The Medical Chronicles

Alright guys, a whole lot of info coming at you. For my premed followers, I want you to seriously evaluate if going the Caribbean med school route is truly worth it, and if you are willing to take on extra anxiety and stress. That being said, a different post on that to come again, but the ask box is always open!

So, the point of this post is to talk about the recent pathways ECFMG came up with for those students who were unable to take Step 2 CS in order to be eligible for certification. These include:

Eligibility for All Pathways

Applicants who are eligible to pursue ECFMG Certification based on one of the pathways include those who:

Have not already passed Step 2 CS.

Are not barred by ECFMG from pursuing certification.

Are not barred by USMLE from taking a Step or Step Component from August 1, 2020 to January 31, 2021.

Have not failed a USMLE Step or Step Component (Step 1, Step 2 CK, or Step 2 CS) two or more times.

Have taken or been registered for any USMLE Step or Step Component since January 1, 2018.

Pathway 1: Already Licensed to Practice Medicine in Another Country Applicant has held a full, unrestricted license or registration to practice medicine in any country at any time on or after January 1, 2015. License does not need to be currently valid. The license or registration has not been subject to disciplinary action.

Pathway 2: Already Passed a Standardized Clinical Skills Exam for Medical Licensure - General Medical Council: Professional and Linguistic Assessment Board (PLAB) Part 2 - Australian Medical Council: Clinical Examination Part 2 - Medical Council of Canada: Qualifying Examination Part 2, National Assessment Collaboration Examination - Medical Council of New Zealand: NZREX Clinical - Medical Council of Ireland: Pre-Registration Examination System (PRES), Level 3

Pathway 3: Medical School Accredited by Agency Recognized by World Federation for Medical Education (WFME) Applicant’s medical school is currently accredited by an agency recognized by WFME (and meets other ECFMG requirements). See the list of eligible schools. Date of graduation must be on or after January 1, 2018. An authorized school official must attest to applicant’s clinical skills.  

Pathway 4: Medical School Participates in U.S. Federal Student Loan Program Applicant’s medical school currently participates in the U.S. Federal Student Loan Program (and meets other ECFMG requirements). See the list of eligible schools. Date of graduation must be on or after January 1, 2018. An authorized school official must attest to applicant’s clinical skills. Pathway 5: Medical School Issues Degree Jointly with a U.S. Medical School Accredited by Liaison Committee on Medical Education (LCME) - Weill-Cornell Medicine - Qatar - Duke University - National University of Singapore Medical School

Now, why are these so troublesome and problematic? They are barring many intelligent and qualified students to go into Match 2021 who would have otherwise been ok if they had Step 2 CS under their belt. The ECFMG is allowed to enforce certain requirements, but they should give time for policies to go into effect, like one year, not one abrupt day:

They originally had the policy that all schools must be accredited by 2023. One Caribbean school with an adequate curriculum consisting of OSCEs, shelf exams, and more had a site visit for accreditation in May, which was postponed due to COVID. This school has previously had students match every year, but according to the new rule, students might not be able to go into Match this year.

USMLE itself allows multiple attempts on Step exams, and although it definitely is frowned upon, a student should be given an equal chance to justify himself in his personal statement, or even personal interview if granted.

Pathway 2 is unfeasible as well since many countries have postponed their exams too, and there are still travel restrictions, quarantines imposed, and even monetary issues for students. As a US IMG, going to Canada to take the NAC exam will be an added $2300, plus travel expenses, and housing, along with 14 day quarantine. Plus, ECFMG hasn’t even refunded the money for Step 2 CS yet.

The required English proficiency exam in lieu of CS: more info has yet to come, but how would this be equivalent? CS tests you on clinical skills and empathy, along with English proficiency. Prometric centers are still cancelling exams on students without proper notice, so how would this work? Plus, if a student can even get to the point of getting a program interview, that’s where they can showcase their language skills and people interactions, no need to pay another whatever hundred dollars just to take and English test.

The ECFMG should be helping IMGs, but at this moment many students are feeling helpless and lost about what their future holds. It will be difficult for many to wait one year or even more, before being able to apply for Match, which further poses the issue of programs considering graduation time; and the advice from many to go into research is always easier said than done - many programs are halted at the moment, and many students do not enjoy having research forced upon them. It’s also not that easy to just find a research place that will take you.

The ECFMG has come out with the requirement that to fulfill the English proficiency, students must take the Occupational English Test (OET). This is an Australian exam…that even if you are a US/Canadian citizen/IMG… you must still fulfill… The test is $410 USD and $557 CAD.

ECFMG is going to be constantly updating, it seems. Regarding some of the concerns from earlier:

For Pathway 2 they added: “In addition to the acceptable exams listed above, ECFMG will consider: Objective Structured Clinical Examinations (OSCEs) administered as part of the medical licensure or registration process, in any language Medical school-administered OSCEs that meet the requirements for clinical skills assessment mandated by the appropriate medical regulator for licensure, only if the medical school: (1) is located in a region/country that is not served by a WFME-recognized accrediting agency; and (2) is accredited by an agency that is recognized by the appropriate government agency in that region/country and that is responsible for licensure.”

