Ecfmg faqs Frequently Asked Questions by amsa international Member Caucus to the Educational Commission for Foreign Medical Graduates

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Frequently Asked Questions by AMSA International Member Caucus to the Educational Commission for Foreign Medical Graduates
Conducted by Greg Lakin, AMSA International Trustee and ECFMG Liaison, 2001-2002


AMSA QUESTION I: Test of English as Foreign Language (TOEFL)

A. Can ECFMG accept transcripts from an English speaking undergraduate university in lieu of taking the TOEFL?

B. If not, is there another form of documentation students can send ECFMG to waive the requirement of taking the TOEFL exam for U.S. citizens and legal permanent residents who speak and write English as their primary language, instead paying $140 to take a test of English as a foreign language, when English is the primary language of many of the test takers?

C. Could the TOEFL be replaced for native English speakers by the CSA which could also be used as a test of English proficiency?

The Test of English as a Foreign Language (TOEFL) is a prerequisite for all candidates prior to applying for CSA, as well as a requirement for ultimate ECFMG certification. Attempting to waive this requirement for native English speakers or for individuals attending medical schools in which instruction is in English could lead to a number of difficult situations in terms of defining and documenting the reasons for the waiver, and applying them fairly. Hence, our position at this time is that the only way to ensure fairness for all candidates is to maintain the same requirements for all candidates.

Spoken English proficiency is also formally tested and scored in the course of CSA. We are currently studying correlations between that assessment of English and TOEFL scores.

AMSA QUESTION II: Financial concerns

A. USMLE fee discrepancy: Why are the ECFMG USMLE Step1 and Step 2 registration fees more costly compared to FSMB USMLE fees ($615 vs $385) even if taking exam in U.S.?

B. Can the ECFMG do anything about the multiple expenses which are becoming a financial hardship to students?

  1. $40 to accept TOEFL scores

  2. Approximately $90 to be in the Match

  3. $45 to have ECFMG forward USMLE scores to a non-ERAS residency program

The fee for the USMLE Step exam is composed of two parts. The first part is for the administration of the Step and goes directly to the National Board of Medical Examiners which produces the examination. The second component of the fee is retained by ECFMG and covers a number of services over and beyond administration of the Step. These include application processing and determination of eligibility, which involves verification of an applicant's status with the medical school before each Step administration. After determining eligibility, the ECFMG registers the applicant with the National Board of Medical Examiners. The ECFMG also reports scores to examinees. To complete the certification process, direct verification of a candidate's medical school diploma must be obtained. ECFMG also thoroughly investigates falsification of applications, score reports, diplomas and ECFMG certificates. ECFMG incurs the costs for all these activities, which involves multiple and worldwide communications.

It should be noted that ECFMG has increased its portion of the fee only once in the past five years in the amount of $10 to absorb the added operating expenses of accepting credit cards and e-checks related to ECFMG's new web-based application process.

The TOEFL fee is charged to evaluate an applicant's TOEFL score received from the Educational Testing Service to ascertain if the score derived is in accordance with the ECFMG's standards. The fee for the reporting of USMLE scores to residency programs covers the cost of researching and preparing the report. Since there is a dedicated resource set aside to perform these two services, there is a cost to ECFMG that must be passed on to the users of the services. Generally it is ECFMG's practice, where cost of service is identifiable, to charge an appropriate fee to the users of the service rather than include it in another fee such as the Step fee.

With respect to the $90 fee to participate in the National Resident Matching Program (NRMP), this fee is totally unrelated to ECFMG's operations, and thus, ECFMG has no control or input as to the amount of the NRMP match fee.

AMSA QUESTIONS III-IV: Number of CSA testing sites / ECFMG Clinical Skills Assessment (CSA) and NBME Standardized Patient (SP) Exam

III. A. Is the ECFMG planning to increase the number of CSA testing sites? At the current time there is only one testing site in Philadelphia which would minimize transportation costs for students

IV. ECFMG Clinical Skills Assessment (CSA) and NBME Standardized Patient (SP) Exam

A. IMGs take the CSA for ECFMG certification.

B. The U.S. med students, beginning with 2005 graduates, may have to take the NBME's SP exam at 5-7 testing sites for $1000 fee for licensure.

