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C A R I B B E A N M E D I C A L S C H O O L SC A R I B B E A NM E D I C A L S C H O O L S

A J o u r n e y a n d G u i d eA J o u r n e y a n d G u i d e

U P D A T E D F o R 2 0 1 2 - 2 0 1 3

C A R I B B E A N M E D I C A L S C H O O L SC A R I B B E A NM E D I C A L S C H O O L S

A J o u r n e y a n d G u i d eA J o u r n e y a n d G u i d e

A s a d R a z a , M . D .A s a d R a z a , M . D .By the author of one of the leading websites for Caribbean Medical

Schools for the past 12 years CaribbeanMedicine.com!

U P D A T E D F o R 2 0 1 2 - 2 0 1 3

Caribbean Medical Schools: A Journey and Guide

Copyright 1999-2012 by Asad Raza, M.D.

All Rights Reserved

This book is available for purchase at the following online bookstores:www.Amazon.comwww.BookSurge.comwww.Abebooks.comwww.Alibris.comwww.BooksinPrint.comwww.GlobalBooksinPrint.com

Printed in the United States of America

International Standard Book NumbersISBN-10: 061555251XISBN-13: 978-0-615-55251-4

To order multiple copies at discount rates, please contact:Create Space customer service department: www.createspace.com

Edited by Carla McDonald | [email protected] Cover and Interior Design by Leigh Anne Ference-Kaemmer | www.laferencekaemmer.comCover Photograph by R. Gino Santa Maria | Dreamstime.com

_____________________

This book is dedicated to the people of Baghdad, Mosul, Basra,Fallujah, Karbala, Najaf, Kabul and Kandahar.

With my love and admiration._____________________

_____________________

Two roads diverged in a yellow wood, and sorry I could not travel both . . .

and I took the one less traveled by and that has made all the difference

_____________________

Robert Frost, 1920 The Road Less Traveled

XI

TABLE oF CoNTENTS

ACKNoWLEDGEMENTS xix Chapter 1INTRoDUCTIoN 1 Preface 1 Basic Path 2 Exams 2 Residency 4 Some Basic Pros and Cons 8 Medical Schools in the Caribbean 10 Admission 14 Tuition 15 Financial Aid 17 Basic Advice 18 About 20

Chapter 2

MY FIRST TWo YEARS oF MEDICAL SCHooL 21 The Journey 21 The Basic Science Classes 22 Anatomy, Histology, Embryology 22 Biochemistry, Physiology, Psychology, Ethics 24 Microbiology, Neuroscience, Genetics , Epidemiology 25 Pathology I, Pharmacology, Physical Diagnosis 27 Clinical Medicine, Pathology, USMLE Board Review 28 Island Life 29 USMLE Step 1 32

XII

Chapter 3

MY THIRD AND FoURTH YEARS oF MEDICAL SCHooL 33 Third Year Clinical Rotations 33 Pediatrics 34 Psychiatry 35 Internal Medicine 35 obstetrics and Gynecology 36 Surgery 37 Fourth Year 38 Summary of Events 39 Chapter 4

USMLE 41 USMLE Step 2 CK (Clinical Knowledge) 41 USMLE Step 2 CS (Clinical Skills) 42 Clinical Skills Assessment 42 USMLE Step 3 45 Chapter 5

MY RESIDENCY APPLICATIoN 47 Choosing a Specialty 47 Make Your Visa List 48 Call the State Licensing Boards 48 Apply with ERAS! 49 Attend Interviews 50 Match Day and Visa Application 50

XIII

Chapter 6

WoRK VISAS 51 J-1 Visa 51 J-1 Waiver 52 H-1B Visa 53 My H-1B Visa Story 55 Green Card 58

Chapter 7

BooKS USED IN MEDICAL SCHooL 61 Chapter 8

HoW I CHoSE A CARIBBEAN MEDICAL SCHooL 67 Evaluating, Researching and Comparing all the Schools 67 Saba Websites 70 Student Websites 70 Business Website For Saba Island 70 Chapter 9

MY PERSoNAL SToRY 71 An Immigrants Journey 71

XIV

Chapter 10

SUMMARIZED TIME LINE 75 A Quick Look at All the Key Steps 75 Chapter 11

DETAILED TIME LINE 77 A Complete Summary of All the Events During Your Four Years 77

Basic Sciences 77 Clinical Sciences 78 Chapter 12

CARIBBEAN MEDICAL STUDENT CoMMENTS 81 What Students from other Schools Have to Say About Their Experiences 81 AUC 81 Ross 85 Saba 87 Spartan 91 St. Eustatius 91 St. George 93 Unibe 94 Windsor 95

XV

Chapter 13

FINANCIAL AID 97 How to Pay for Medical School 97 Financial Aid Sources 98

Chapter 14

HELPFUL URLS 99 Essential Websites for Your Research 99 Caribbean Medical Schools 99 Medical organizations of the United States 100

Chapter 15

MY RANKINGS 101 My Ranking of the Medical Schools in the Caribbean 101

Chapter 16

MCAT AND USMLE ADVICE 105Information and Tips on How to Pass These Exams 105

XVI

Chapter 17

RESIDENCY PRoGRAMS 111 Descriptions of the Residency Programs Completed After Medical School 111

Chapter 18

oPPoRTUNITIES FoR INTERNATIoNAL MEDICAL GRADUATES IN CANADA 121

Chapter 19

HIGH CoST oF AN INFERIoR EDUCATIoN 125

Chapter 20

FACTS FoR INTERNATIoNAL MEDICAL STUDENTS 129

Chapter 21

WoRDS oF WISDoM 133

XVII

Chapter 22

FREQUENTLY ASKED QUESTIoNS 139 Admission 139 Financial Aid 159 Medical School 161 Clinical Rotations 164 USMLE 169 Immigration and Visas 170 Residency Training 176 Licensure 183

Chapter 23

ABoUT THE AUTHoR 191

Chapter 24

TESTIMoNIALS ABoUT THIS BooK 193

XIX

ACKNoWLEDGEMENTS

To my grandfathers, Hashmath Raza and Jawad Ali Baig, both of whose biological fathers died when they were young boys, but with the help of their mothers, studied hard, earned University degrees and became great men . . . still remembered by many to this day.

To my father Rashid Raza and my mother Zainab Raza, both of Hyderabad, India, for raising me with a tremendous emphasis on education.

To my sister Mariam Mirza in Dubai, UAE and my brother Ali Raza in ontario, Canada for being great siblings. We are a great team. I love you.

To my teachers, professors and coaches at the schools I graduated from: Brampton Centennial Secondary School, York University and Saba University School of Medicine.

Finally, to the United States of America for providing me with all the opportunity I could ever desire in life.

INTRoDUCTIoN 1

Chapter 1INTRoDUCTIoN

PREFACE

Caribbean medical schools have become a very popular option for undergraduates wishing to pursue a career in medicine.

In Canada, a country of 34 million people, there are 14 English language medical schools (3 French). Nationwide, those 14 medi-cal schools offer only 2,043 spots annually. In ontario, where I grew up, only one out of every six applicants gets accepted and matriculates (in 2010 there were 5,412 applicants for 954 spots in that province). As a result, many qualified students are being rejected year after year.

A typical path for Canadian students has been to apply to medical schools in the United States, but this has proven to be a difficult and extremely expensive route.

In the United States there are 125 medical schools offering a total of 18,655 spots; and, one out of every 2.3 applicants gets accepted. In 2010 there were 42,742 applicants for those 18,655 spots. But, if you are a Canadian applying to the U.S., you are considered a foreign applicant.

In 2010, only 171 foreign (non-U.S. citizen) students entered

2 CARIBBEAN MEDICAL SCHooLS | A Journey and Guide

the first year class at a U.S. medical school. So, 99% of students that are accepted and matriculate at a U.S. medical school are U.S. citizens or permanent residents of the United States (Green Card holders).

Therefore, instead of giving up on what, for most, is a very deeply-felt goal of attending medical school, many students have chosen to enter medical schools in the Caribbean with the goal of obtaining a residency and eventually practicing in the United States or Canada.

I want to provide much-needed information to students, like you, who are considering this option, as there must be many un-certainties you are facing.

BASIC PATH

1. Graduate from a Caribbean Medical School (M.D. degree)

2. obtain ECFMG certification

3. obtain a residency in the United States

EXAMS

ECFMG

ECFMG (Educational Commission for Foreign Medical Gradu-ates) is an organization that issues a certificate that you will need to obtain to become eligible to enter a residency (post-graduate training) position in the United States. To obtain the certificate you must pass:

INTRoDUCTIoN 3

USMLE Step 1 (taken after the first two years of med school) USMLE Step 2 CK (taken after the third year of med school) USMLE Step 2 CS (taken after the third year of med school)

USMLE

The United States Medical Licensing Exam Steps I, II and III are standardized tests that U.S. medical students have to take and pass as well.

1. USMLE Step I is based on the first two years of medical school - the basic sciences.

2. USMLE Step II is based on the third year core clinical rotations.

3. USMLE Step III is all clinical, with an emphasis on the management and treatment of a patient. Most take it after their first year of residency.

Also, twelve states will allow candidates to register for the Step 3 examination before they have started a residency program.

USMLE STEP 2 CS

The USMLE Step 2 CS (Clinical Skills), which was formerly known as the CSA (Clinical Skills Assessment), is a one-day (pass/fail) exam in which you interview and diagnose patients.

