How to Get Into the Alternate Entry Path Without USA residency? IMG Success Guide

What specialties offer alternate entry path for primary certification?

The following American Board of Medical Specialties offer primary certification to be board certified

American Board of Anesthesiology

This blog post is dedicated to my experience in Anesthesiology. Some of the principles may be applicable to other specialties.

American Board of Obstetrics & Gynecology 

This is an excerpt from the American Board of Obstetrics & Gynecology website “ABOG is implementing an alternative pathway to achieve Initial Certification for qualified physicians who have completed training in Obstetrics and Gynecology (OB GYN) residency programs accredited by organizations other than the Accreditation Council for Graduate Medical Education (ACGME) and achieved OB GYN certification in another country or by another certification organization.

ABOG policies currently allow qualified graduates of the Royal College of Physicians and Surgeons of Canada Programs located in Canada to be eligible for OB GYN certification.”

American Board of Radiology

This is an excerpt from the American Board of Radiology website “The American Board of Radiology (ABR) offers the following alternate pathways to certification in diagnostic radiology:

The International Medical Graduate (IMG) Alternate Pathway An international medical graduate is defined as an individual trained in institutions outside the U.S., its territories, or Canada

The Holman Research Alternate Pathway The ABR recognizes the shortage of physician investigators in diagnostic radiology. To address this shortage, a research pathway program was designed for individuals to simultaneously train in diagnostic radiology and basic science, clinical, or transitional investigation. This pathway is named for B. Leonard Holman, MD, who first proposed this initiative.”

American Board of Surgery

This is an excerpt from the American Board of Surgery website “An alternate pathway into the American Board of Surgery (ABS) certification process is available for truly exceptional academic surgeons who are International Medical Graduates (IMGs). Surgeons who trained internationally in non-Accreditation Council for Graduate Medical Education (ACGME) or Royal College of Physicians and Surgeons of Canada (RCPSC) programs may be eligible. This pathway is intended for candidates who have and will contribute to the field of surgery through scholarship, education and research. ABS considers this situation extraordinary, and will approve or disallow entrance into this alternate pathway on a case-by-case basis. The chair of the Department of Surgery, the general surgery residency program director and, if applicable, the subspecialty surgery program director at the institution where the candidate holds a current full-time faculty appointment must propose the candidate.”

American Board of Thoracic Surgery

This is an excerpt from the American Board of Thoracic Surgery website “An alternate pathway into the American Board of Thoracic Surgery (ABTS) Certification process has been created for truly exceptional cardiothoracic surgeons who are International Medical Graduates (IMG).  IMG is defined as completion of training programs in Thoracic Surgery outside of the United States not approved by the Accreditation Council for Graduate Medical Education (ACGME) or Royal College of Physicians and Surgeons of Canada (RCPSC)”.

How to become board certified after clinical fellowship as an International Medical Graduate (IMG)?

I see this happen all the time. You entered a fellowship as an international medical graduate (IMG) after your residency outside USA. To be eligible to become board certified in Anesthesiology you have to enter into the US system through one of the below pathways:

1. Anesthesia Residency – This is the most common route. Most people I know of have used this route. They have used the fellowship as a US experience to be competitive for the residency application and have been successful in matching into reputed programs.
2. American Board of Anesthesiology Alternate Entry Path (AEP) Program – This is offered for outstanding and exceptional anesthesiologists. With this pathway, you enter the system as a fellow or faculty or both depending on your previous accomplishments. This is a 4 year program and following successful completion, you become eligible to be board certified by the American Board of Anesthesiology. 

Does multiple fellowships make residency matching easy?

At the outset it may seem logical that multiple fellowships increases clinical experience and makes residency matching easier. However, this can be a double edged sword.

During your interview, I suggest you be prepared to answer questions like why did you not apply for residency earlier? What made you do so many fellowships? etc. Remember as an IMG a fellowship is a dead end job with regards to practicing medicine. After this the options are

1. Return back to home country – For many people this is a great viable option. I have come across many people who have done this. They go back to the home country, use the USA experience, get a different perspective to improve care in their home countries.
2. Get into the USA system – Either through residency or through the ABA alternate entry path program.

How much are we paid for research fellowship in the Alternate Entry Path (AEP) pathway?

First, I will make this clear. The Alternate Entry Path program is a 4-year program formally approved by ABA. During these 4 years, the time can be split between a fellowship or a consultant anesthesiologist or both. I use the terms consultant, faculty, attending interchangeably. Do not get hung up on these terms but rather see the bigger picture.

The pay during research fellowship is based on the negotiation between you and the hospital who is hiring you. For the alternate entry path , the hospital hiring you will invest considerable time and effort. Typically, you will not be in a strong negotiable position in terms of salary when you are starting out.

Here is the salary set forth by National Institute of Health that the hospitals follow as a guideline:

In my experience, this is the minimum and you are likely to get paid the same or more but not less. In my experience, the hospitals also pay a benefit package (that includes insurance and other benefits) which sometimes may go up to 20% of the base pay or even higher so the effective salary will be much higher than this.

Who is a faculty clinician in the USA?