C. Does the ECFMG expect the NBME's SP exam will have any effect on IMGs taking the CSA?

D. Will IMGs be able to take the CSA at testing sites where the SP exam will be offered?

E. Will the CSA be replaced by the SP exam for ECFMG certification?

Plans for the expansion of testing facilities for CSA are very much linked to the ongoing collaboration with the National Board of Medical Examiners (NBME) in moving toward the establishment of a single clinical skills examination as part of the USMLE series and required of all students, both U.S. and IMGs within the next two to three years. As part of that plan, five or more regional test centers would be opened throughout the United States. All candidates would have access to all centers so that U.S. students and IMGs would not only be taking the same examination, but would be doing so side by side in centers throughout the United States.

It would seem prudent to wait until those centers are operational and assess what impact their locations might have on access by IMGs before moving ahead with plans for any additional international test centers.

AMSA QUESTION V: Time to process CSA

A. Why does it take as long as 4 weeks to complete the registration process for the CSA?

B. Is there any way to decrease the registration process time?

The stated time period for processing of CSA applications is four weeks. On many occasions, however, we process CSA applications in a shorter period. For example, currently we are processing CSA applications in approximately 20 calendar days.

The prime reason that a CSA application is rejected is because ECFMG has not received a TOEFL score. TOEFL along with USMLE Step 1 are examination prerequisites for applying for CSA. In order to accommodate CSA applicants, we will hold a CSA application lacking TOEFL for three weeks to allow the TOEFL score to "catch up" with the application. This benefits CSA applicants because we often receive the TOEFL score during this three week period, and we are able to register the applicant rather than reject the application for lack of TOEFL.

AMSA QUESTION VI: Communication

A. Is it possible for the ECFMG to invest in a toll free 800 telephone number for IMGs studying in the U.S. because students may spend as long as 10 minutes on hold to get a question answered?

We have focused our communication efforts on expanding ways that individuals, both in the United States and internationally, can communicate with ECFMG. We are also enhancing the way ECFMG communicates with applicants. The On-line Applicant Status and Information System (OASIS), which was implemented in July 2001, has been a major success. It allows individuals to ascertain their status with various ECFMG programs, including USMLE and CSA applications and TOEFL scores. To date, approximately 10,700 individuals have accessed OASIS. In addition, we have expanded e-mail access so that individuals can electronically submit issues to us that are time sensitive such as credential issues, problems involving scheduling permits, and questions regarding our on-line application process. We receive approximately 300 such e-mails each week. We continue to monitor waiting time on the phone and expand our staff during the busiest time of the week. We also have tried to respond proactively to individuals' concerns through electronic newsletters such as the ECFMG Reporter, which addresses topics of specific interest to ECFMG applicants. Currently, approximately 14,500 individuals subscribe to the Reporter.

AMSA QUESTION VII: Exchange visitor sponsorship program J-1 Visa

A. Could the ECFMG provide more information on J-1 visas and the other visa possibilities? There is only "commercial" information from lawyer's websites.

ECFMG is always interested in providing more information on visa possibilities on our website. Currently, we have links to the United States Immigration and Naturalization Service website, as well as to the United States Department of State Exchange Visitor site. Both of these sites offer a wide array of information on J01 and other visa options. We also provide a link to the American Immigration Lawyers Association website which is the premier professional organization in this country for attorneys specializing in immigration and naturalization law. It features legislation updates and other news of interest. Links to three immigration law firms are included because each site includes background information on immigration matters that might be helpful to individuals seeking ECFMG certification. If you have suggestions for additional information on links regarding visa matters, we would be pleased to consider the material.