You can take it at one of the five ECFMG centers that offer it: Pennsylvania, Georgia, California, Illinois, Texas.


RESIDENCY

This is by far the most important aspect. Remember, the M.D. degree can be earned anywhere. It is a residency that will be your ultimate goal.

There were 16,893 U.S. medical graduates in 2011, and there were 26,158 total residency positions available in the United States NRMP residency match. This means that the difference of 9,265 spots were available to the Independent Applicant pool.

This pool includes U.S. D.o. (Doctor of osteopathic Medi-cine) graduates, Canadian medical school graduates, and all International Medical Graduates (IMGs) from all over the world, regardless if they are a U.S. citizen, Canadian citizen or a citizen of any other country.

In 2011 a total of 20,842 Independent Applicants were com-peting for those remaining 9,265 spots.

Caribbean medical schools place their students in clinical rotations in affiliated hospitals in the United States during the third and fourth year of medical school. Therefore, Caribbean medical students are at a far greater advantage when competing with other IMGs for U.S. residency (post-graduate training) positions.

Residency programs tend to feel more comfortable with students that have been trained in a U.S. hospital and are fa-miliar with basic procedures and technology. This also gives Caribbean medical students the benefit of establishing contacts and friendships with the doctors and supervisors during the clinical years. Those people will not only write your letters of reference, but can aid you in obtaining a position in a U.S. residency program.

INTRoDUCTIoN 5

U.S. RESIDENCY PRoGRAMS

Residencies for recognized specialties are diagrammed below.The length of each bar represents the years of training required

for certification.

1 2 3 4 5 6-7FAMILY PRACTICEEMERGENCY MEDICINEPEDIATRICS SUBSPECIALTIESINTERNAL MEDICINE SUBSPECIALTIESoBSTETRICS/GYNECoLoGYPATHoLoGYG EN ERA L SURGERY

SUBSPECIALTIESNEURoLoGICAL SURGERYoRTHoPAEDIC SURGERYoToLARYNGoLoGYURoLoGY

TRANSI-TIoNALorPRELIMMEDICINEorPRELIMSURGERY

ANESTHESIoLoGYDERMAToLoGYNEURoLoGYNUCLEAR MEDICINEoPHTHALMoLoGYPHYSICAL MEDICINEPSYCHIATRYRADIoLoGY - DIAGNoSTICRADIATIoN oNCoLoGY


CoMPARISoN oF RESIDENCY PoSITIoNS AvAILABLE IN CANADA AND THE U.S.

FREIDA (www.ama-assn.org/go/freida) lists all ACGME-accred-ited residency programs. The U.S. column in this table is the NRMP (www.nrmp.org) list, which only has those programs that participate in their Match, which is a lower number. In the U.S. a certain number of residency positions are available outside of the NRMP match (non-NRMP residencies).

The Canadian column is complete (stats taken from www.carms.ca). Keep in mind that the U.S. Match is much better for Caribbean grads as it has around a 50% IMG match rate; whereas the Canadian match rate for IMGs averages around 10%.Residency Program

Spots in Canada in 2011

Spots in the U.S. in 2011

Anatomic Pathology 24 1081Anesthesiology 118 841Dermatology 26 362Diagnostic Radiology 88 1124Emergency Medicine 65 1626Family Medicine 1089 2708General Surgery 114 1108Internal Medicine 402 5121Neurology 40 594Neurosurgery 16 195obstetrics/Gynecology 100 1205ophthalmology 38 Non-NRMPorthopaedic Surgery 81 670otolaryngology 29 283Pediatrics 157 2482Physical Med and Rehab 23 373Plastic Surgery 28 108Psychiatry 131 1097Radiation oncology 21 171Urology 32 Non-NRMP

INTRoDUCTIoN 7

Residency Program

% IMGs in the U.S. in 2011

Avg hrs/week(PGY-1)

Avg Salary(U.S. $) (PGY-1) in 2011

Anesthesiology 14.4 61.6 48,343Anatomic Pathology 37.1 50.9 47,505Dermatology 3.5 45.2 49,142Diagnostic Radiology 10.3 51.7 49,973Emergency Medicine 8.7 56.3 47,912Family Medicine 41.6 63.3 47,394General Surgery 20.5 75.5 48,023Internal Medicine 53.7 64.2 47,699Neurology 40.9 64.4 48,786Neurosurgery 11.8 76.6 47,580obstetrics/ Gynecology 20.2 71.1 47,793ophthalmology 6.9 51.6 49,062orthopaedic Surgery 2.9 70.5 47,577otolaryngology 2.4 67.6 47,556Pediatrics 32.1 65.6 48,090Physical Med/ Rehab 19.7 54.6 48,959Plastic Surgery 10.6 64.9 55,151Psychiatry 38.7 56.2 48,448Radiation oncology 3.6 50.0 49,120Urology 4.9 66.4 49,771


SoME BASIC PRoS AND CoNS

THESE ARE THE PRoS:

1) Split camp U.S. program: first two years (sciences) completed in the Caribbean, last two years (clinicals) completed at affiliated hospitals in the U.S.

2) U.S. curriculum: hence, better preparation for the USMLE than other foreign schools.

3) Much easier to get accepted than U.S. or Canadian schools. 4) Three entering dates: September, January and May.

BUT THESE ARE THE CoNS:

1) Having to go from state to state to do your clinicals. However, if you enjoy traveling and going to different places

and meeting new people, and want to take advantage of establishing contacts, this could be a PRo! Also, it is pos-sible to get most of your rotations in the same place with certain schools.

2) The Visa problem for non-U.S. citizens when trying to get a residency in the U.S.

There are two types of visas available to do residency in the United States. The first one is the J-1 visa, which you can get through the ECFMG. You will need to have an offer from a U.S. residency program and a Statement of Need from the Ministry of Health in your home country. However, after completion of your residency in the U.S., you must return to your home country for two years, unless you get a J-1 waiver.

INTRoDUCTIoN 9

The second visa is H-1B. This requires that you take an additional exam (USMLE Step 3) before applying for the visa. This may take several months to get before starting residency, so its good to plan ahead with a timeline. Twelve states (Arkansas, California, Connecticut, Florida, Louisi-ana, Maryland, Nebraska, New York, South Dakota, Texas, Utah, West Virginia) will allow candidates to register for the Step 3 examination before they have started a residency program. So getting a visa is very possible, but will require some additional time.

NoTE: you are not limited to those states for a residency. You are free to do a residency in other states. Those states listed are the ones that allow students to register for Step 3 before starting a residency.

3) May have to do better than the average U.S. grad on USMLE Step 1 and USMLE Step 2 CK to get a residency, and also have to pass the USMLE Step 2 CS!

Examinations are given in a format compatible with that of the USMLE at some schools. But success on the boards will depend on the students work ethic and determination. Be prepared to work hard.

4) If you are from Canada, obtaining a residency in Canada as a foreign medical graduate is very difficult.


MEDICAL SCHooLS IN THE CARIBBEAN

All these schools are listed with the WHo (World Health organization) and the IMED here: https://imed.faimer.org

Readers are reminded that WHo has no authority to grant any form of recognition or accreditation to schools of medicine or other training institutions. Such a procedure remains the ex-clusive prerogative of the national government concerned.

WHo limits itself to publishing information on medical schools that have been provided or confirmed by the govern-ments of its member states.

ENGLISH LANGUAGE CARIBBEAN MEDICAL SCHooLS RECoGNIzED BY THE MEDICAL BoARD oF CALIFoRNIA

Source: www.mbc.ca.gov/applicant/schools_recognized.html

M.D. Programs

DoMINICARoss University School of Medicine www.rossu.eduGRENADASt. Georges University School of Medicine www.sgu.eduNETHERLANDS ANTILLESSaba University School of Medicine www.saba.eduST MAARTENAmerican University of the Caribbean School of Medicine www.aucmed.edu

INTRoDUCTIoN 11

M.B.B.S. Programs

JAMAICAUniversity of the West Indies Faculty of Medical Sciences www.mona.uwi.edu/fmsBARBADoSUniversity of the West Indies School of Clinical Medicine www.cavehill.uwi.eduTRINIDAD AND ToBAGoUniversity of the West Indies Faculty of Medicine St. Augustine www.sta.uwi.edu/fms

The above listed seven medical schools are the only English language medical schools located in the Caribbean that are ap-proved by the Medical Board of California.

THE IMPoRTANCE oF CALIFoRNIA LICENSURE:

States in the U.S. are becoming increasingly strict with regard to recognizing foreign medical diplomas, in particular from gradu-ates of new offshore Caribbean medical schools. Most states are slowly, but surely, approaching the high standards of California, which is the strictest state.

Therefore, it is best to only consider schools that are licensed in California, as the other states in the U.S. will soon adopt the same guidelines as to which foreign medical diplomas they rec-ognize and approve for licensure.


