In the April Issue of Visalaw’s Healthcare Immigration Newsletter, we published an article entitled “New ECFMG Rules Make Obtaining J Visas More Difficult”. The article criticized ECFMG policies that have had the effect of reducing the number of J-1s issued to foreign medical graduates (FMGs) by more than 25% over the last three years.

Some policies, like imposing the Clinical Skills Assessment (CSA) exam, have been particularly tough on the FMG community. The exam fee of $1200 is extremely expensive, and doctors can expect to pay several thousand more dollars just to get to the US to take the exam. Readers will recall our previous reports about the not infrequent denials of visas to doctors seeking to enter the US to take the CSA exam.

ECFMG has recently responded to our article in the letter published below:  

Dear Mr. Siskind and Ms. Ballentine:

We read your recent article "New ECFMG Rules Make Obtaining J Visas More Difficult," and offer the following clarifying comments.

Through its program of certification, ECFMG assesses the readiness of international medical graduates (IMGs) to enter the US system of graduate medical education. The ACGME requires ECFMG certification as a prerequisite to an IMG’s participation in an ACGME-accredited program. This certification requirement is not unique to the J-1 physician. It applies to all international medical graduates, including US citizens, US legal permanent residents, and foreign nationals. The current requirements for ECFMG certification include the primary source verification of the graduate’s medical school diploma credential, passing Steps 1 and 2 of the United States Medical Licensing Examination  (USMLE™), the ECFMG Clinical Skills Assessment (CSA®), and TOEFL.

ECFMG implemented the CSA as an additional examination requirement for ECFMG certification on July 1, 1998.  The purpose of CSA is to ensure that IMGs demonstrate the ability to gather and interpret clinical patient data and communicate effectively at a level comparable to a standard reasonably expected of students graduating from accredited US medical schools.  The incorporation of CSA as an additional requirement for all individuals seeking  ECFMG certification helps ensure that such individuals possess the necessary basic clinical skills for entry into supervised graduate medical education in the US.  Through March 2002, ECFMG has tested  over 24,000 CSA examinees.  It is worth noting that the number of CSA examinees in 2002 represented an 18% increase over CSA examinees in 2001.  We note your comments regarding visa denials.  Visa denials are also of interest to us, and we track visa denials of individuals seeking to take CSA.  From September 11, 2001 through mid-March 2002, we received reports of visa denials for 39 individuals (this compared to 31 denials for the same period in the previous year).

The J-1 regulations name ECFMG as the sole sponsor of J-1 exchange visitor physicians in clinical training. As with all designated J programs, ECFMG must adhere to the US Department of State’s (DOS) guidelines regarding program administration.  ECFMG does not, as your article suggests, “make the rules.”  The current discussion regarding J-1 sponsorship eligibility for highly specialized training programs for which ACGME-accreditation is not available represents an ongoing dialogue between DOS and the graduate medical education community, with ECFMG acting as a facilitator.

As announced on the ECFMG website, DOS has confirmed that ECFMG shall be permitted to continue to sponsor individuals in clinical fellowships in recognized subspecialties that are directly associated with an ACGME-accredited residency or fellowship, but not independently accredited by ACGME through June 30, 2003. Additionally, DOS has clarified that ECFMG may continue to sponsor individuals in a subspecialty that is recognized by the appropriate Specialty Board of the American Board of Medical Specialties (as evidenced by a letter from the Executive Director of the appropriate Specialty Board), even if that subspecialty is not accredited by ACGME.

Finally, you may be interested in trend data regarding ECFMG certification and USMLE takers. As with CSA examinees, the number registering for USMLE and obtaining ECFMG certification increased in 2001. The number of individuals certified by ECFMG in 2001 increased by 15% over 2000. The number of ECFMG registrants in 2001 increased by 8% over 2000.

Thank you for this opportunity to provide this additional information regarding these important issues.

Sincerely, 

Eleanor M. Fitzpatrick, M.A.

