February 10, 2004

     Belaboring a topic is one thing writers should often watch out for. However, it was quite surprising to receive such a robust response about the choices some people have to make: staying as a doctor, or switching gears to become a nurse and going abroad. Which by the way is not a matter of ethics, but a matter or means and necessity. To balance things, it was posted in a forum regarding other hidden and not so hidden expenses would be FMG’s (foreign medical graduates) would have to dole out to work here (or rather, to TRY to get to work in the United States). It really isn’t an easy and cheap process after all. Looking at the nurse’s side, more than one reader pointed out that there are now agencies that hire their clients without placement fees and the like. As Neal Yerkes, RN wrote: "Just wanted to let you know there are a few of us that operate in an ethical manner." An anonymous "nurse-medic" person also claimed: "You get to the US without even spending anything for the exams. All fees paid by the hospital, no salary deduction, including a free immigrant visa application, free lawyer, free airfare from manila to US, free NCLEX (includes airfare and accommodation in Saipan), and a free housing accommodation for 3 months when you get to the US, not adding the fact that you can bring your family with you with financial assistance."

"I have been swallowing my pride and heartaches since I started studying nursing here in North America. I had applied for residency for four years, and every year the same thing happened. Not matched. So to survive, I have to find a better and stable job to sustain my family." - a reader

     It would be good to know which agency this is, for the benefit of other possible applicants. This prospect seems too good to be true, but there must be strings attached. How does the company survive therefore? Through charity? In addition, it was postulated that: "The likelihood of being denied at the embassy is higher for doctors seeking for an employment there in the US." This is contrary to my experience, as it is quite the opposite, unless this is backed by factual statistics. Doctors fly in and out of the USA all the time. Lastly, it was said "right now, because of the shortage of nurses there in the US, hospitals have better offer for nurses from other countries like the Philippines". Which is indeed true; but there is also a shortage of physicians because of declining medical school enrollment and early retirement due to the malpractice problem.

     Another reader named Liza Miller who forgot to leave an email address stated, "I just came from the Philippines and am a doctor. I graduated from one of the most prestigious universities in the Philippines and found that my education in no way even comes close to what students here in the U.S. get". Liza, I and many other Filipino doctors here also graduated from the Philippines, including obscure WVSU, but we are doing quite OK and even excel sometimes over local grads. It’s up to you, not your school. Regarding the claim that: "I paid much more to register with ECFMG than what you are showing, plus the huge fees for review. I don’t know if it is worth it or not". The fees I mentioned are in the ECFMG website so if you paid more, you were duped. On the other hand, review fees are huge. Many Pinoy docs here never even formally reviewed but passed. If you feel not confident about yourself then review you must. Again, it’s up to you, not your reviewer. If you pass, it will be worth it. The fees you can pay off with your first month’s salary. Lastly, about making the call: "My husband made $105k last year as a NICU nurse in Indianapolis, IN. He also only worked about 48 hours per week. BTW, residency is 3 years here... Joke: Why are they called residents? Because they live in the hospital. 80-90 hours per week is not unheard of. Anyway, my hubby does well as a nurse, without the hassle. You make the call." It was mentioned in my previous articles that nurses can earn over $100,000 in special areas or doing longer shifts, and that residents work an average of 95 hours per week (I did residency here too) and consultants about 80 hours a week. And 105K is less than half of what a good doctor can earn if he works hard enough. The call is on you.

     If the call however, is to choose between starvation and feeding your family, it is easy to choose whichever way is possible, including leaving the motherland and your hard earned degree. Like what a colleague wrote: "Who in the world would prefer a BSN-RN in their name instead of an MD. Who wants to work as a nurse if you can work as a doctor? I have been swallowing my pride and heartaches since I started studying nursing here in North America. I had applied for residency for four years, and every year the same thing happened. Not matched. So to survive, I have to find a better and stable job to sustain my family. I have spent a lot of money flying here and there for an interview and also meeting people who might be able to help. I guess, I am just one of those who don't have the luck."

