Internationally Trained Health Professionals

Current practice and trends in licensure

MEDICINE

United States

International medical graduates (IMGs) are graduates of medical schools located outside the United States and Canada. IMGs include U.S. citizens but do not include non-U.S. citizens educated at U.S. medical schools. IMGs must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG) prior to entering an accredited residency or fellowship program, of which completion is a prerequisite for state licensure. ECFMG certification is required to obtain an unrestricted license. The ECFMG certification process includes verification of educational credentials. IMGs are required to take and pass all three steps of the United States Medical Licensure Exam (USMLE). USMLE Step 1 and Step 2 (Clinical Knowledge) are computer-based exams that can be taken at specific testing centers located around the world. USMLE Step 2 (Clinical Skills) is an objective-structured clinical examination offered at limited testing centers in the U.S. only. These three exams are the same exams taken by graduates of U.S. and Canadian medical schools. Recent revisions to the ECFMG certification process include implementation of the USMLE Step 2CS for the previously required clinical skills and English proficiency exams. ECFMG members are: American Board of Medical Specialties, American Medical Association, Association of American Medical Colleges, Association for Hospital Medical Education, Federation of State Medical Board of the United States, Inc., and the National Medical Association. The USMLE is sponsored by the Federation of State Medical Boards (FSMB) of the United States, Inc., and the National Board of Medical Examiners ® (NBME®).

Nearly 25 percent of active physicians in the U.S. are IMGs. The American Medical Association reports many IMGs were educated in India (19.9% of IMGs), the Philippines (8.7%), Mexico (5.8%), Pakistan (4.8%), and the Dominican Republic (3.3%). Twelve and a half percent of IMGs are U.S.-born. New York, New Jersey, Pennsylvania, Ohio, Maryland, Florida, Illinois, Michigan, Texas, and California are home to 70.5% of IMGs in 2001.

California

IMGs must submit original diplomas and medical school transcripts or have their medical school send directly to the Medical Board certified copies of these documents. Also required are letters of good standing, fingerprints, completed required state forms, fees, and proof of ECFMG certification.
“While the review of applications filed by international graduates is more complex, delays usually are the result of education and training which does not meet the standard required in law and which therefore must be remediated. Other extensive delays occur as applicants try to obtain documents from foreign institutions or when certified translations are needed. Lastly, when all documents have been submitted and an application is complete, regulations allow an additional 100 days for processing. This time frame may include a senior management review of complex files and a request for clarification of some documented information.” (CMB)
Medical Board has approved several hundred medical schools located in over 120 countries. Approved and disapproved medical schools are listed on the Medical Board’s web site. B&P 2089 and 2089.5 specifies mandatory subjects and length of curriculum. CCR 16, Section 1314.1 sets criteria for the board’s approval of international medical schools.
Medical Board, as of 1991, may accept a passing score on the Medical Council of Canada Qualifying Examination to satisfy examination requirements for licensure.

NURSING

United States

All nursing licensure candidates take the National Council Licensure Examination (NCLEX-
RN). All candidates, either nationally or internationally-trained, must apply to a state or territorial board of nursing to receive an "Authorization to Test" before they are allowed to schedule an examination. Examinations are administered at over 200 test centers in the U.S., five U.S. territories, London, England, Hong Kong, PRC, and Seoul, South Korea. The international sites were used for the first time in 2005 and more international sites will be added later. NCLEX-RN is developed and delivered by the National Council of State Boards of Nursing (NCSBN), an association of state regulatory agencies. Test centers are owned and operated by a single company under contract with NCSBN.

NCSBN has statistics comparing test outcomes among U.S.-educated and international-educated candidates in the first three quarters of 2004, as well as tracking candidates’ country of origin. The council has established a standard TOEFL score considered minimally acceptable for entry into nursing practice. The council also will research and review whether the NCLEX should be offered in languages other than English. NCSBN monitors trends in the approval/accreditation processes of nursing education programs since two national nursing accrediting agencies emerged in the mid 1990s.