Manager, Exchange Visitor Sponsorship Program

Educational Commission for Foreign Medical Graduates

With all due respect to Ms. Fitzpatrick, the letter fails to address the basic truth that the number of J-1 physicians admitted to the US has dropped dramatically in the last three years and the only logical explanation is that changes in the ECFMG certification process is the cause.  The drop has coincided exactly with the implementation of the CSA exam. While ECFMG is only aware of 39 visa denials for doctors, they really have no way to know how many applications were really denied. The State Department does not keep track of this data and the 39 cases of which ECFMG is aware could be just the tip of the iceberg.

Ms. Fitzpatrick’s letter also fails to address our article’s chief criticism of the CSA – the tremendous costs to the doctor and that the exam is deterring many doctors from even applying for the J-1. While it is encouraging that more doctors are taking the exam, one has to ask the fundamental question of whether American health care is really better off with the CSA. The exam may be directly responsible for a substantial drop in the number of medical residents serving in US hospitals especially in inner city areas where health care professional shortages are already severe. The pool of J-1 doctors available to serve rural communities with doctor shortages is also shrinking as a result of the CSA. Did residency programs really do such a poor job of screening doctors for J-1 sponsorship before the CSA? The reality is that American residency programs have been able to choose from a pool of the world’s top medical graduates, and if there is evidence that residency programs have chosen poorly, then the ECFMG should reveal its hand.

The fact of the matter is that the ECFMG DOES make the rules with respect to foreign physicians. Its actions have had a dramatic impact on the number of J-1 physicians coming to the US, and this point is not denied in ECMFG’s letter. The ECFMG plays a role as large in the process as a government agency. To pretend that ECFMG just follows what others mandate does not do a service to anyone.

For readers who did not see the original article, we reprint it below:

New ECFMG Rules Make Obtaining J Visas More Difficult 

by Greg Siskind and Amy Ballentine

Foreign physicians have been in the news a good deal lately because of the termination of the US Department of Agriculture J-1 visa waiver program. While this decision has received substantial publicity, it is not the only one to have a negative impact on international medical graduates.

The Educational Commission on Foreign Medical Graduates (ECFMG), which is the only organization that can sponsor a foreign medical graduate seeking clinical training in the US on a J-1 visa, has, over the past few years, made a number of changes that seem to be resulting in a decrease in the number of international medical residents. International medical graduates make up about 25 percent of medical residents in US training programs because there are not enough graduates of US medical schools to fill all the available residency slots. For years, foreign students were recruited to fill these slots, but recent changes seem to indicate that many would rather the slots go unfilled. 

In 1998, the ECFMG began requiring international medical graduates to pass an English language test and a clinical skills assessment before being eligible for a J-1 visa. Because the clinical skills assessment is offered only in Philadelphia, Pennsylvania, it is difficult for many to take it. Not only is there the trouble and expense of coming to the US for it, but also many people have reported having their application for a visa denied, leaving them unable to come to the US for the test. Also, the fee to take the test is $1,200, which means many are simply not able to afford it. The implementation of this requirement led to a drop of about 20 percent in the number of J-1 visas issued to foreign medical graduates. 

Now another change may make J-1 visas even less attractive. At the end of February, the ECFMG announced that it would no longer sponsor visas for people seeking clinical training in programs that are not accredited by the Accreditation Council for Graduate Medical Education. These programs, often referred to as “non-standard” programs, are directly associated with accredited programs, but because they involve cutting edge techniques and treatments, have not yet themselves been accredited. 

According to the ECFMG, the State Department indicates that the Department of Health and Human Services maintains that the J-1 program is for use only for training in an accredited program. However, there are two factors that make this decision not as negative as it could be. First, ECFMG will be allowed to continue sponsoring international medical graduates for nonaccredited programs until June 30, 2003. Second, ECFMG maintains that it can sponsor a student for a J-1 visa for study in a nonaccredited program so long as the program is in a subspecialty recognized by the appropriate Specialty Board of the American Board of Medical Specialties. 

ECFMG is also in the process of convening a meeting with a number of medical organizations for further discussion of this topic so that it can present recommendations on the issue to the Department of Health and Human Services. 

Many observers and advocates are concerned that the Department of Health and Human Services will not change its mind on this issue, and that opportunities for international medical graduates to obtain training in cutting edge medicine will be severely limited.