Medical students have faced innumerable challenges since the onset of the COVID-19 pandemic in March 2020, and international medical students (IMGs) have been greatly affected due to the unique circumstances of our journey to and through medical school.

In addition to enduring the transition to virtual anatomy labs, lecture halls and patient examinations, IMGs have also been faced with unprecedented delays in USMLE testing due to widespread Prometric testing center closures, a complex new system for ECFMG certification to participate in the 2021 Match, and an uncertain path through the first-ever completely virtual residency application season.

While there are many additional challenges facing IMGs during this tumultuous time, this blog post focuses mainly on the effects of the COVID-19 pandemic on testing and residency applications.

*All information is current at the time of writing (September 11, 2020) but is subject to change at any time. Please check the sites listed below under ‘Resources’ frequently for updates.

Prometric Testing Centers: Access Amid COVID-19

Prometric sites in the United States are currently operating on an individual basis in accordance with state and local laws and social distancing guidelines.

Testing has also resumed in many global test centers at either full or limited capacity based on local and government mandates. A list of open testing sites with opening dates that is updated daily Monday-Friday is available on the Prometric website, as well as a list of Prometric site closures. Prometric reserves the right to close sites with limited notice due to unforseen events such as extreme weather, natural disasters, and power outages.

COVID-19 Prometric Testing Limitations

Testing is only being administered for “essential services programs.” USMLE and NBME are included in this designation, which includes the following medical school exams: USMLE Step 1, USMLE Step 2 CK, and NBME shelf (subject) exams.

Testing candidates are reminded to wash and sanitize their hands frequently, wear a mask in the testing center at all times except when eating or drinking on breaks, avoid touching their eyes, nose and mouth, and to frequently review CDC and WHO best practice guidelines.

Check out our post on how to handle USMLE test day with PPE.

Of note, all cancellation and rescheduling fees that were previously waived due to COVID-19-related closures have now been reinstated where applicable by the testing program as of August 3, 2020.

USMLE “Event Testing” During COVID-19 and How this Effects IMGs

Due to the initial drastic reduction in Prometric testing spaces in the early months of the pandemic, the USMLE responded by creating a protocol known as “event testing” for the administration of Step 1 and Step 2 CK exams at U.S. medical school campuses.

After a period of initial controversy regarding the decision to administer a shortened version of this exam without experimental items, the USMLE decided to reverse this decision and stick to standard-length exams for all candidates, regardless of testing environment.

There have now been four “event testing” dates on July 30^th, August 13^th, August 27^th and September 10^th, with participation by 29, 38, and 63 medical schools for the first three respective dates (data from September 10^th date pending). This option is not currently available to IMGs.

The USMLE has decided to delay the implementation of a policy change to reduce allowable number of exam attempts on each Step component from six to four until at least July 1, 2021 due to reduced testing capacity.

However, they will be proceeding with scheduled changes to exam content as detailed below for each individual exam. Fees are currently waived for eligibility period extensions and testing region changes as of March 13, 2020 to ensure flexibility in scheduling during the pandemic.

COVID-19 Step 1 Testing for IMGs

IMGs currently completing their basic science curriculum probably have one important question about Step 1: when will the USMLE Step 1 exam become pass/fail?

This change has provoked significant anxiety in international medical students, as earning a high Step 1 score is a major way that IMGs can shine among their U.S. MD and DO counterparts when applying to competitive specialties.

After announcing this momentous decision months prior to the pandemic, the USMLE has decided that the switch to pass/fail scoring will occur no earlier than January 1, 2022 and will not affect students currently preparing to take the exam.

There are updated USMLE practice materials available for those testing on or after October 20, 2020 to reflect the previously announced content changes to Step 1, including an increased number of questions assessing communication and interpersonal skills.

Current score reporting should take place within four weeks of the testing administration date.

COVID-19 Step 2 CK Testing for IMGs

Similarly to Step 1, the USMLE has provided updated practice materials for those testing on or after November 11, 2020 to reflect previously announced content changes to Step 2 CK including an increased number of questions on systems-based practice, patient safety, legal/ethical issues, and professionalism.

Current score reporting should take place within four weeks of the testing administration date.

Of note, IMGs applying to residency this year should take Step 2 CK no later than the last week of September 2020 (the earlier the better!) to ensure that scores are submitted to ECFMG in time to be included on their ERAS application, which will be made available to residency programs on October 21, 2020.

Step 2 CS is Suspended Due to COVID-19

As of May 26, 2020, Step 2 CS is suspended until at least June 1, 2021, despite early efforts to create a virtual test-taking platform based on tele-health concepts.