FULL LIST oF ENGLISH LANGUAGE MEDICAL SCHooLS IN THE CARIBBEAN

ANGUILLASaint James School of Medicine Anguillaanguilla.sjsm.orgANTIGUA AND BARBUDAAmerican University of Antigua College of Medicinewww.auamed.orgUniversity of Health Sciences Antigua School of Medicinewww.uhsa.agARUBAAureus University School of Medicinewww.aureusuniversity.com/arubaXavier University School of Medicine www.xusom.nlBARBADoS University of the West Indies, Barbados Faculty of Medical Sciences cavehill.uwi.eduBoNAIRESaint James School of Medicine Bonairebonaire.sjsm.orgCAYMAN ISLANDS St. Matthews University School of Medicine (Grand Cayman)www.stmatthews.edu

INTRoDUCTIoN 13

CURACAoAvalon University School of Medicinewww.avalonu.orgCaribbean Medical University School of Medicinecmumed.orgSt. Martinus University Faculty of Medicinewww.martinus.eduDoMINICAAll Saints University School of Medicine, Dominicawww.allsaintsuniversity.orgRoss University School of Medicinewww.rossu.eduGRENADASt. Georges University School of Medicinewww.sgu.eduJAMAICAAll American Institute of Medical Sciencesaaimsedu.comUniversity of the West Indies Faculty of Medical Scienceswww.mona.uwi.edu/fmsMoNTSERRATSeoul Central College of Medicine www.seoulmed.orgUniversity of Science, Arts & Technology (USAT) Faculty of Medicinewww.usat-montserrat.org/medicine.htm


SABA ISLANDSaba University School of Medicinewww.saba.eduST. KITTS AND NEVISInternational University of the Health Sciences (IUHS)www.iuhs.eduMedical University of the Americas (Nevis) www.mua.eduUniversity of Medicine and Health Sciences, St. Kittswww.umhs-sk.orgWindsor University School of Medicinewww.windsor.eduST. LUCIAAmerican International Medical University School of Medicineaimu-edu.usAtlantic University School of Medicine ausom.org

ADMISSIoNThe mean GPA (Grade Point Average) and MCAT (Medi-

cal College Admission Test) for accepted students at Caribbean medical schools varies greatly. A competitive applicant usually has a GPA of around 3.2 and MCAT scores of 7 or 8. Most of these schools require at least three years of undergrad, but some will accept students after only two years.

Chances for admission are better if you apply well before the date you would like to enter, as most of the spots are open then. But buyer beware! Some of these schools are so desperate for students that they will accept anyone that applies.

INTRoDUCTIoN 15

Two big problems arise with this:First, several of these newer schools are really bad, so get-

ting admission into them means nothing. Second, many of the students that are offered these easy admissions are totally not academically suitable for medical school and therefore will never pass the USMLEs. In the process they and their parents will lose tens of thousands of dollars.

The MCAT is optional at most schools, but it is highly recom-mended that you write it. It is excellent preparation for medical school studies.

TUITIoN

Here is a table comparing the tuition (in U.S. $) at the Caribbean medical schools. one semester is four months in duration. These tuition rates were valid as of January 2012. But may have changed since then. Please verify these values with each school.

Medical School

Caribbean Island

School is Located on

Tuition for Basic

Sciences per semester

Tuition for Clinical

Rotations per semester

All American Institute of Medical Sciences Jamaica $6,000 $7,200All Saints University Dominica $4,995 $6,995American International Medical University St. Lucia $9,500 $9,850St. James School of Medicine Anguilla $6,500 $7,500American University of Antigua Antigua $12,282 $13,970University of Health Sciences Antigua $11,500 $11,300Atlantic University School of Medicine St. Lucia $3,800 $6,800AUC St. Maarten $16,900 $18,900


Medical School

Caribbean Island

School is Located on

Tuition for Basic

Sciences per semester

Tuition for Clinical

Rotations per semester

Aureus University School of Medicine Aruba $6,495 $7,995Avalon University Curacao $6,500 $7,700CAHSU Belize $8,000 $9,500Caribbean Medical University Curacao $4,900 $6,900Destiny University St. Lucia $7,000 $8,000International American University St. Lucia $6,000 $9,500MUA Nevis $9,500 $10,450Ross Dominica $16,575 $18,200Saba Netherlands Antilles $10,150 $10,950Seoul Central College of Medicine Montserrat $4,999/trimester $6,000Spartan St. Lucia $4,950 $9,750St. Eustatius St. Eustatius $7,800 $8,400

St. George GrenadaTerms

1&2: $22,4143&4: $30,660

$22,625

St. James School of Medicine Bonaire $5,000 $7,500St. Martinus University Curacao $7,400 $10,500St. Matthews Cayman Islands $9,400 $10,950Trinity School of Medicine St. Vincent $10,800 $12,500University of Medical and Health Sciences St. Kitts $7,925 $11,000University of Science, Arts and Technology Montserrat $4,100 $4,500UWI - Faculty of Medical Sciences Jamaica $18,126 Per yearUWI School of Clinical Medicine Barbados $16,618 Per yearUWI Faculty of Medicine St. Augustine

Trinidad and Tobago $21,500 $25,000

Windsor St. Kitts and Nevis $4,990 $4,990Xavier University School of Medicine Aruba $6,500 $9,000

INTRoDUCTIoN 17

FINANCIAL AID

UNITED STATESFederal: www.fafsa.ed.govSallie Mae: www.salliemae.comStafford: www.staffordloan.com

CANADABank of Montreal: www.bmo.comCanada Trust: www.tdcanadatrust.com/student/pro.jspCIBC: www.cibc.comoSAP: osap.gov.on.ca Royal Bank: www.royalbank.ca Scotia Bank: www.scotiabank.com

INTERNATIoNAL IEFA: www.iefa.orgFinancial Aid Guide:www.princetonreview.com/scholarships-f inancial-aid.aspx


BASIC ADvICE

Keep in mind that a school listed with the World Health organization (WHo) or the International Medical Education Directory (IMED) still may not qualify for licensure in the United States.

What really matters is state approval. Currently only five Eng-lish language medical schools located in the Caribbean islands are approved by all fifty states in the United States.

Those Caribbean medical schools are American University of the Caribbean, Ross University, Saba University, St. Georges University and the University of the West Indies.

Be prepared. Know what you are getting yourself into:

1. Please contact several people in your search for info, pref-erably the source (school administration, medical orga-nization, etc.). Research, research, research!

2. Be VERY aware of the RISKS involved with attending a foreign medical school and becoming an international medical graduate (IMG). Contact the AAMC, AMA, NRMP, CaRMS and find out the facts regarding this issue. only go to an established California-approved medical school. Stay away from schools that just opened up in the last few years and are promising basic sciences on their island with USMLE preparation and guaranteed clinical rotations.

3. The most important thing I can tell you about attending medical school is to make sure you are academically suit-able. In other words, be certain that you will be able to handle the intense medical curriculum. I found, for me, the biology section of the MCAT prepared me quite well for my studies in medical school. If you feel your background is weak, and that you may have problems, then before

INTRoDUCTIoN 19

you attend, I strongly recommend taking some college/university courses, in biology, physiology, biochemistry, etc. Just take a look at the medical school curriculum to get an idea of what types of courses you need to prepare for, and make certain that you do!

4. ...and lastly, follow your heart. Dont attend medical school because it will make your parents happy, or because you think it will make you prestigious or rich. All this is ac-tually not true about a career in medicine. Attend only if you have a genuine interest in the study of medicine and the subjects involved, and you love to study. This way you will be happy. otherwise you will be miserable and will drop out.

Find out the FACTS. Get them directly from the source - the horses mouth, as they say - whether that is the medical schools, the ECFMG, FSMB or other governing bodies. It is important to know the truth and the risks involved with Caribbean medical schools, and the realities. That is the only way you can make the most informed decision for yourself.

Some basic questions one should ask the Caribbean school are:

1) What is your USMLE Step 1 and Step 2 first-time pass rate? 2) What is your clinical placement rate (at affiliated hospitals

in the U.S.)? 3) What percentage of your graduates obtain a residency in

the U.S.?Ask away! Dont be satisfied until you know everything. Then,

and only then, can you decide whether or not to attend a Carib-bean medical school. Read this great book, post on the forums and share your information. I sincerely wish the best of luck to you all. I know the pain you are going through.


ABoUT

This guide was originally started in 1999 by me for a few friends who were interested in attending a foreign medical school. It was soon realized that this information was very much needed by many others as well.

Since then, in the past 13 years now, my guide, book, website and forum have been widely read, with tens of thousands of stu-dents from all over the world taking advantage of the valuable information they provide. I honestly never thought the response would be so profound.

The goal of the guide remains the same: to provide step-by-step information to anyone who is interested in studying medicine at a Caribbean medical school and then going to the United States to obtain a residency and later a license to practice medicine.

I have gone through the entire process: I have attended and graduated from a Caribbean medical school, completed the two years on the island, completed the two years of clinical rotations in the United States. I have passed the MCAT, USMLE Step 1, USMLE Step 2 CK, USMLE Step 2 CS, ToEFL, MCCEE, MCCQE Part 1 and USMLE Step 3.

I received my ECFMG certificate and the H-1B Visa and I did my post-graduate (residency) training in the United States. I obtained my full state medical license and am now practicing as a physician in the U.S.

If you wish my success to be yours, I can show you how: its all outlined and explained in detail in this book. Simply read the book and be on your way. I wish you the very best in achieving your goals!

MY FIRST TWo YEARS oF MEDICAL SCHooL 21

Chapter 2MY FIRST TWo YEARS oF MEDICAL SCHooL

THE JoURNEY

After a lack of success in gaining admission at a Canadian or U.S. medical school, I decided to pursue an M.D. degree in the Caribbean.

With over 1600 medical schools worldwide, why the Carib-bean? Well, as a Canadian, I knew that once I left Canada to go to a foreign medical school, getting back into Canada would be very difficult, so my goal was to go to the U.S. and work there.