Regarding the multiple attempts: “If an applicant has two or more fails on the same USMLE Step or Step Component, it is prudent for ECFMG to require the applicant to demonstrate clinical skills through a structured, measured examination, given in the United States, before entering the U.S. health care system.” This still feels a bit troublesome because OSCES in Caribbean med schools are structured exams based on U.S healthcare, and even if you are eligible for Pathway 2, you’ve demonstrated your English proficiency and clinical skills.

OET still required. Also a little fun fact. We know Americans speak and write a  different English than Brits and Australians...but the people at OET think Kansas is spelled with a “Z”

I’m twenty-one-years-old and I’ve swallowed half a bottle of acetaminophen. The nurse had given me a cup of charcoal to neutralize the acid in my stomach. My vomit is the color of midnight. My body is ejecting a nightmare.

One of the nurses tells me, “You’ve been Baker Act’ed.” Like it was a gameshow. It’s a seventy-two hour hold. I get moved from the hospital to a mental institution called Bay Care or Bay Pointe or Bay Life. It might as well be Bay Prison. By the end of three days, I lose thirteen pounds and one of my socks.

The patients and I go to this group meeting, and the lead counselor passes out these giant rubber pens and circular sheets of paper. He asks us, “What’s your goal today?” One of the guys pulls the fire alarm and yells that he’ll never stop doing favors for crack. “It’s a free country,” he yells, while two nurses sedate him and drag him across the linoleum. He’s still yelling but the fire alarm drowns him out. The counselor asks again, “What’s your goal today?” I write down, “To get out.”

That night, my bunkmate wakes me up. He’s the same guy they dragged out of the meeting. He’s spinning his mattress over his head and he tells me, “Roaches in my bed, my veins, come on, it’s true, it’s really true!” I know my options. I can grab a counselor to stop him. I can ask to switch rooms. I can tell the guy, “It’s not true, you’re hallucinating, that’s why you’re here.”

“Hey,” I tell him. “I know. Let’s look for them, you know? If we don’t find any, we can sleep, how’s that? Let’s look for them together.” My bunkmate likes this plan. We get on our hands and knees to look for cockroaches. After thirty seconds, he gets back on his mattress and falls asleep.

I touched upon something that has since informed the way I treat people. The way I treat their mental health. The way I treat their feelings of loneliness, of being unheard, of being a minority, of being silenced.

If it’s important to you, it’s important to me. If it’s real to you, it’s real to me. If it hurts you, it hurts me. Your pain is my pain.

— J.S.

[Excerpt from my book, The Voices We Carry. https://www.amazon.com/The-Voices-We-Carry/dp/0802419895]

Alright guys, a whole lot of info coming at you. For my premed followers, I want you to seriously evaluate if going the Caribbean med school route is truly worth it, and if you are willing to take on extra anxiety and stress. That being said, a different post on that to come again, but the ask box is always open!

So, the point of this post is to talk about the recent pathways ECFMG came up with for those students who were unable to take Step 2 CS in order to be eligible for certification. These include:

Eligibility for All Pathways

Applicants who are eligible to pursue ECFMG Certification based on one of the pathways include those who:

Have not already passed Step 2 CS.

Are not barred by ECFMG from pursuing certification.

Are not barred by USMLE from taking a Step or Step Component from August 1, 2020 to January 31, 2021.

Have not failed a USMLE Step or Step Component (Step 1, Step 2 CK, or Step 2 CS) two or more times.

Have taken or been registered for any USMLE Step or Step Component since January 1, 2018.

Pathway 1: Already Licensed to Practice Medicine in Another Country Applicant has held a full, unrestricted license or registration to practice medicine in any country at any time on or after January 1, 2015. License does not need to be currently valid. The license or registration has not been subject to disciplinary action.

Pathway 2: Already Passed a Standardized Clinical Skills Exam for Medical Licensure - General Medical Council: Professional and Linguistic Assessment Board (PLAB) Part 2 - Australian Medical Council: Clinical Examination Part 2 - Medical Council of Canada: Qualifying Examination Part 2, National Assessment Collaboration Examination - Medical Council of New Zealand: NZREX Clinical - Medical Council of Ireland: Pre-Registration Examination System (PRES), Level 3

Pathway 3: Medical School Accredited by Agency Recognized by World Federation for Medical Education (WFME) Applicant’s medical school is currently accredited by an agency recognized by WFME (and meets other ECFMG requirements). See the list of eligible schools. Date of graduation must be on or after January 1, 2018. An authorized school official must attest to applicant’s clinical skills.  