     Here is the gist of what I wrote in the forum to balance things:

• The Exam. The exams are way harder than the local boards (in my opinion) and from what I have gathered from others here. If you fail the test, retaking it will mean another 1300+ green money.
• Hidden expenses: even though there is no placement fee, you have to mail/DHL/LBC applications, visa applications, coming over as a tourist to do interviews, then the match. This amounts to several hundred dollars and the plane tickets aren’t cheap.
• The match. After all this, most programs require a match (just like PGI-ship). This is how Uncle Sam weeds out the unworthy while raising more money from the third world (it’s a darn big business). If you don't match, you need to reapply again and again and that can mean thousands more each time (applications and interviews).
• The time. The whole process, granting you pass the tests, apply and interview immediately then match on the first pass, is less than two years. It's shorter than a 4-year BSN degree. Failing on the first attempt bodes ill omen but should not stop one from persisting.
• Oldies. Agreed, if you are late 30's, 40's or 50's, it will be extremely hard to become an intern and resident again, especially staying up every 3rd day and being treated like dung by younger senior residents and nurses.
• Need. WE NEED DOCTORS IN THE PHILIPPINES TOO! Why go abroad if one's conscience dictates one to stay and directly serve the nation where we are most in need? (Even though you die of hunger or kidnapping in the process?)

     In addition, there are also fees for TOEFL, the CSA and other ECFMG fees not mentioned previously (pointed out by Dr. Gallos-Martir). Yes, unfortunately the process is indeed expensive, difficult and has no guarantees.

     JUST LIKE LIFE.

     A reader "docikabod" queried: "Do you have information as to what happens to a foreign medical graduate after taking the US MLE?" Well, it depends if you pass. It is a common assumption among FMG’s that there is discrimination. However, the fact that passing rates differ between natives and foreigners imply the probability that American education and technology is superior, or that the medical background of non-Americans is simply different due to geography and epidemiology. Thus, if you are a barbarian in Rome, you have to somehow sort of prove yourself as a gladiator in their own Coliseum first before you can do as the Romans do. But consider these numbers:

USMLE passing rates in 2002:
Step 1:	US first time takers: 92%, FMG’s: 64% US repeaters: 59%, FMG’s: 36%
Step 2:	US first time takers: 97%, FMG’s: 80% US repeaters: 70%, FMG’s: 54%
Step 3:	US first time takers: 95%, FMG’s: 66% US repeaters: 65%, FMG’s: 50%

     There is a glaring difference in passing rates between foreign graduates and Americans. If each examination costs $675, imagine how much money Uncle Sam gets out of it, especially from repeaters. If an FMG passes, what is the outlook? Not bad actually, still hard but not as steep. The "Match" comes next.

National Residency Matching Program Positions filled in 2002:
PGY 1:	89.9% US graduates: 63.9% FMG’s: 26%
PGY 2:	97% US graduates: 76.5% FMG’s: 20.5%

     Looking at three popular specialties, FMG’s have much better chances in Family Practice and Internal Medicine than Surgical specialties.

Family Practice:	76.3% (FMG’s: 58%)
Internal Medicine:	95% (FMG’s: 45%)
Surgery:	99% (FMG’s: 7%)

     When you do finally Match, you get into residency (first year as an intern, then another 2-4 years) and then fellowship (also needs a "Match" in some subspecialties) if you choose to "sub". Granting you did not migrate as a relative of one lucky ancestor or married an American or nurse, the next step would be getting a J1 waiver if you came as a J1 Exchange Visitor. Some doctors do get in with H1 visas to start with, and may be able to apply for permanent residency right away, while others try an "O" visa, which is used for "Outstanding" individuals (such as in research or significant achievements). This process is not only extremely complicated but also very expensive and goes beyond this article and explaining it may bore you to tears. The bottom line is you may need a lot of savings, a lawyer, and a lot of work to do.

     Finally, just to show how much more you’ll earn as a doctor rather than as a "nurse-medic" and since we mentioned how much the average starting salaries of doctors are in the US, this is the average annual salary of some specialties across the board (Source: Medical Group Management Association, "Physician Compensation and Production Survey"): Family Practice: $150, 267 +, Internal Medicine: $155, 530 +, Pediatrics: $152, 690 +, Cardiology: $385, 000 +. Most sub specialists tend to earn more (such as Cardiology mentioned here) and income increases also with more patients and effort. These are just random thoughts, hoping that more of us will stay as physicians after a dozen years of education instead of shifting and going abroad as something else if we could help it.

Feedback: send your comments to the editor (anonymously, if you wish) e-mail the author at docdan1(at)pol.net (private and personal, if you prefer)

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