Now, getting into the U.S. for a residency depends largely on your USMLE board scores. Since the USMLE is based entirely on the U.S. medical curriculum, many foreign medical graduates have a tough time doing well on this exam because they learned medicine in another country, at a school that has a different cur-riculum than the U.S. schools.

So, in choosing a foreign school, with the goal of eventually working in the U.S., I chose a Caribbean school because these schools have a U.S. curriculum and you can do your third and


fourth years of medical school (the clinical rotations) in the U.S. This maximizes your chance of obtaining a residency position in the U.S..

After looking through all the schools, I chose Saba University School of Medicine. So let me tell you all about how my years went on this rock.

Hence begins the story of an International Medical Graduate (IMG).

THE BASIC SCIENCE CLASSES

I started FIRST SEMESTER (of five on the island) on September 6, 1999. What a historic day in my life!

our classes were 1) Anatomy, 2) Histology and 3) Embryology.

1) ANAToMY

The professors structured this course in an excellent way. At the start of each block they gave you a handout, which had everything you needed to know. During the lectures they supplemented the handout. Plan on wasting your time reading that big Moore book? Well, that is a no-no. Just know those handouts cold for the tests.

I recommend the Board Review Series for Anatomy. The Netter Atlas is a must, always have it open while studying. Now, for the lab, you need to go after hours to the lab (with other med students) and quiz each other on all the cadavers: dont just know your cadaver, you must know all of them. This course will teach you where all the organs, vessels and nerves are so that later you can learn about their diseases with a better understanding.

2) HISToLoGY

This course was easily the worst experience I had at Saba. The professor was this incredibly conceited and rude person, who


quite honestly did not care about you or what you learned. He just walked into class every day and recited (by memory) the days lecture, at a New York taxi cabs speed and then left. The students who came to Saba with a really good histology background were able to do well, but otherwise you were screwed.

on at least three times during this course, the Scranton in-correctly marked questions wrong on our tests. All these times this professor said that he would give us these points at the end of the course. These are points that we had EARNED (not a curve!). Well, at the end of the course he didnt give them to us. He was a liar on a big power trip. I complained about him to the President of the school, the school did nothing.

This is one thing you will notice very early on when you at-tend a Caribbean medical school: there is no real professionalism among the teaching staff.

A great book is the Wheaters w/CD ROM. Now for the lab component, like anatomy, you need to go after hours to the lab and learn the slides. This is largely a course that deals with the way something looks under a microscope, normally and abnormally, and to learn how to differentiate between the two.

3) EMBRYoLoGY

Basically, if you just read your textbook, you were fine. Lectures were like a story. I preferred reading the text (even though I hate reading big books). But this book is very readable and interesting. Read the book! There is no shortcut. You may think that there is, but it wont work.

The High Yield book for embryology is terrible, way too point form. A lot of people dismiss this class, but it IS important be-cause many of the diseases you learn in Pathology are embryo-logical. This course will teach you about the nine month period that a baby goes through from conception to birth.


SECoND SEMESTER we had Biochemistry, Physiology, Psychology and Ethics.

4) BIoCHEMISTRY

A lot of stuff to learn, but Dr. S. was excellent. He made bio-chemistry seem easy. Dr. L. taught us the harder blocks, so it was tough. Pathways, pathways ... and more. Enzymes, rate-limiting steps and all that short term memory stuff. Make yourself some nice charts and keep them for when you get to pharmacology, where you learn about drugs that block these pathways.

Class notes and Lippincott is all you need. Lippincott text rules. There is a lot of stuff on this course, but that book, with your time commitment, will help you really get a handle on this course. Dr. S. based his final exam on the 30 Biochemistry pages in the famous First Aid for the USMLE Step 1 book: a great idea, I think.

5) PHYSIoLoGY

This is a very important course because physiology is the study of the normal functioning of the human body. You need to get a good handle on it before you get to pathology, which is the study of the abnormal. So learn as much as you can. I had a good experience in this course.

I recommend the Saunders Physiology book by Costanza. Great subject. Saunders Physiology by Costanza is the #1 book for physiology. There is a lot of controversy about whether to use Guyton. My opinion? You have got to be kidding me ... waaay too much info in that book for a one-semester course. That Guyton book is awful.


6) PSYCHoLoGY

Dr. K (a fellow York University grad!) makes your life a lot easier in this course. Believe me, this course could be really hard, but Dr. K teaches it in a fun way. I recommend the High Yield book. Psych is a good read. You can relax (at least I did) and read the Kaplan and Saddock Pocket Handbook and learn a lot.

7) ETHICS

The J.D. who taught this brought his 17 years of law practice experience to this course. It is quite interesting. So sit back, relax (everyone got an A) and just listen and talk about medical ethics, and learn some cool things.

THIRD SEMESTER we had Microbiology, Neuroscience, Genetics and Epidemiology.

8) MICRoBIoLoGY

The first month of this course was - God - such a struggle. I mean, the prof was just awful. our class notes were basically a bunch of random words with no correlation ... a word salad. So every student was reading a different source to TRY to under-stand what the hell was going on. Just look at the books people in my class were reading a Immunology required text, Langes, High Yield, BRS, USMLE Review Book, Medical Micro Book, etc.

With the students who took their course before, their schema once again compensated, but me, the math major, got killed. Just when I thought I had to throw in the towel, Dr. T. came in and taught us. She was like our MESSIAH saving us from the falling depths of hell. She was wonderful.

In five semesters on the island, my favorite textbook was the Clinical Microbiology Made Ridiculously Simple - get it! For Im-munology we all used different sources because it was sooo badly


organized. Microbiology is very important. Get a good handle on all the bugs: bacteria, parasites, fungi and viruses. Make charts with a list of all the bugs and some classic buzzwords about each. It will help you later on.

9) NEURoSCIENCE

Please rescue me! Could things get any worse? The lectures for this class are the biggest joke. You sit in class for two hours every day and learn nothing. So I would go home after class and read that God-awful Snell book. I read the entire book (540 pages) and recall, I HATE reading big textbooks. But I had no choice. I typed up chapter summaries for the entire book. Neuro can be very hard, so dont get bogged down with details, just learn the big picture.

10) GENETICS

The prof plagiarized this course straight from the Thompson and Thompson Genetics books. He put all his copied lectures in one notebook. During class he explained them as if he wrote them. In addition, unfortunately he demonstrated terribly unprofessional behavior: from verbally abusing students to physically abusing teachers (yes, this is true), to failing students he did not like. Welcome to the Caribbean, folks.

He desperately needed professional help in controlling his tem-per. I think he had a very sad and troubled life. I have no idea why the school kept him on staff. Genetics was easy so dont worry.

11) EPIDEMIoLoGY

Just print out her PowerPoint lectures and read them and the book. Dont sweat this course the amount of Epidemiology you need to know for the USMLE Step 1 would probably take about two weeks to learn. This course is about statistics related to health care.


FoURTH SEMESTER (second year begins!). We had Pa-thology I, Pharmacology and Physical Diagnosis.

12) PATHoLoGY I

This course was largely a review of stuff you already know (the first half of the Robbins book). The profs were terrible and you basically realize what a waste of time it is after a few weeks. Just read the pocket Robbins and read their PowerPoint lectures (which were basically pocket Robbins typed word-for-word into PowerPoint).

Pathology is arguably the most important course. It is held over two semesters. Robbins text is used here, its a horrible book. Personal opinion? The Golgan book is way better. Can you read and understand all that is Robbins? If yes, then thats great! If not, get the pocket Robbins. Pathology I is mostly all cellular ga-ga - really boring. Learn it all because, unfortunately, they will be on the boards.

13) PHARMACoLoGY

Dr. N. and Dr. I. did a great job at teaching this course of 700 drugs. The orange Katzung review book is excellent. The green Katzung book is far too detailed for a one-semester course. Also, the board simulator series pharmacology questions are very good to do for preparation.

Read their PowerPoint lectures first, then read the corre-sponding chapter in that review book and do the MCQs. For the final exam, I did all 570 pharmacology questions from the Board Simulator CD Rom; it helped a lot!

You have to know this course well; it is extremely important. For each drug learn the generic names, drug class, mechanism of action, usage, side effects and drug interactions. Study this course hard.


14) PHYSICAL DIAGNoSIS

I did the absolute bare minimum in this course, because it was so badly taught and disorganized, and I learned next to nothing. So I cant tell you anything about it, sorry.

FIFTH SEMESTER (almost out of here!), we had Introduc-tion to Clinical Medicine, Pathology II and at the end of the semester, USMLE Review.

15) INTRoDUCTIoN To CLINICAL MEDICINE

This was by far the most useless course of the entire five semes-ters. I mean, they could have made this course very helpful, and really solidify what we had learned so far. But they didnt. It was mostly student presentations, which are snooze city, and irrelevant lectures by useless profs. Geez, what can I say, presentations! So learn how to use Microsoft PowerPoint and get a head start on writing History and Physicals if you have time.

16) PATHoLoGY II

Arguably the most important course for the boards, but we had the most horrible profs this side of the Atlantic ocean. Sometimes I could not believe how bad they were. They were mostly heavy-accent losers from foreign countries. I mean, this course had the worst professors. Man, oh man. The only reason I would even attend class is because we had this bogus attendance policy. But people still skipped! Just read Robbins, Golgan or the Kaplan books and teach yourself.