Pathway 4: Medical School Participates in U.S. Federal Student Loan Program Applicant’s medical school currently participates in the U.S. Federal Student Loan Program (and meets other ECFMG requirements). See the list of eligible schools. Date of graduation must be on or after January 1, 2018. An authorized school official must attest to applicant’s clinical skills. Pathway 5: Medical School Issues Degree Jointly with a U.S. Medical School Accredited by Liaison Committee on Medical Education (LCME) - Weill-Cornell Medicine - Qatar - Duke University - National University of Singapore Medical School

Now, why are these so troublesome and problematic? They are barring many intelligent and qualified students to go into Match 2021 who would have otherwise been ok if they had Step 2 CS under their belt. The ECFMG is allowed to enforce certain requirements, but they should give time for policies to go into effect, like one year, not one abrupt day:

They originally had the policy that all schools must be accredited by 2023. One Caribbean school with an adequate curriculum consisting of OSCEs, shelf exams, and more had a site visit for accreditation in May, which was postponed due to COVID. This school has previously had students match every year, but according to the new rule, students might not be able to go into Match this year.

USMLE itself allows multiple attempts on Step exams, and although it definitely is frowned upon, a student should be given an equal chance to justify himself in his personal statement, or even personal interview if granted.

Pathway 2 is unfeasible as well since many countries have postponed their exams too, and there are still travel restrictions, quarantines imposed, and even monetary issues for students. As a US IMG, going to Canada to take the NAC exam will be an added $2300, plus travel expenses, and housing, along with 14 day quarantine. Plus, ECFMG hasn’t even refunded the money for Step 2 CS yet.

The required English proficiency exam in lieu of CS: more info has yet to come, but how would this be equivalent? CS tests you on clinical skills and empathy, along with English proficiency. Prometric centers are still cancelling exams on students without proper notice, so how would this work? Plus, if a student can even get to the point of getting a program interview, that’s where they can showcase their language skills and people interactions, no need to pay another whatever hundred dollars just to take and English test.

The ECFMG should be helping IMGs, but at this moment many students are feeling helpless and lost about what their future holds. It will be difficult for many to wait one year or even more, before being able to apply for Match, which further poses the issue of programs considering graduation time; and the advice from many to go into research is always easier said than done - many programs are halted at the moment, and many students do not enjoy having research forced upon them. It’s also not that easy to just find a research place that will take you.

The ECFMG has come out with the requirement that to fulfill the English proficiency, students must take the Occupational English Test (OET). This is an Australian exam...that even if you are a US/Canadian citizen/IMG... you must still fulfill... The test is $410 USD and $557 CAD.

This post is going to try and summarize the AAP statement regarding returning to school in the age of COVID-19.  The article CAN BE FOUND HERE.  I highly recommend primary care providers review this material directly.  It is very thoughtfully written and brings up a lot of issues that most folks don’t take into account when talking about and formulating opinions on this topic.  I’m going to be focusing on the WHY more than the HOW.  I will touch on some major themes with the HOW, but that aspect is very age dependent and depends on available school resources, personnel, and planning.  This is going to be dense, but let’s do it.

Today Dr. B is going to teach you some old, outdated medicine that will only help you at some sort of medical trivia event.  Good times!  As you can probably guess, if its called Fifth disease there must be first through fourth diseases, right?!  Well there used to be.  The list was based on the most common causes of infectious rashes in kids.  I’m not sure when the list was in wide use but it was essentially obsolete by the 90s.

FIRST DISEASE - Measles.  That’s easy.

SECOND DISEASE - Scarlet Fever.  Another easy one.

THIRD DISEASE - Rubella.  Seems pretty easy.

FOURTH DISEASE - This is where it goes off the rails.  We’ll finish the list and circle back.

FIFTH DISEASE - Parvovirus B19, a.k.a. Erythema Infectiosum

SIXTH DISEASE - Roseola Infantum or Erythema Subitum.  Caused by human herpes virus 6B and 7.

So let’s go back.  What the hell is Fourth Disease?  When the list was in widespread use, Fourth Disease referred to Filatow-Dukes’ Disease.  Originally described by Clement Dukes in 1900, there is a debate in modern medicine as to what exactly he was talking about.  Some folks think that it refers to Staph Scalded Skin Syndrome, also known as Ritter’s Disease.  Other folks, however, believe that Filatow-Dukes’ Disease is actually people misdiagnosing scarlet fever and therefore doesn’t really exist as its own entity.  By the late 60s-early 70s folks were already questioning Fourth Disease with a 1979 article in The American Journal of Disease in Children publishing an article linking it to epidermolytic toxin-producing Staphylococcus.

Despite all this, occasional outbreaks of mysterious rashes in children often raise the question, “Is this Filatow-Dukes’?” and occasionally papers show up in journals positing another etiology which would reestablish it as a credible diagnosis.

“Treat people the way you expect to be treated.”