A. Would it be possible to provide sample questions from the different steps?

Under current practice, ECFMG provides sample questions for both Step 1 and Step 2 of USMLE. Upon registration for either Step, every ECFMG registrant receives a CD which contains sample questions for USMLE. In addition, for individuals who do not use the Internet to apply for USMLE, we provide a written booklet containing the Content Description and Sample Test Materials for the applicable Step. Sample test items are also available on the USMLE website at

AMSA QUESTION IX: American Association of International Medical Graduates (AAIMG)

A. Could the ECFMG grant special status to students graduating from a school endorsed by the AAIMG? Since 1999 the AAIMG has undertaken a rigorous and comprehensive accreditation process to evaluate foreign medical schools in the Caribbean, Central America and Europe based on numerous criteria. Such an accreditation process has long been overdue, given that WHO and ECFMG recognition of foreign medical schools is basically a formality once a school has received a charter from its home country. AAIMG will also periodically reevaluate schools having received both passing and failing grades, as well as schools which have recently been established, to encourage that certain standards are met and maintained. The AAIMG's list of schools is not complete, but it might be an excellent foundation from which to build on, and hopefully it can be expanded with funding from ECFMG. For more information, you can visit the AAIMG's website at

There are a number of organizations throughout the world that accredit medical schools, either regionally, or world-wide. Graduates of these schools must meet all requirements for ECFMG certification. No "special status" is granted to such graduates. Any granting of "special status" would raise complex issues (ECFMG is not an accreditation organization) and possible, unintended consequences. For example, if the requested "special status" resulted in a waiver of the requirements for USMLE Step 1 or Step 2, there is a question how such an individual would meet eligibility requirements for Step 3 and state licensure.


A. Regarding the CSA Patient Note paper that we are required to write all our information on, while the patients might be acting real diseases the lack of space on the paper is hardly REAL. The reason that this is significant because the CSA graders can fail applicants on legibility, which of course if very subjective. If a given applicant is gifted at taking history and needs to elaborate about his/her findings on the note and they have to CRAM it in the little space for fear of not missing anything, they'll be subject to somebody's whim and reading skills.

The Patient Note represents a summary of the pertinent history and physical examination findings for each case, as well as a differential diagnosis and proposed diagnostic workup plan. It is completed by the candidate immediately following each patient encounter and follows a traditional S-O-A-P format. The note is handwritten on a single sheet of paper which is preformatted to contain candidate and case information, and to designate certain areas on the form for actual entry of the various sections of the note.

Candidates are limited to the actual spaces provided on the front side of the note. In both the written and on-site orientations, it is stressed that the only information that need be recorded on the note is that which is relevant to the chief complaint, or reason for seeing the doctor on that particular day. That is, a complete medical history and physical examination are not required nor even expected. Hence, the space available to enter this information is generally found quite adequate by almost all candidates. The space available to enter data is also limited by the operational requirements to score and process the notes. Notes are routinely scanned into an application which saves them as one-page images. For that reason, any writing on the reverse side of the note would be lost.

Notes are handwritten by candidates, although we are beginning to explore the feasibility of allowing typed text entry. Legibility certainly does enter into the patient note raters' ability to read and score the notes. However, this is considered to be a legitimate element of evaluating the note since the purpose of the note is in part to assess the candidates' ability to communicate with other members of the health-care team, individuals who would need to be able to read and understand notes written in a medical record. Hence any negative impact of illegibility on a candidate score is quite defensible.

AMSA QUESTION XI: Travel Visas to Take CSA

A. When candidates complete the registration process for CSA, why are they sometimes denied a travel visa?

B. If a CSA candidate is denied a visa is their application fee refunded?

When candidates complete the registration process for CSA they are sent notification that they are registered, along with instruction for scheduling their actual CSA session. Routinely included in the packet is a letter which candidates can take to any consulate explaining the nature of CSA, how it relates to ECFMG certification and the necessity for the candidate to travel to Philadelphia in order to take the examination. Consular staff are requested to provide assistance and consideration to applicants presenting to them seeking appropriate travel visas. In the majority of cases, this form letter seems to be adequate.

In some cases, however, candidates are denied a visa on their first attempt, and then generally notify us and request additional assistance. At that point we routinely provide them another letter which is personalized to include their name, ECFMG identification number and the date requirements by which they must schedule and take CSA. Once again, this letter urges the consular staff to provide assistance and consideration to these individuals.

Unfortunately, in a small number of cases this is also unsuccessful and candidates are unable to obtain the necessary travel documents to take CSA. It is, and has always been, standard operating policy for ECFMG to refund all registration fees to candidates who are unable to obtain visas to travel to Philadelphia.

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