You have to know your pathology of organs systems. otherwise you will never pass the boards. Learn patient presentations, even for Step 1. Be able to link pathology to pharmacology and mi-crobiology, as these types of questions appear in large numbers. Get the First Aid book and the Vignettes and a good digestible pathology book and study, study, study!


17) USMLE BoARD REvIEw

They put this at the very end. Four weeks of professors coming in and trying to review two years worth of basic sciences. I just sat in the back of the class and read my Kaplan books.

Well, on April 18, 2001, a day I never thought would come, I finally finished my time on that boring island (yeah!).

I started my third year clinical rotations in August of 2001 in the United States.

IMPoRTANT NoTE:

My dear friends, please remember that finishing five semesters of basic sciences at a Caribbean medical school does not mean much. In fact, it means absolutely zero!

EVERYTHING you have to do in order to get a residency in the United States happens AFTER you leave the island.

ISLAND LIFE

EXERCISE

I continued to run, but not nearly as often as I used to. I did some weights at the gym in Windwardside (which is where I lived). But man, did I miss my track club back home - all the training and the races I used to run.

SABA BAY To BAY RoAD RACE When I first came to Saba Island I saw how hilly the place was

and, I must admit, I was pretty disappointed. I knew it would be very hard for me to continue running on Saba the way I used to back home in ontario, Canada.


I started anyhow, but it was pathetic. I mean, a 25-minute run was exhausting me on those monster hills and back home I used to run for an hour everyday!

In July, 2000 the wonderful people of Saba, including Suzanne Nielsen, held the Bay-to-Bay (Island Wide) run/walk on Saba. From the airport all the way to the other end of the island Fort Bay. Approximately 12km (7.5 miles).

I thought it would be impossible to run it. I mean the climb from the airport to the first three villages is crazy. You go from zero to 2000 feet above sea level within the first part. I walked half of it and still won the event in 1 hour and 16 minutes. Later they told me that the Saba record was 1 hour and 7 minutes.

In December 2000 they held the event again and I ran the entire way! The first part, from the airport to the church at Up-per Hells Gate was entirely uphill! But I ran it in 19 minutes. I knew I would break the record when I saw this time on my watch. Anyhow, I had not been training, to be honest, just going for 25 minute runs here and there. But I still put in a very strong effort and reached the bottom in 39 minutes and made it to the finish in 43:33. New Saba record!

It was pretty cool. I am sure someone can break this record, but I dont think someone can lower it below 41 minutes. However, you never know! Its all really in the mind because when Profes-sor David Aarons and I set the pace that day, we led a total of six people under the old record.

SoCIAL

Well, for me, life on the island was not as great as it could be. The island is very small with only around 1400 people.

I chose to live as inexpensively as possible. I had no cable, phone or vehicle.

In a way its good, because I got a lot of studying done, but yes, I have to admit, things got very boring and lonely. It was a sad time in my life.

MY THIRD AND FoURTH YEARS oF MEDICAL SCHooL 31

Sometimes I would go out to a party at the house of some of the students; or go to Guidos, Lollipops or Queens Garden for a dance or whatever.

other students, however, were living with all the luxuries you can have on Saba: phone, internet, vehicle, cable, nice houses, warm water for a shower, air conditioning, etc.

I figured I could do without these things for 20 months, because I could barely afford to go to this school I had an excellent ability for sacrifice.

As far as finances go, I just paid tuition/fees and $470/month for rent (I lived in Windwardside, which is the heart of Saba). If you lived in some crappy place in St. Johns or Hells Gate you could probably get a place for $300 or less. I spent money on food, photocopies and not much else.

BREAKS

During the break after first semester I went to St. Vincent (a nearby island). I was there for three weeks. It was a really memo-rable time, and I had a lot of fun.

In second semester, I went to St. Barts for a day trip. It is a nice little French island with some neat places to shop, dine and beach.

During the break after second semester I went to St. Martin with a friend of mine. St. Martin is nice, man. That is a really beautiful place for a vacation and to meet women.

The break after third I HAD to go home, otherwise my mother would have killed me. It was nice to see my family after a year. They made fun of how much weight I had gained.

INTERNET

The internet was, as always, my source of info and communi-cation to the outside world. Internet access is difficult as there is only one free place the library. You can get internet in your room to your PC, but that requires getting a phone line and


internet access, which is costly.But I continued to post on my website forums to help incoming

students or to learn a little myself from what others had posted.

PoST ISLAND

USMLE STEP 1 After I completed the first two years of medical school (the

basic sciences) on the island, I went back home to Toronto, on-tario, Canada to study for USMLE Step 1.

I took the Kaplan center access med pass for USMLE Step 1 which consisted of:

1) Preview (Step 1 books) 2) Lesson (videotaped lectures) 3) Review (question banks)

The first 30 days (which included the books) were $600 Canadian dollars.

I studied for 14 weeks for USMLE Step 1. The first seven weeks I read the Kaplan USMLE Step 1 books and I went to the Kaplan center and watched the videotaped lectures with a 30-day Kaplan Med Pass.

Info at: www.kaplanmedical.com

Then the second seven weeks I completed questions online with Kaplan QBank and several other CD roms I had.

I also read the High Yield section of the First Aid for USMLE Step 1, and a few other books I had. I studied very hard for this exam. I wrote the test on July 28, 2001. I got my results four weeks later and I passed.


Chapter 3MY THIRD AND

FoURTH YEARS oF MEDICAL SCHooL

THIRD YEAR/CLINICAL RoTATIoNS

My third year schedule was as follows:

Pediatrics (6 wks) Aug 13, 2001 Sept 21, 2001

Psychiatry (6 wks) Nov 5, 2001 Dec 14, 2001

Internal Medicine (12 wks) Dec 17, 2001 March 8, 2002

OBGYN (6 wks) March 11, 2002 April 19, 2002

Surgery (12 wks) April 22, 2002 July 12, 2002

I started my third year clinical rotations on August 13, 2001. I completed my first rotation at Leonard J. Chabert Medical Center in Houma, Louisiana, USA.


PEDIATRICS (6 wKS) AUG 13, 2001 - SEPT 21, 2001

This is a six-week rotation that I did to start off my third year. There were four physicians that we rounded with, one physician per day in the morning. There were five students in this rotation. It was an 8 a.m. 4 p.m. type shift, not that stressful. Because it was my very first rotation, there was a lot to be learned, including simple things like common hospital abbreviations that I did not know.

In the morning we were in the hospital. When we arrived we had about an hour or so to go see the patients that had been admitted to the hospital (the In-Patients). When we went to see the patient, we would write a daily report in standard S.o.A.P. (Subject, objective, Assessment, Plan) format - basically the patients complaints, their current vital signs, the current assessment and possible treatments.

When the doctor arrived we would then do rounds. At this time we would have to present the patient to the doctor; in other words, tell the doctor about the patient. The doc would then agree or disagree with what we had written and further advise on the plan for the patient and discuss the patients condition.

In the afternoon we were in the clinic. These were the out-Patients. When a patient came in, we (the students) would first go in and perform a physical exam, just the basics, looking at their ears, listening to their heart, lungs, bowel sounds, and then writing down what we found - normal or abnormal. Then the doctor would come in and take a look at what we had written and proceed with the treatment of the patient. Bread and butter of pediatrics is asthma, ADHD and otitis media. We had a test at the end of this rotation.

After this rotation, I wrote and passed the ToEFL to get that requirement out of the way. (Note that this test is no longer re-quired for IMGs).

I did my next three rotations in Elgin, Illinois, USA at Provena Saint Joseph Hospital.

More info see: http://www.provena.org/stjoes/


PSYCHIATRY (6 wKS) Nov 5, 2001 DEC 14, 2001

This was a laid-back rotation. Basically, I spent time up on the Psych floor and with a psychiatrist. I saw the doc a couple of times a week and he would go over some patients with me and look over History and Physical reports I had done. There was a psych lecture series given at a nearby mental health clinic that I attended. In the afternoons all the in-patients had group sessions which were quite interesting and amusing at times. There were also out-patient programs on weekends that I went to. Bread and butter of psych is depression, depression, depression, bipolar and some schizophrenia.

INTERNAL MEDICINE (12 wKS) DEC 17, 2001 MARCH 8, 2002

This was an extensive rotation that covered far more than you could grasp in three months. The first four weeks I was with an internist/geriatric specialist in his office. I saw all the patients with him. I drew blood, gave shots, wrote prescriptions, etc. I spent time with him at lunch and did rounds with him at two hospitals and nursing homes. Bread and butter of this practice is hypertension, diabetes, hyperlipidemia, thyroid disorders and urinary incontinence.

The next three weeks I spent in the Emergency Room. I learned how to put in IVs, foleys, do EKGs and suture. The ER is not like what most people think; its not the excitement that you see on TV. Its more like a walk-in clinic.

The last five weeks I rotated one week at a time through five specialties (oncology, Nephrology, Gastroenterology, Cardiol-ogy, Neurology). Whew! Too much to soak in, but I would just go home at the end of the day and read about the stuff that I saw during the day. I read the Blueprints books mostly. These are great books.


The most enjoyable part of this rotation, for me, was helping out at the free clinic. The Chief of Staff at Saint Joseph Hospital ran this clinic and he would let med students come and just hop right in, as if we were the docs! of course, he would have the final say on any treatment. It was great experience to be given the responsibility of handling patients. I would go in, do a SoAP note, talk to the patient and then come out and present it to the doctor, and he would approve or disapprove of what I wanted to do. He would then explain what should be the proper manage-ment of the patient.

