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This section only applies to current medical students attending English-based, non-governmental/private medical schools that lack accreditation by the AAMC. Most American-based international medical schools are located in the Caribbean, Central America (primarily Mexico), India, Poland, Czech Republic or Russia (just to name a few), and offer a unique avenue to medical students who plan to complete any portion of their clinical rotations in the United States prior to obtaining a medical degree from those institutions. We at AmeriClerkships Medical Society try not to refer to student clinicals as “Green Book” or “Blue Book,” since summarizing the complete scope of clinicals and their effects on future licensure using colors is misleading. Let us explain (once again, the response is very lengthy but definitely worth reading).
Green Book vs. Blue Book Clerkships
U.S. students do not typically use the term “Green Book” or “Blue Book” rotations; these terms were coined by International Medical Students (IMSs) and International Medical Graduates (IMGs) who typically attend Caribbean medical schools and want to complete their clinicals in a similar manner as U.S. medical students, in an attempt to compete for U.S. medical residency slots. Generally speaking, Green Book refers to a rotation where the IMS is able to set foot in a hospital that is listed in ACGME or AOA (with or without permission from that hospital); Blue Book generally refers to the same, but that hospital has a “family medicine residency” associated with it (again, student’s entry into the hospital may or may not have been authorized). As one can easily ascertain, this fails to capture what would truly resemble clinicals conducted by U.S. medical students, since conducting student type clerkships is much more than being able to set foot on hospital grounds; furthermore, international medical schools typically do not own nor manage their own teaching hospitals or sponsor their own residency programs, which minimizes their footprint in the medical education arena. For these reasons, AmeriClerkships strongly discourages the usage of the terms Green or Blue Book, since they often mislead an IMS into believing that the rotations are somehow sanctioned by that hospital, and also by ignoring the many clerkship verification policies that have long been implemented by all U.S. medical boards and jurisdictions.
What AmeriClerkships Is Doing to Address These Issues
Each state licensing body has individual rules, policies, regulations and requirements of licensure applicants who graduate from non-LCME accredited schools. Although not the most important, one such requirement has to do with clinical rotations conducted by students before they graduate (clinicals after graduation is a whole other subject). Other regulations that are specific to IMSs who intend to complete any portion of their clinical clerkships in the United States at the time of licensure include:
- The quality of clinical clerkships is monitored (20 states)
- Clinical clerkships are regulated (13 states)
- IMS clinical clerkships are forbidden in the state (3 states)
- Clinical clerkships are accepted in hospital departments with ACGME-accredited residency programs (22 states)
- Additional regulations exist regarding regulation of clerkships provided to students of foreign medical schools (9 states)
Securing a residency does not ensure completion of residency. Certain state medical licensure rules may inhibit a Matched IMG/IMS from starting in that residency. Other very important rules/policies/regulations/requirements (according to importance) that can affect your ultimate medical career outcomes are:
- Graduating from a state-approved medical school – typically a rigid policy: many states are using the California List of Recognized Medical Schools
- Problems with an applicant’s history
- Practice of Medicine Without a License issues
- Any arrests, DUIs, previous issues in medical school, criminal histories
- Appropriate number of residency years, in accredited programs – typically 2 years minimum (1 year in 3 regions)
- Number of years and attempts that it took an applicant to complete USMLE Steps 1, 2 CK and 2 CS (typically from first attempt at any USMLE)
- Passing/failing of USMLE Step 3
- National Physician Databank resources for past failed licensure attempts or any other negative history
- Previous rejected applications to state licensing bodies
- Irregular behavior during USMLE, NRMP, ERAS, etc.
- ECFMG reports on an individual applicant
- Ability to provide the appropriate documents requested, such as medical school diploma to ECFMG when the medical school no longer exists
- Unexplained spans of time spent away from patient care (typically more than 30 days)
- Performance during the licensure interviews
- Licensure requirement before/during/immediately after residency
- Resident may not qualify to obtain a license in that state (we see this a lot in California, Georgia and Illinois)
Therefore, there is a lot more to worry about than simply completing clinicals in teaching hospitals.
Just because an IMG secures a residency, that does not mean that the state medical board will issue him/her a license. Therefore, the best pre-licensure and pre-residency practices by IMGs are as follows:
- Prepare early, maintain your cool, and be prepared to deal with hundreds of different policies that change from one state to another
- Be cognizant of both residency as well as state licensure rules
- Licensure typically takes place during or after residency, but some states require training licensure prior to residency (i.e., Illinois and California)
- Choose the state to practice medicine very carefully, as you may lose your residency position if unable to secure training/temporary licensure as required by that state
- Be reasonable; saying “I want to practice in all 50 states” is unreasonable
- Focus on all state regulations that have to do with IMG licensure (see Issue #1), not just clinicals
- Remember that you may be required to get licensed before or during residency, so familiarize yourself with state licensure before applying to residency programs
- Choose the states in which it is easier to get licensed if you have doubts – typically Florida, Wisconsin, Puerto Rico or the U.S. Virgin Islands
Not all states have the same clinical clerkship requirements. AmeriClerkships recommends that IMSs keep the following in mind:
- Not all clinicals conducted in/associated with “Green Book” hospitals address the problems faced by IMG applicants and the states alike when time comes for medical licensure
- Many teaching hospitals fail to maintain records of IMS/IMG clinicals
- The first response of most teaching hospitals is to refuse to verify IMS/IMG clinicals, regardless of the presence of a Clinical Affiliation Agreement with the student’s sponsor or medical school, forcing all parties to pursue legal action (seldom successful) or take the path of least resistance – which is verification by supervising attending physician
- A majority rely on the supervising physician to verify the clinicals, which can satisfy the state licensure need and requirements if done correctly
- Some physicians or hospitals may reject to verify, due to advice from their legal department
- Most verifications will confirm the date, time, and name of the supervising physician, but will most likely not address the main issue, which is the quality of clinicals conducted
- The term “Green Book Clinicals” lacks a specific definition since this never applies to U.S. medical graduates
NEXT STEPS TO BECOMING A DOCTOR…
Step 1: Where do you want to practice?
- Familiarize yourself with the ongoing research AmeriClerkships is hosting at our Medical Licensure & Student Clinical Clerkship verification policies Google Communities page
- Purchase and review the State Medical Licensure Requirements and Statistics, 2014
- Visit the Federation of State Medical Boards for Initial Licensure USMLE requirements
- Identify the states which require a temporary training license for residency, and those you will definitely not qualify to secure a training license in (avoid these), then
- Strategize a plan to apply to nearly all programs in the remaining states by contacting AmeriClerkships
Step 2: Know your rights!
- There are several ways in which you can complete your clinicals and still receive credit for them when applying to residency and medical licensure. They can be conducted in:
Government teaching hospitals in the country where your medical school is located, or
Step 3: Avoid costly mistakes!
- Watch the webinar below:
- Begin to steer away from potentially devastating mistakes by becoming a member of AmeriClerkships Medical Society! You will be assigned to your own personal Residency Enrollment Strategist, Dr. Mizani, as your Healthcare Advisor, and an in-house Healthcare Writer & Editor to help you perfect your residency application.
- Focus on competing with U.S. medical students, learning about the U.S. healthcare and job market cultures, and becoming a great doctor; let AmeriClerkships Medical Society and its team of professionals help you tackle the barriers.
- Protect yourself: have your medical school agree and authorize your away rotations by completing your “Clinical Authorization Letter”.