you will need to submit documentation required for a MTL renewal application between March 1 and May 31 of the training year.
Medical residents who are rotating for less than 120 days in any of the academic training institutions in the District must complete the medical training registrant (MTR) form.
IV. APPLY FOR A WASHINGTON D.C. PHYSICIAN LICENSE
As of June 14, 2021, the District will no longer accept paper applications for a health professional license. Any person applying for a new health professional licenses, or to renew, reinstate, or reactive an existing license, must do so by submitting an online application.
There are five basic methods for becoming licensed to practice medicine in the District. They are:
- Examination. First attempt in D.C. to pass USMLE, Step 3.
- Re-examination. Second or subsequent attempt in D.C. to pass USMLE, Step 3. Note that after three failure in any jurisdiction of USMLE, Step 3, applications are required to complete an additional year of ACGME- or AOA- approved postgraduate training.
- License by exam. Successful completion of USMLE (Steps 1, 2, and 3); NBME or NBOME (Parts 1, 2, and 3), or FLEX (Components 1 and 2; or Components 1, 2, and 3 in a single sitting for pre-1985 examinees); the licensing examination that is administered by the Licentiate of the Medical Council of Canada; combinations of FLEX, NBME, and USMLE as specified in section 17 DCMR 4605.1-14 of the medical regulations; or passing a state-constructed examination that is judged by the Board of Medicine to be substantially equivalent to these requirements of the license law prior to June 30, 1979, and meet other requirements.
- Eminence 1. A foreign-trained physician, who is of recognized eminence and standing in a field of medicine or medical research in the international community and meets additional requirements as outlined in DCMR 4608.1; has practiced for at least 10 years; has successfully completed a two-year clinical training program in the U.S.; possesses a valid ECFMG certificate and a foreign license in good standing; and meets other requirements.
- Eminence 2. A foreign trained physician who has practiced at least ten (10) years; nominated by the Dean of an accredited school of medicine in District of Columbia, the Director of the National Institutes of Health or the Director of an accredited and licensed hospital in the District of Columbia; and meets other requirements. License is limited to practice of a specialty at the nominating institution.
Applicants educated in a foreign country must also have completed three years of postgraduate clinical training in a program accredited by the ACGME, LMCC, or AOA.
In addition to examination requirements, applicants must submit a character reference form, American Medical Association physician profile, and verification or certification of prior education and other documentation. You can find a helpful guide to the application and all of the required documentation here.
Tests
There are a number of exams you must take and pass to become fully licensed in Washington, D.C. The tests are called United States Medical Licensure Examinations (USMLE) and there are three tests you must take: Step 1, Step 2 CK, and Step 3.
You will apply to take Steps 1 and 2 CK 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 focuses on 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 up to 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
- Immunology
- Nutrition
- 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 (CS) was an in-person simulated practice exam, given at only five testing centers in the country. During the COVID-19 pandemic, Step 2 CS was suspended due to public health measures. The USMLE announced in January 2021 that it would not resume Step 2 Clinical Skills. In response to the suspension and subsequent discontinuation of Step 2 CS, ECFMG has offered Pathways to allow IMGs to meet the clinical skills requirement and the communication skills requirement for ECFMG certification.
The USMLE Step 2 Clinical Knowledge (CK) exam is a 9-hour long computer exam consisting of up to 318 multiple-choice questions. 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:
- Medicine
- Obstetrics and gynecology
- Pediatrics
- Psychiatry
- Surgery
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 licensure in the District. Step 3 is administered by the Federation of State Medical Boards (FSMB). To be eligible to take Step 3, you must first have passed Step 1 and Step 2 CK and obtained ECFMG certification.
The USMLE Step 3 exam is a two-day computer-based exam, which lasts 7-9 hours each day.
The entire first day consists of approximately 232 multiple-choice questions divided into six blocks of 38-39 questions.
The second day begins with 4.5 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 patient care scenarios in simulated time. 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 CK, and Step 3 tests. There are also content outlines available of all USMLEs. There are also other companies which 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 4 attempt limit on any USMLE Step, 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 lower level job in healthcare in the short-term can help you meet longer-term goals of licensing as a 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
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 the District 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
As noted above, the District of Columbia grants licensing to MDs either by examination or by eminence. A physician must independently meet all District 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 Washington, D.C. and want to practice medicine in another state, you will need to research the legal requirements for that state.
MAINTAINING YOUR WASHINGTON D.C LICENSE
Your Washington, D.C. Physician License must be renewed every two years through the D.C. Board of Medicine. You are responsible to renew your license even if you do not receive a notice from the D.C. Board of Medicine. As of June 14, 2021, renewals must be done online. Be careful: if you let your license expire, you will be fined, and if you let it expire for 5 years or more, then you will need to meet the requirements for obtaining an initial license in order to become licensed again.
Every time you renew your license you must state that you have met a 50-hour continuing education requirement over the prior two years. In Washington, D.C., this 50-hour requirement must include two hours in the subject of LGBTQ cultural competency and at least one course in pharmacology. In addition, effective January 1, 2021, the Board of Medicine requires all licensees to complete at least 10% of their required total continuing education hours in topics identified by the Director of the Department of Health as public health priorities. Thus, for physicians, at least five hours must be on such designated topics. 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 Board of Medicine website for details, or consider joining a professional association that offers continuing education opportunities to members.
Tips
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 IMGs 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.
And, 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 at 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 4 failures on any USMLE Step, 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.