At the end of this rotation I had an oral exam and a written exam. The doctor that had supervised me the longest completed my student evaluation that my university required for each rota-tion.

This hospital had a lecture series given by the Chief of Staff mixed in with student presentations. We went to lecture three times a week, time permitting. Even though Provena St. Joes was not an ACGME (Green Book) hospital, it was a great place to do rotations.

oBSTETRICS AND GYNECoLoGY (6 wKS) MARCH 11, 2002 - APRIL 19, 2002

This was one of those rotations that pleasantly surprised me. I had heard from other students that an oB/GYN rotation is hard and really a pain; but, for me, it turned out pretty memorable.

I was with a very successful physician/business man. He had three practices and a lab business.

I was with him in his offices and assisted him with deliveries (vaginal and cesarean). He was a rather interesting character, always cracking jokes. He took me out three times (twice to ladies night in the Chicago area) and we had great discussions on medicine and other world issues. He really motivated me to work hard and made me realize how competitive the private practice setting is.


He learned Spanish (from scratch) so he could better serve the large Hispanic community in Elgin, Illinois. Also, he mas-tered doing laparoscopic hysterectomies. See, 85% of the large hysterectomies in the United States are done abdominally, but he has done 95% of his laparoscopically. It takes more time to learn this procedure, but it results in a shorter recovery time for the patient. I assisted him in these lap hysterectomies as well as other procedures like Dilation and Curettage and Loop Electro-surgical Excision procedures and Cesarean and vaginal deliveries.

Bread and butter of oB/GYN is routine pregnancy exams, pap smears, uterine fibroids, endometriosis, pelvic pain, cervical dys-plasia, hysterectomies, ultrasounds and unfortunately - cancer.

SURGERY (12 wKS) APRIL 22, 2002 JULY 12, 2002

I did this rotation at Peninsula Hospital Center in Far Rocka-way, New York, USA. I was living in Jamaica, Queens, New York (home of rapper 50 Cent!) Down the street was a KFC with cashiers taking orders behind bullet-proof glass.

Twelve weeks in the operating room you get to see and assist in a wide variety of surgeries, for example: cholecystectomies, appendectomies, amputations, pericardial window, bowel resec-tions, arterial grafts, and many other procedures. The operating room can be a grueling place.

There was a lecture series at the hospital, with grand rounds, and also tumor board. We also had an opportunity to gain valu-able experience at three clinics (vascular, surgical and breast).

I took the USMLE Step 2 CS (it was called the CSA back then) in December of 2002 and the USMLE Step 2 CK in Janu-ary of 2003.

My third year was 42 weeks of core rotations, my fourth year was 30 weeks of electives that I completed in Toledo, ohio, USA from July 15, 2002 to February 21, 2003.


FoURTH YEAR

I completed my fourth year in Toledo, ohio, USA. I set up all my rotation there myself. It went as follows:

Family Practice (inpatient) (4 wks)

July 15, 2002 Aug 9, 2002

Family Practice (outpatient)(4 wks)

Aug 12, 2002 Sept 6, 2002

Internal Medicine (outpatient)(4 wks)

Sept 16, 2002 oct 11, 2002

Gastroenterology(6 wks)

oct 21, 2002 Nov 29, 2002

Infectious Disease(6 wks)

Dec 2, 2002 Jan 10, 2003

Nephrology(6 wks)

Jan 13, 2003 Feb 21, 2003

Basically, fourth year is a time for you to choose certain areas that you feel will be beneficial to you and your future plans. I think Gastroenterology is very high yield. Also inpatient Internal Medicine is an area where you can learn a lot. Since I wanted to be in primary care I chose my electives in those fields (Family Practice, Internal Medicine, etc.).

You dont really have to set up your rotations. You can stay at the same hospitals where you did your third year and that is the easiest way. I guess I wanted to make my life difficult, so I tried to set up all of my fourth year by myself. I just emailed several Family Practice residency programs, and a few said yes, I could come for an elective or two. Then, once I was there, I just started talking to doctors and asked them if I could hang out with them for six weeks or so. Thats pretty much the way it went.


My advice for clinical rotations is to try to do them at AC-GME hospitals that have residency programs. Also, make sure that the rotations offer didactic sessions (lectures or meetings). Some clinical rotations I did were just completely worthless. I learned absolutely nothing in them. The attending was never there and I just sat around. There is also an enormous amount of self-teaching. You basically have to be a self-starter and just get some good books and teach yourself.

If you can teach yourself, you will do well. But if you require spoon feeding, you will never survive and will never pass the USMLEs.

My friends, do NoT underestimate the amount of time you will need to complete everything (rotations, tests). You need a lot of time and hard work! Do NoT take time off during your clinical rotations. This has been proven to be the kiss of death. Guaranteed. The thing is that once you get into rotations, you are on your own. The school does not care if you take two years or four years to complete your rotations.

The problem with this is that if you give a slacker an inch, he will take a mile. So people take time off and never get things done on time, miss the Match, miss two matches, etc.

SUMMARY oF EvENTS

My dates for all my important events were as follows:

1 September 1999 Started Medical School in Caribbean2 April 2001 Finished Second Year on the Island3 July 2001 Passed USMLE Step 14 August 2001 Started Third Year in the U.S.5 october 2001 Passed ToEFL6 July 2002 Started Fourth Year


7 December 2002 Passed USMLE Step 2 CS8 January 2003 Passed USMLE Step 2 CK9 Feb 21, 2003 Finished Fourth Year10 April 11, 2003 Received M.D. Diploma11 April 17, 2003 Received ECFMG Certificate12 May 29, 2003 Received Step 3 Permit13 July 1, 2003 Took USMLE Step 314 August 15, 2003 Got Step 3 Result15 Sept 1, 2003 Sent out Residency Application16 oct, 2003-Jan, 2004 Attended Interviews17 March 2004 Residency Program Match18 April 2004 State Training License Application19 April 2004 H-1B Visa Application20 June 2004 obtain Social Security Number21 July 1, 2004 Start Residency

It is my firm belief that it is chronologically impossible to complete all this in four years. Guaranteed. Canadians and other non-U.S. citizens who want the H-1B Visa will need an extra year (or two!) to complete all this.

I have never heard of any non-U.S. citizen who started in Sep-tember to successfully be able to start residency on July 1 four years later. Even the lucky ones, who match on time, need several months extension from the residency program to complete Step 3, get a training license, get a social security number, etc.

USMLE 41

Chapter 4USMLE

USMLE STEP 2 CK (CLINICAL KNowLEDGE)

I started studying for this test about two months into third year and studied straight into my fourth year. A lot of studying! I initially read the:

1) Blueprints Series (five books Psyh, Peds, Surgery, Int Med, oBGYN)

2) Blueprints Q&A books (five books) The Blueprints series is a good start. They are easy to read,

you can read each book in just a few days (or weeks). The books are concise and have some good questions in the back. The matching Q&A books are good, but they only have approximately one hundred questions per book. once I read the Blueprints, I was ready to get into more details. So I started with the:


3) Kaplan USMLE Step 2 CK books These books are very detailed and have a ton of info. I think

they are the very best books on the market for USMLE Step 2 CK. They should be read repeatedly.

After I finished with them I started practicing questions with:

4) Kaplan Step 2 QBook (850 questions) 5) Kaplan Step 2 QBank (1000 questions) 6) Kaplan CD Rom (400 questions) 7) NMS Step 2 QBook (900 questions)once I finished I reviewed with this great little book by Adam

Brochert called: 8) USMLE Step 2 SecretsGreat book! Best review book out there for Step 2 CK! The

author also has written a matching question book called Mock Exam.

www.usmle.org also has 150 questions that you can get from

them for free.

USMLE STEP 2 CS (CLINICAL SKILLS)CLINICAL SKILLS ASSESSMENT(formerly known as the CSA - CLINICAL SKILLS ASSESSMENT)

This exam consists of 11 patients (not real patients, they are actors). You basically go into each room with a clipboard in your hand. You have 15 minutes to take a history, do a physical exam and discuss tests and possible diagnosis. Then you come out of the room and you have 10 minutes to write a patient note.

USMLE 43

There are certain things you must do with every patient (or you will fail). Those things are:

1) Always examine directly on skin. Never through a gown. 2) Always auscultate directly on skin. Never through a gown. 3) Always wash your hands before touching a patient.

Basically, before you go into the room, there will be a note on the door. It contains the introduction info about the patient, like the chief complaint and vitals.

You then knock and enter. Introduce yourself. Hi, Im Asad Raza. I am a medical student, and your name is?

You then start asking questions. 1) Chief complaint 2) HPI (History of Present Illness) onset, Duration, Pro-

gression, Frequency, Location, Radiation, Quality, Inten-sity, Alleviating factors, Aggravating factors, Associated symptoms. The mnemonic is oDP FLR QI All Agg Ass

3) PMH (Past Medical History) 4) PSH (Past Surgical History) 5) FH (Family History) 6) SH (Social History) Alcohol, Tobacco, Drugs, occupa-

tion, Marital status, Diet, Sleep, Sexual activity, Exercise. Mnemonic is ATD oMD SSE

7) Medications 8) Allergies 9) Review of SystemsJust go through this standard list. Write down the answers the

patient gives you on the paper and clipboard you are provided.