A faculty clinician is a doctor doing clinical care on patients, has an independent license and is typically affiliated with a university. When an anesthesiologist is hired to a hospital under the alternate entry path program, they initially start as a hospital employee. Subsequently, the person then becomes a part of a university under which the hospital functions. Then the position on paper changes to them being a faculty. This is sometimes used as a loose term and interchangeably with an attending or a consultant. Consultant is a term mostly used in countries other than USA while the same is called an attending in the USA.

Since the alternate entry path is offered in hospitals with an ACGME accredited residency or fellowship or both, there will be teaching responsibilities of the AEP candidate to these residents and fellows. This typically involves teaching in the operating room, delivery resident/fellow lectures etc.  This is also the reason these hospitals are typically affiliated with a University.

Is the clinician educator considered a resident or a faculty during the alternate entry path?

The American Board of Anesthesiology states that the clinician educator track is offered to candidates who have anesthesiology certification from countries that have existing training and certification systems which is similar to the USA. This includes the following countries

• Australia & New Zealand
• Canada, Ireland
• Singapore
• South Africa
• United Kingdom
• Europe (other than UK and Ireland)
• Other countries are assessed on a case-by-case basis

During the alternate entry path in the clinical educator pathway, the candidate will function as a faculty or a fellow or both but not as a resident. This is also true for the research and fellowship method. This is the difference between getting board certified via residency or the alternate entry path program.

Bottomline: Irrespective of what country the candidate is certified from (e.g. Singapore, India, China) or the alternate entry path, the role will be a fellow or a faculty or both.

How can we look for vacancies in a faculty post for the alternate entry path program? 

The alternate entry path program is offered by programs that has an ACGME accredited residency or fellowship or both. The first step is to find out the list of programs that are ACGME accredited.

Click this link to the ACGME website with the list of programs with ACGME accreditation.

Do we write to the program directors for the alternate entry path program and ask for a faculty position?

I will say write to the Anesthesia Chair. The Chair is often referred to as the Head of the Department in many countries. If you would like to copy the email to the program director that should be fine but I don’t recommend sending it to program directors alone. You need not ask for a faculty position but rather focus on highlighting your accomplishments and your interest to be in the alternate entry path program. The eventual position which is faculty or fellow or both will be based on your CV and what the program is interested to offer. Either ways your focus should be to get into the alternate entry path program and satisfy the high standards set forth by the ABA.

Although the list of ACGME accredited program is long, you wouldn’t know which of these programs would like to offer the alternate entry path program. I find there are 3 categories of the programs

1. Program offers alternate entry path program
2. Program may not offer alternate entry path program but can consider if there is a suitable candidate
3. Program will not offer alternate entry path program

Since you cannot predict which programs presently offer the alternate entry path, the application should be sent to the many programs citing your accomplishments in the CV and your interest. The application packaged should be emailed to the Chair of Anesthesiology with the following information

• Letter of intent highlighting your accomplishments and what makes you eligible for the AEP
• Your CV

If you find a program that already has a candidate in the AEP pathway, consider yourself lucky. This program will be more likely to sponsor you. If you like a copy of the program names, the program directors and their email, contact me via youtube video.

Is USMLE required for those who work as a faculty and then enter the alternate entry path program? 

Based on my experience, I have seen anesthesiologists working as a faculty without residency or USMLE. This is possible based on the hospital offering the position as a visiting professor. Only few hospitals offer this and this is a temporary position. I have seen people do this from one year to a few years. If this person would like to enter the alternate entry path program either via the clinician educator pathway or the research/fellowship pathway, USMLE will be required and i recommend you complete your USMLE as soon as possible.

There are three steps to USMLE and you can check all this information here about USMLE on usmle.org

• USMLE Step 1 and Step 2 CK will get you ECFMG certified
• USMLE Step 3 will make you eligible for an independent license which is required to work as a faculty/consultant under the alternate entry path program

Would Canadian experience count towards the 4 years of the alternate entry path program?

Canadian experience or experience in any country outside the USA will not count towards the 4 year alternate entry path program. The alternate entry path program or the AEP program will start only after the American Board of Anesthesiology formally approves the candidate. The alternate entry path program  is offered only in the USA hospitals.

However, here is the good news. Canadian experience may help candidates to get used to the USA system as they are very similar. In addition, Canadian experience may help get an independent/full license in the USA after USMLE as some states consider the work experience in hospitals with The Canadian Royal College of Physicians and Surgeons accredited residency or fellowship equal to ACGME accredited training. This accredited training is a mandatory requirement to obtain an independent license to work as a faculty.

In the 4-year alternate entry path program , while waiting for a full license, can we be a researcher for 1 year combined with a faculty anesthesiologist for 3 years?

A scenario of working as a research fellow for 1 year and 3 years as faculty is possible. Based on my personal experience, I have seen internationally trained anesthesiologists work as a research fellow or as a clinical fellow with training license while waiting for the full license. Once the full license is received by the State Medical Board the candidate can then transition as a faculty anesthesiologist and work as a consultant with an independent license. These are clarified a priori by the hospital hiring you to the ABA while drafting the 4-year ABA alternate entry path program plan. The ABA then formally approves the candidate.

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