To ensure equivalency of education, some state boards require international graduates to be certified by the Commission on Graduates of Foreign Nursing Schools. The certification program is comprised of three parts: a credentials review of nursing education, registration and licensure; the CGFNS Qualifying Exam testing nursing knowledge (offered three times a year in over 40 test sites worldwide); and an English language proficiency examination.

California

The board may issue a license without examination to any candidate who is licensed or registered as a nurse in Canada with certain qualifications.
All candidates must have completed an educational program meeting California requirements. The board decides the equivalency of education provided in another country by reviewing individual applicant’s official transcripts with California requirements. The process takes from four to eight weeks.
B&P 2786 gives the board authority to accredit schools and set standards for accreditation. The standards are found in CCR 16, Sections 1420 – 1430. Because the board accredits nursing schools in the state, it has nurse education consultants on staff to assist in determining equivalency of international nursing education. The board keeps data on international nursing programs, assigning codes to each program.
Test of English as a Foreign Language (TOEFL) is required if applicant attended a non-English speaking nursing program and is applying for an interim permit.
Interim permits may be issued to candidates who are currently licensed in another country and who meet the board’s educational requirements. Interim permits are non-renewable. Interim permits may be issued to candidates who have applied to take the licensure examination and have completed the educational requirements for licensure. An interim permitee must practice under the direct supervision of a registered nurse.

PHARMACY

United States

The National Association of Boards of Pharmacy developed and delivers the Foreign Pharmacy Graduate Equivalency Examination® (FPGEE®). Passage of the exam is just one step toward achieving certification by the Foreign Pharmacy Graduate Equivalency Committee (FPGEC) of the association. The exam is a paper-and-pencil test and is offered twice a year in U.S. locations only. Candidates seeking FPGEC certification also must provide documents that verify education and licensure or registration as a pharmacist in another country. Candidates’ educational qualifications are evaluated and candidates must pass the Test of Spoken English and the Test of English as a Foreign Language, both administered by the Educational Testing Service.

California

Effective January 1, 2005, all internationally-trained graduates must obtain FPGEC certification prior to applying for an intern license, taking the licensure exam, or becoming a licensed pharmacist. At the same time, the board discontinued evaluations of pharmacy educational programs outside the U.S. (Business & Professions Code Section 4200) All other requirements for licensure, such as proof of 1,500 hours of internship and passing the jurisprudence exam, are the same as those required of U.S.-educated candidates.

Areas of Concern and Trends With Licensing International Graduates

Equivalency of education – Trend is to have national system of examination and evaluation of educational equivalency
Defensible legal standard
Cultural competence, i.e., knowledge of American idioms
Trade agreements – NAFTA, GATT

Resources

American Medical Association, International Medical Graduates, www.ama-assn.org/ama/pub/category/17.html, accessed September 21, 2007
California Board of Registered Nursing, www.rn.ca.gov/, accessed September 21, 2007
California Medical Board, www.medbd.ca.gov, accessed September 21, 2007
California State Board of Pharmacy, www.pharmacy.ca.gov and www.pharmacy.ca.gov/forms/foreign_grad_law.pdf, accessed September 25, 2007
Commission on Graduates of Foreign Nursing School, www.cgfns.org/, accessed September 21, 2007
Educational Commission for Foreign Medical Graduates, www.ecfmg.org/, accessed September 21, 2007
Gomez L. Licensing Division, CBRN, personal communication, January 19, 2005
Hart L, Skillman S, et al, International Medical Graduate Physicians in the United States: Changes Since 1981, Health Affairs, Vol. 26, July 2007
National Association of Boards of Pharmacy, www.nabp.net, accessed September 25, 2007
National Council of State Boards of Nursing, https://www.ncsbn.org/index.htm, accessed September 21, 2007
National Council of State Boards of Nursing, 2007 NCLEX Candidate Bulletin

September 2007