Its actually very easy. Some cases have a few other things you need to ask (of course). And, for some cases, you dont need to ask as much. This part of asking questions should only take about five minutes. Now, at this point, you are ready to do the physi-cal exam. Remember to wash your hands. Palpate, percuss and auscultate directly on skin not through a gown. The standard things to check on a physical exam are: Heart, Lungs, Abdomen.

There is one very important and interesting thing I want to point out. This test is not really a test of your physical diagnosis skills. For example, as long as you put your stethoscope on the patients heart, you will earn the point for that part of the exam. Remember the patients are not doctors! They are just normal people who are there to act. If you spend a lot of time with your cardiovascular exam, you will still only earn that one point. So stick the stethoscope on the patient and then move on to the next thing.

The physical exam should take about five minutes. Now, for the final five minutes of the 15 minutes you are in the room, you discuss the tests you are going to order and what possible things you think the patient might have. Basically, you tell the patient the work-up plan and the differential diagnosis.

Then you thank the patient, shake hands, walk out of the room and sit down and write your patient note. You have ten minutes for this. You are given a standard form to fill out. You write down basically exactly what happened in the room.

I took the exam on December 13, 2002 in Atlanta, Georgia. I took the Greyhound Bus from Toledo, ohio to get there.

The only thing I used to prepare for this exam was those 40 cases that are floating around the internet. Its a PDF file that has 40 cases that are written exactly the way they appear on test day! The file, when printed out, is 190 pages. Each case goes through:

oPENING SCENARIo: This is exactly what is hanging on the patients room door. PATIENT PRoToCoL: What the patient has memorized.

USMLE 45

CHECKLIST: The exact questions you need to ask for this case to score the points you need to pass. WRITE-UP: Sample answers of what you should write on test day!

These cases are exactly what the actual test is like. They are the best. Just memorize them cold and you will be set. Dont waste your money on that worthless oSCE book. Those 40 cases are all you need.

The cases that I used to study for the USMLE Step 2 CS are available here: www.CanadaQBank.com

USMLE STEP 3After I finished all my fourth year electives on February 21,

2003, I contacted my school to request my M.D. Diploma. They sent it to me on April 11, 2003. I immediately sent a copy to ECFMG and I got my ECFMG certificate on April 17, 2003. I then sent out my application for Step 3 to FSMB with a copy of my M.D. diploma and ECFMG certificate. I got the permit to take the exam on May 29, 2003. I registered for the state of Connecticut. After I got the permit I called my nearest Prometric center (in Michigan) and scheduled a date for July 1 and July 2 (it is a two-day test). I got my results six weeks later in the middle of August. Then I was ready to apply for a residency with ERAS. The ERAS cycle opens up on September 1. Perfect timing.

I started studying for USMLE Step 3 as soon as I was done with Step 2. I read:

1) Kaplan USMLE Step 3 books (Internal Med, Neuro, Peds, Psych, oBGYN, Surgery, Epi/Ethics)

These are really good. I read them twice and then started on questions with:


2) Kaplan Step 3 QBook (850 questions) 3) Kaplan Step 3 QBank (1000 questions) 4) Kaplan Step 3 CD Rom (200 questions, 20 CCS cases) 5) NMS Step 3 QBook (900 questions)Step 3 is done in two parts. The first part is 480 multiple-choice

questions, similar to ones you get on Step 2. The second part consists of nine CCS cases (CCS means Clinical Case Simula-tions). Its basically a patient on the computer that you have to manage, work up, order tests on and come up with a diagnosis and treatment.

I had 20 CCS cases that I wrote out and memorized from the Kaplan CD. Five CCS cases on the CD that www.usmle.org makes available. And 50 CCS cases on this CD:

Interactive Step 3 CCS CasesIts a private CD I purchased on www.ebay.com, those cases

were excellent. So, in total, I had 75 CCS cases that I memorized in preparation for the Step 3 exam.

MY RESIDENCY APPLICATIoN 47

Chapter 5MY RESIDENCY APPLICATIoN

Here are my Six Steps to Applying for Residency in the United States:

1) CHooSING A SPECIALTY

Well, this is a personal decision. Choose something you like, something that matches your personality. Do you want to work all day and all night for the next five years? or do you want a more relaxed life? Do you like people? or would you rather to look at specimens and x-rays? Also, if you are an IMG, the tough specialties are out. Stick to primary care and a few other IMG-friendly areas.

All the programs are listed at websites like: www.careermd.com and www.ama-assn.org/go/freida

Decide what specialty you want to apply for. Choose an IMG-friendly area like Family Practice, Internal Medicine, Pediatrics, Psychiatry, oBGYN, etc.


As an IMG you should stick to primary care. If you have high board scores and you are a U.S. citizen, then you can consider other specialties. otherwise, FP, IM, Peds or Psych. By far, IM is the most realistic to get. PMR, oBGYN, Neurology, Pathology and Anesthesiology are also IMG-friendly.

Go to FREIDA online here: www.ama-assn.org/go/freida or you can go to this website: www.careermd.com and e-mail or call all the programs you are interested in.

All the Family Practice residency programs are at this site: www.aafp.org/residencies

If you are a non-U.S. citizen the biggest and most important (and perhaps the oNLY) question you should ask is, quite simply: Does your program sponsor the J-1 Visa and/or H-1B Visa?

2) MAKE YoUR vISA LIST

Well, this only applies to non-U.S. citizens who need a work visa. If you are a citizen or Green Card holder, then ignore this step.

Just email all the programs you are interested in and ask them, Do you sponsor J-1 or H-1B? I emailed all 500+ FP programs in the U.S. and about 50 programs said that they would sponsor H-1B. You will have to contact the programs yourself.

If you require a work visa, make sure you email the programs and ask them if they sponsor the J-1 Visa and/or H-1B visa.

3) CALL THE STATE LICENSING BoARDS

This is a very important step, but it is also a huge pain in the behind. I started calling and, after a few states, I gave up. It just takes so long to get the right department and nobody has an answer to your question. When I called and asked the simple question, How many of my 72 weeks of clinical rotations have to be at ACGME hospitals for me to be eligible for a training

MY RESIDENCY APPLICATIoN 49

license in your state? the reply was, uhwe have no idea what you are talking about. This was very frustrating. So I basically just waited until my interviews and asked all my questions to the Program Director.

Good news. I actually did all this research for you already. I have published the full list of rules and requirements on my forum at www.CaribbeanMedicine.com in the Main Forum section. Look at the post titled State Training License Requirements.

Figure out which states you are eligible for a training license in. Contact the State Medical Boards at: www.fsmb.org

once you have made your final list of programs, then you MUST and, I repeat, MUST call the state medical boards that these programs are located in and ask, As a (fill in your school here) University graduate, am I eligible for a training license in your state?

My dear friends, residency program directors dont care about where you did your rotations; but, the state licensing boards Do CARE!

There is nothing more painful than to match to a program and then find out a few weeks later that you are not eligible for a training license in that state either because you dont have the required clinical rotations, or because you did rotations at non-ACGME hospitals. So, for your sake, CALL the State Medical Boards! The phone numbers are all listed here: www.fsmb.org

4) APPLY wITH ERAS!

Narrow down your list of states based on geographic preference related to weather, close proximity/distance to current location and family, etc.

I took my list of programs, narrowed it down to forty and applied. The ERAS application is all online. I filled it out and wrote a personal statement.

Then I sent ECFMG my Deans Letter, four LoRs, Transcript


and a color photo. This application process may seem a bit over-whelming, but its really not that bad. Just plan ahead of time or you will find yourself going crazy at the last minute trying to get all the documents and information you need.

The ERAS application opens up on September 1. They allow you to start entering your info into the website in mid-July. ERAS website is here: www.aamc.org

Go to the ERAS website, and fill out your application online and send ERAS your LoRs and Deans Letter by mail.

Also, register with NRMP here: www.nrmp.orgThe NRMP are the ones who will match you!

5) ATTEND INTERvIEwS

Now sit back and wait for interviews. The residency programs will either email, call or send a letter in the mail. Attend the interviews.

Most interviews are held between october and January. Be sure to ask the relevant questions during your interview. After interviews, when you come back home, be sure to write the pro-gram director a thank-you letter.

Ask the appropriate questions. Write thank-you letters. Then, when its all over, rank the places where you interviewed, and enter your rank order list on the NRMP website.

6) MATCH DAY AND vISA APPLICATIoN

The Match day is in mid-March or so. You can apply for your visa after you match to a residency program. The Match is done by the NRMP here: www.nrmp.org

If you match in March, then congrats. Now contact a compe-tent immigration attorney and start your H-1B Visa application process. once you get the visa, you are finally done. Walk proudly into your residency program on July 1!

WoRK VISAS 51

Chapter 6WoRK VISAS

FoR CANADIANS AND oTHER NoN-U.S. CITIzENS

J-1 vISA

You can get current information about the requirements by emailing: [email protected]

Here is my executive summary:

From 1993-2001, trying to get the J-1 visa as a Canadian was really hard, sometimes even impossible. So it was quite discourag-ing. But things have changed. In 2002 Health Canada changed the policies a tad and made it a little more open to get this visa. But it is still a difficult visa to obtain for many reasons.

Here are the steps. Basically, to get this visa you need:

1) An offer from a U.S. residency program saying that they have accepted you

2) Your ECFMG certificate (of course) 3) To write and pass the MCCEE (write this in your fourth

year of med school)


4) A letter from the Royal College of Canada stating that the residency you are going to doing in the U.S. is acceptable to Canadian standards.