The USMLE is using this time to plan a long-awaited “revitalization” of this clinical skills assessment by identifying the optimal approach and attempting to deliver a performance-based metric that meets the needs of the community, but this cannot take place until it is safe to resume this type of testing.

Students who took Step 2 CS prior to its suspension will have their score included on their USMLE transcript, including failed attempts.

International students who registered for the exam through ECFMG but were unable to test should have received a full refund of $1,580 USD by the end of August.

ECFMG Certification

The Educational Commission for Foreign Medical Graduates (ECFMG) facilitates the certification of international medical students prior to submitting an National Resident Matching Program (NRMP) Rank Order List to ensure that IMGs are ready to enter supervised residency training in accredited U.S. Graduate Medical Education (GME) programs.

This certification requires IMGs to pass Step 1, Step 2 CK, and Step 2 CS. However, due to the suspension of Step 2 CS imposed by the COVID-19 pandemic, ECFMG has created a novel “pathway” system in which applicants in the 2020-2021 Match cycle can demonstrate their clinical competency in other ways to satisfy this requirement without taking Step 2 CS.

Of note, these pathways do NOT apply to students who have already taken Step 2 CS – the exam results will be included on their USMLE transcript as it normally would, and these students may apply for certification without participating in a pathway.

The 5 Available ECFMG Pathways for the 2020-2021 Match cycle:

• Pathway 1: Already licensed to practice medicine in another country
• Pathway 2: Already passed a standardized clinical skills exam for medical licensure in another country
• Pathway 3: Medical school accredited by an agency recognized by the World Federation for Medical Education (WFME)
• Pathway 4: Medical school participates in U.S. Federal Student Loan Program [students from most major Caribbean medical schools (SGU, AUA, Ross, Saba, AUC) fall under this category – full eligibility list available here]
• Pathway 5: Medical school issues a degree jointly with a U.S. medical school accredited by the Liaison Committee on Medical Education (LCME)

Certification via these pathways will expire if the applicant does not enter a U.S. GME program accredited by the Accreditation Council for Graduate Medical Education (ACGME) for the 2021-2022 academic year, but if the applicant successfully completes the first year of ACGME-accredited training, the certificate is no longer subject to expiration.

Applicants in all pathways must take the Occupational English Test (OET), and those who pursue pathways 3, 4 and 5 must also complete a Clinical Skills Attestation through their medical school.

Occupational English Test (OET) for IMGs

The OET Medicine is designed specifically for physicians by assessing the language skills of healthcare professionals who wish to practice in an English-speaking environment. This is the only exam that meets ECFMG certification criteria, and all applicants must take it, regardless of citizenship or native language.

The exam costs 587 AUD, or roughly $425 USD depending on daily exchange rates. The OET is currently offered in 44 countries and 8 US states (CA, FL, IL, MA, NY, OH, OR, PA) with new dates and locations being added frequently, and while the exam website still advertises the possibility of an “OET@Home” testing platform tentatively scheduled to release in September 2020, remote proctoring from home has not yet been formally announced as an option.

Examinees must attain a minimum score of 350 (grade B) on each of the four exam components: listening, reading, writing and speaking. Free practice exams and other learning materials are available on the OET website. Exam results are generally available in 14 business days and applicants are expected to log in to the MyOET portal and add ECFMG as a “verifier” so that they have access to their results. If an applicant fails one or more sections, they must retake all four components in order to achieve the minimum required score on all of them in a single testing period, which may prove to be difficult due to the extremely limited availability of testing centers and dates. Students must take and pass all four sections of the OET by December 31, 2020 at the latest in order to be eligible for the 2021 Match cycle.

Clinical Skills Attestation

The Clinical Skills Attestation form must be completed by a medical school dean and received by ECFMG no later than January 31, 2021 in order to be eligible for ECFMG certification for the 2021 Match cycle.

By filling out this form, the medical school dean certifies that he or she has received three “Mini-Clinical Evaluation Exercise (Mini-CEX)” forms from the student, each filled out by a different clinical rotation faculty member who routinely evaluates medical students. The Mini-CEX form is a new tool designed to assess student performance of patient encounters, each lasting 10-20 minutes, one of which must be on the general medical hospital service.

Students will be graded on seven criteria:

• medical interviewing skills
• physical examination skills
• humanistic qualities and professionalism
• clinical judgement and reasoning
• communication skills
• organization/efficiency
• overall clinical competence on a scale of 1-9, with 1 being unsatisfactory and 9 being superior

There are also “fill-in-the-blank” spaces for “What went well?” and “What can be improved?”.

Applications for ECFMG certification are now open on the ECFMG website and must be submitted no later than December 31, 2020.

