key: cord-290620-dvlnx2z3 authors: Park, Jewel; Rhim, Hye Chang title: Consequences of COVID-19 on international medical graduates and students applying to residencies in the United States date: 2020-04-21 journal: Korean J Med Educ DOI: 10.3946/kjme.2020.156 sha: doc_id: 290620 cord_uid: dvlnx2z3 nan The coronavirus disease 2019 (COVID-19) pandemic has necessitated unprecedented measures to contain the virus, including restricting foreigners from entering the United States. Since January 31, 2020, several presidential proclamations have sequentially restricted the entry of foreign nationals from China, Iran, and much of Europe; and as of March 20, the Department of State has temporarily suspended routine visa services at all US Embassies and Consulates [1] . Previous immigration restrictions, such as Presidential Proclamation 9645 in 2018, had already raised concerns about hindering the entrance of international medical graduates (IMGs), who constitute 25% of the physician workforce in the United States [2] . According to the National Resident Matching Program (NRMP), also known as the Match, approximately 7,000 non-US IMGs, in addition to 5,000 US IMGs, apply for residencies in the United States every year, citing various reasons such as greater professional opportunities, a better training environment, or political stability [3] . The application process for IMGs is complex and rigorous, often requiring several years after graduation from medical school, and it is inherently unpredictable, with only 60% of applicants matched successfully [4] . Thus, the process is especially vulnerable to perturbations such as the current pandemic, and the consequences will negatively affect not only the flow of the physician workforce into the United States, but also the career fulfillment of IMGs and bilateral exchange of knowledge between the United States and other countries [5] . While the negative impacts of the pandemic on the residency application process may be minimal if the pandemic is controlled in the near future, estimates suggest the spread of COVID-19 in the United States will peak in June 2020, and due to the risk of rebound transmission, widespread social distancing will need to be maintained for at least 18 months, until vaccines are available to immunize the population [6] . Here, we summarize the potential consequences of the COVID-19 pandemic on the process of medical residency applications for current IMGs and international medical students (IMSs) and recommend measures that can be taken to minimize the disruption to their participation in US healthcare. Many steps in the process of residency application for IMGs require that applicants be physically present in the United States, such as the Step 2 clinical skills (CS) and Step 3 exam, and complete residency interviews. Also, although it is not compulsory, many IMGs participate in observerships/externships or research in the United States to increase their competitiveness. All these activities can be severely affected by the current travel restrictions. Step 2 CS exam is particularly important. Given the unavoidable human-to-human contact that takes place during the exam, the United States Medical Licensing Examination (USMLE) program has closed all of its five test centers as of March 16, 2020, and plans to reopen them on June 1 at the earliest [7] . While the USMLE program, after reopening, "will open additional testing appointments to help meet increased, timesensitive testing demands," not only is there a possibility that the reopening will be significantly delayed given the uncertain trajectory of the current pandemic, but a great practical difficulty is likely to arise in the plan to offer additional appointments, as the number of trained standardized patients (SPs) is limited and may even decrease if SPs decline to participate due to health concerns. This problem is especially significant because Step 2 CS testing appointments are already notorious for being extremely limited and completely fill up at least 3 to 4 months in advance. Moreover, score reporting can take up to 3 months, which means that test appointments have to be scheduled very early on to meet the deadlines set by residency programs. The process is even more complicated for non-US IMGs, who have to apply for a visa just to take the exam. With the current suspension of visa services, many IMGs will find it difficult to secure a date that will enable them to meet the deadlines, and consequently, they may have to forego applying for the 2021 Match. Since the trajectory of the current pandemic is unpredictable, a delay in reopening the USMLE test centers seems inevitable. Therefore, plans for reopening should be prepared and announced in a timely manner to avoid critical disruptions to the application process. Alternatively, authorities may consider granting a temporary waiver in the 2021 Match for Step 2 CS qualification to allopathic US medical students, for whom the need for the accreditation has comparatively less utility given the first-time pass rate of 98% [11] ; this will solve the issue of the limited availability of Step 2 CS test appointments, which is currently putting US and international applicants alike at risk of not meeting the application deadline. For IMSs who have yet to graduate, the cancellation of visiting electives in the United States is the gravest concern. Due to safety concerns arising from the COVID-19 pandemic, many medical schools in the United States have cancelled clinical rotations and stopped receiving visiting students. As of April 7, 2020, out of the 41 schools that reported their policies on visiting students to the Association of American Medical Colleges, 28 schools are not receiving visiting students [12] . It is uncertain when these medical schools will start receiving visiting medical students again. In addition to the well-recognized advantage of participating in visiting electives for successful candidacy in the Match [13] , visiting electives benefit Step 1 reporting from three-digit scores to a pass/fail grade is expected to increase the importance of visiting electives and letters of recommendation for IMSs, since they now have lost one important objective measure attesting to their clinical competency [14] . Applying to a visiting elective in the United States is already a difficult and stressful process for IMSs, due to visa issues, financial burdens, incompatibility with the home institution's curriculum, and the extremely limited number of schools that offer visiting electives to international students (just before the pandemic, only 21 medical schools offered spots for IMSs from institutions without affiliation agreements). Since many IMSs solidify their intent to practice medicine in the United Current outbreak of coronavirus disease Long-term potential implications of immigration barriers for medical education International medical graduates in the USA: a qualitative study on perceptions of physician migration Easing international medical graduates' entry into US training The importance of international medical graduates in the United States COVID-19 Response Team, Imperial College London. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand United States Medical Licensing Examination. COVID-19 updates and resources Conducting a high-stakes OSCE in a COVID-19 environment Governor Murphy signs executive order to remove barriers to health care professionals joining New Jersey's COVID-19 response and provide protections for Front Line health care responders National Resident Matching Program. NRMP FAQs during COVID-19 pandemic The USMLE Step 2 CS: time for a change Association of American Medical Colleges. VSLO Program updates The impact of visiting student electives on surgical match outcomes Change in reporting of USMLE Step 1 scores and potential implications for international medical graduates Acknowledgements: None.