5) A Statement of Need letter from the Canadian Health Ministry

Statement of Need what is that, you ask? Well, remember what the J-1 visa is it is an EXCHANGE visa. Which means that after you finish your residency in the U.S. you must return to your home country (e.g., Canada) for a minimum of two years. So, Canada has to tell the U.S. that they actually have a need for you once you return. Pretty basic thing.

Anyhow, how does one get a Statement of Need letter? You need to write and pass a test: MCCEE. Info about this test is at: www.mcc.ca

Then apply for the Statement of Need letter with Health Canada: [email protected]

You will apply for the J-1 visa with the ECFMG (not the USCIS), read: www.ecfmg.org/evsp/index.html

Now, if you do NoT want to return to Canada for that two year requirement, then you CAN stay in the U.S. if you agree to go and work as a physician in a rural/under serviced area in the U.S. for 3-5 years.

After you finish this two-year return to Canada requirement, you are free to go back to the U.S. to work as a doctor. Now, what visa will you need to get to this point, to work in the U.S., you may ask. The answer is surprisingly simple an H-1B. Makes you wonder why you didnt get it in the first place, doesnt it?

J-1 wAIvER

okay, now for some good news related to the J-1 visa. Finally! After you finish a residency in the U.S., it IS possible to stay in the U.S. The way is to get a J-1 waiver.

Detailed info about the J-1 Waiver can be found by contact-

WoRK VISAS 53

ing the J-1 Waiver programs for each state. They are listed here: www.CaribbeanMedicine.com/j1waiver.htm

Also read the posts on the Caribbean Medical School forums at: www.CaribbeanMedicine.com

Look in the Canadian Forum for the J-1 Waiver information.To get your Statement of Need letter, contact your home

countrys Ministry of Health. A list of Ministries of Health for countries around the world are here: www.fda.gov/InternationalPrograms/Agreements/ucm131179.htmen.wikipedia.org/wiki/Ministry_of_Health

H-1B vISA

PRoCESS To GET THE H-1B vISA(THE GoLDEN vISA oF CHoICE!)

(a) Pass USMLE Step 1 (b) Pass USMLE Step 2 CK (c) Pass USMLE Step 2 CS, finish all your clinicals. 1) After you finish your final clinical rotation, call your medi-

cal school and ask if your evaluation form from your last rotation has arrived. If so, request your M.D. diploma. (It is wise to request your M.D. diploma two months in advance so that the school has adequate time to order it for you.)

2) Get your M.D. diploma in the mail from your school. If you have planned this correctly, you should receive your M.D. diploma within four weeks of completing your final rotation.

Then send to ECFMG: two passport sized pictures and two photo photocopies of the diploma.

3) once ECFMG gets your M.D. diploma photocopy, they


will then send you the ECFMG certificate. So, from the time you get your M.D. diploma, it will take approximately three weeks to get the ECFMG certificate.

4) As soon as you get your ECFMG certificate, send a copy of it with the USMLE Step 3 application to FSMB immediately. You must have your ECFMG certificate to apply for the USMLE Step 3. The application form for USMLE Step 3 is at: www.fsmb.org The test is done over two days. It consists of 480 MCQs and nine CCS cases.

Note: only 12 states in the U.S. allow IMGs to register for Step 3 before starting residency. They are: Arkansas, California, Connecticut, Florida, Louisiana, Maryland, Nebraska, New York, South Dakota, Texas, Utah and West Virginia. The best state to apply for is Connecticut. Re-member, you can take the test in any state. Also, you are free to do residency in any state. Contact FSMB for details.

5) Four weeks later you will get your orange USMLE Step 3 scheduling permit. Call the Prometric testing center in the state you wish to write it in and schedule a date. Note: Prometric centers might not have a two-day open slot for you. So you may have to wait around three weeks to get a date to write Step 3.

6) Take the USMLE Step 3. 7) Five weeks later you will get your Step 3 result, if you

have passed (no one cares about your score, you just need to pass). At this point you are eligible to apply for the H-1B visa. You must (of course) have an offer from a U.S. residency program that is willing to sponsor you.

8) Before you can apply for the H-1B visa, you need to ob-tain a State Training License. The time it takes to get this depends on which state you are starting residency in. For

WoRK VISAS 55

some states, this will take several months, while other states do not even require a training license! It is up to you to find out the details.

9) The H-1B visa application process takes three months. But if you pay an extra $1000 (one thousand) you can apply with premium processing that will expedite your application to only 15 DAYS. It is done by the hospital, immigration attorney and the USCIS.

10) The final step is to apply for a Social Security Number (SSN). This is done after you enter the U.S. This process takes anywhere from 4-8 weeks. It all depends upon your country of origin/citizenship and your ethnic background.

11) once you get the SSN, then you can finally walk proudly into your U.S. residency program and start your post-graduate training.

SUMMARY: From the day you finish your last clinical rotation it will take approximately 19 WEEKS (5 MoNTHS) to have a Step 3 result in your hand. The breakdown is: 4 (M.D. Diploma) + 3 (ECFMG Certificate) + 4 (Step 3 Permit) + 3 (Step 3 date) + 5 (Step 3 result) = 19 weeks. See above for details.

The best thing about H-1B is that after you get it, you are eligible to apply for a Green Card, which will allow you to live and work in the United States permanently.

MY H-1B vISA SToRY

After I matched, the residency program that I matched to as-signed the immigration attorney they work with to me. I gathered all my documents. I had to send her:


Application for H-1B visa

My USMLE exam reports (Steps 1, 2 and 3)

All medical certificates (ECFMG, etc.)

Copies of my degrees (BSc, M.D.)

Copies of my passport

Copy of my drivers license

Birth certificate

All University transcripts

Resume

Letters of reference

The H-1B visa fees were:Immigration lawyer fee $1495H-1B application fee $185Premium Processing fee $1000Total: $2680

My residency program paid for the lawyer and application fees. I only had to pay the premium processing fee (which speeds up an H-1B application to less than 15 days). My residency program was exempt from the annual H-1B cap of 65,000 because they were a non-profit hospital affiliated with a University.

This was my very first time applying for an H-1B work visa. I was in my country of citizenship (Canada) at the time I applied. The state that I matched in does not require a training license for residents (someone doing a residency). So I did not have to apply for a training license. I used an immigration attorney that the program assigned to me. It is the same for most programs. The program will assign their immigration attorney to you. The H-1B visa was valid for all years of my residency training.

WoRK VISAS 57

My H-1B visa did not begin until July 1 and I was only allowed to enter the U.S. ten days before this start date. Therefore, once my H-1B petition was approved, I was not permitted to enter the United States (was not able to cross the border) any earlier than June 21. So, since my orientation started on June 21, I crossed right after midnight on the morning of June 21 and made it to the orientation on time.

So the basic steps in the H-1B process are: 1) Match to a residency program 2) Apply for a state training license (I did not have to do

this, because the state that I matched in does not require a training license for first-year residents). Warning! Many states do require a training license and the process to get one can take very long for IMGs, up to several months! So plan ahead!

3) Apply for the H-1B visa with an immigration attorney (with premium processing this should take less than 15 days).

4) once you get your H-1B Approval Notice (Form I-797B) you can enter the U.S., but no earlier than 10 days before your start date (most residency programs start on July 1).

5) When you are going to the U.S. (from Canada in my case), at the point of entry (U.S. border at Sarnia, ontario for me) show the border officials your Approval Notice. They will give you an I-94 (its a little white card) and they will put an H-1B visa stamp on it (they do this for you on the spot).

6) once you arrive in your city in the U.S., go to the nearest SSN (Social Security Number) office and apply for your SSN. Show them your Birth Certificate, Passport, I-94 and H-1B Approval Notice. You need an SSN to start your residency. It can take on average of 4-8 weeks to get


one. once you apply for your SSN, give the receipt to your residency program. This should allow you to start your job. Some residency programs may assign you a temporary SSN until you get your real one.

Whew! What a crazy and complicated process. Made me wish I was a U.S. citizen!

GREEN CARD

After residency, I got a job with an employer that agreed to sponsor me for the Green Card. Note that I did my residency on an H-1B visa. When I started the job after residency, I was placed on another H-1B initially. My employer immediately got the application for the Green Card started with my immigration consultant. My Green Card application fees totaled $8,500.

The way it works at this stage is that first you get an EAD (Employment Authorization Document). Think of this as a pre-Green Card. This EAD allows you to work in the U.S. without having to be on the H-1B visa anymore.

Then you get the Green Card later. It takes anywhere from six months to five years to get the Green Card. How long it takes depends on your country of birth. As of the writing of this book, the wait times are longest for persons born in India and China, about 4-5 years. Everyone else should be able to get a Green Card within one year or so.

I applied for my Green Card through a Labor Certification. This is a process by which an employer shows that it has tried to hire a U.S. physician for the position without success. The em-ployer must meet a number of requirements including advertis-ing the job in a major national publication or a major specialty publication, then review all the CVs that come in to make sure no qualified U.S. physicians are available.

WoRK VISAS 59

I had my Green Card filed under the EB-2 category. Em-ployment-Based Second Preference (EB-2) includes members of professions holding advanced degrees (e.g., M.D.). once your Green Card application is in process, you get an EAD within a few months.

Keep in mind that when you apply for a U.S. Green Card the USCIS will put you on a waiting list based on your country of birth. Currently backlogs exist for people born in two countries: India

Caribe Book

Documents

Transcript of Caribe Book