There is a notable new $900 fee (increased significantly from $135 in 2019) that is due at the time of application, which ECFMG states is due to the “significant work required to determine applicant eligibility, process applications, and verify the documentation required” in this unique application year. This $900 fee coupled with the $425 cost of the OET is about $255 cheaper than the cost of taking Step 2 CS.

The only available exceptions to the new pathway system are certain academic or employment pursuits that “significantly and substantively impacted the applicant’s timeline for pursuing ECFMG certification,” including enrollment in an advanced degree program in health care or a related degree (MPH, PhD), active participation in basic or clinical science-related research, or current employment as an advanced clinical care provider in a clinical setting in USA, or extraordinary circumstances outside applicant’s control, such as a serious medical condition or illness/death of family member, military service, or inability to obtain a visa to travel to the US to take Step 2 CS.

Applying for one of these exceptions is an arduous process requiring a great deal of paperwork for verification, along with a fee of $1,200 that will not be refunded even if the application for exemption is rejected.

IMGs, ERAS & NRMP Match 

As of September 1, 2020, applicants seeking residency positions in the 2021 Match may begin submitting applications to residency programs through the Electronic Residency Application Service (ERAS).

However, residency program directors do not have access to these applications until October 21, 2020 at 9:00 AM ET, which is also the date that Medical School Performance Evaluations (MSPEs) are distributed to programs.

All applications submitted between September 1^st and October 21^st at 9:00 AM ET will be marked as “Submitted on October 21^st at 9:00 AM ET,” and all applications submitted afterward will be date and timestamped, so it is best to certify and submit the application several days prior to that date to avoid any connectivity issues on October 21^st.

Match Week is still scheduled to take place on March 15-19, 2021, with NRMP main residency match results available to applicants on March 19^th, 2021 at 1:00 PM ET. The Supplemental Offer and Acceptance Program (SOAP) is scheduled to begin on March 15, 2020 at 11:00 AM ET, and an additional fourth round of the SOAP process has been added in anticipation of an increase in unmatched positions this year.

Per the 2020 NRMP Match statistics, of the 5,167 U.S. IMGs who submitted rank order lists of programs, 3,154 matched to a PGY-1 position for a match rate of 61% across all specialties, and of the 6,907 non-U.S. IMGs who submitted rank order lists, 4,222 matched to a PGY-1 position for a match rate of 61.1%. The PGY-1 match rates for U.S. citizen IMGs and non-U.S. citizen IMGs were the highest since 1991 and 1990, respectively.

The top three specialties for both U.S. and non-U.S. IMGs were internal medicine, family medicine, and pediatrics, with #4 and #5 spots going to psychiatry and emergency medicine for U.S. IMGs and neurology and pathology for non-U.S. IMGs, respectively.

IMGs who are successful in matching to their preferred specialty are more likely to rank more programs within that specialty, have higher USMLE Step 1 and 2 CK scores, and be U.S. citizens. In 2020, U.S. and non-U.S. IMGs together constituted more than two thirds (65.0%) of SOAP-eligible applicants. Compared with 2019, 487 fewer non-U.S. citizen IMGs and 239 fewer U.S. citizen IMGs were eligible for the SOAP.

While the challenges of taking a USMLE Step exam and applying to residency during a global pandemic may seem daunting, I don’t know a single group of people who work harder than international medical students.

We are determined, courageous, and dedicated to becoming the best physicians we can be, and I know that we will overcome any obstacles that this year has placed in our paths while growing as a human and a future physician in the process.

I wish you all the very best of luck in your medical school journey, and I look forward to seeing you all on the other side of the Match. In the meantime, please stay safe, wear a mask and wash your hands!

Resources

Association of American Medical Colleges (AAMC) ERAS 2021 Residency Timeline for IMGs: https://students-residents.aamc.org/applying-residency/article/eras-timeline-img-residency/

Educational Commission for Foreign Medical Graduates (ECFMG) Requirements for ECFMG Certification for 2021 Match: https://www.ecfmg.org/certification-requirements-2021-match/

National Resident Matching Program (NRMP) Charting Outcomes in the Match: International Medical Graduates: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/07/Charting-Outcomes-in-the-Match-2020_IMG_final.pdf

National Resident Matching Program (NRMP) Results and Data: 2020 Main Residency Match Report: https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/06/MM_Results_and-Data_2020-1.pdf

Occupational English Test (OET) for ECFMG Certification: https://www.occupationalenglishtest.org/l/ecfmg/

Prometric Testing Center Coronavirus Update: https://www.prometric.com/corona-virus-update

United States Medical Licensing Examination (USMLE) COVID-19 Announcements: https://covid.usmle.org/