A brief guide for trainees interested in undertaking a fellowship or working in the USA

Kyle Robinson
President-Elect, Resident Component, American Society of Anesthesiologists

We hope to provide a brief overview of the requirements to train or work as an anesthesiologist in the United States as a Foreign Medical Graduate (FMG). This is intended to be nothing more than friendly advice and a starting point for someone considering anesthesia options within the United States. This document was put together using public licensing and board certification websites with additional insights from FMG colleagues that have participated in residency, fellowship or employment opportunities in the United States. It is important to note that each institution and state has slightly different requirements, so please take this as a general guide. The ASA Resident Component has no influence over such opportunities and any further considerations to pursue a future in anesthesiology in the United States require further research into the topics discussed.

To provide context for the requirements, here is a reminder of the minimum educational and training requirements for a US citizen to become an anesthesiologist:

  • Undergraduate College Education (4 years)
    • Medical College Admission Test (MCAT)
  • Medical School (4 years)
    • United States Medical Licensing Examination (USMLE) Step 1, Step 2CK & CS
  • Internship (1 year)
    • USMLE Step 3
  • Anesthesiology Residency (3 years)
    • American Board of Anesthesiology (ABA) BASIC, ADVANCED & Oral Boards
  • Subspecialty Fellowship (1 year)
    • +/- Subspecialty Board Examination

The first hurdle to overcome prior to applying for a training position or coming to the United States is obtaining an Educational Commission for Foreign Medical Graduates (ECFMG) Certification. In addition to having graduated from medical school, the individual is required to take the United States Medical Licensing Examination (USMLE) Step 1, Step 2CK and Step 2CS. These exams are administered to all US medical students during the second, third, and fourth year of medical school respectively and the scores are extremely important for getting into desired residency programs. For FMGs, scoring well on these exams is even more important to be seriously considered for a residency or fellowship position.

Before starting anesthesia training, most residency programs will also require USMLE Step 3. This fourth exam in the USMLE series is also a prerequisite to be considered for an anesthesia subspecialty fellowship position. Taking this series of exams is a prerequisite to ECFMG Certification because they are also required to obtain the necessary state medical licensing needed to provide clinical care to patients. Whether considering a non-ACGME or ACGME approved fellowship program, this state medical license is needed.

Completing fellowship in the United States is not enough to practice in any clinical setting. Despite previous anesthesia training and subsequent advanced subspecialty training in the US, Board Certification through the American Board of Anesthesiology (ABA) is required. I have provided a link below to the ABA website which describes the process. This is not trivial and requires years of working at an academic institution and further residency-level anesthesiology examinations. Given these restrictions, most fellowship-trained FMGs are not able to obtain an Unlimited State Medical License required to practice in the community and are limited to employment at the institution where they completed their fellowship training.

All of these requirements are further complicated by an individual’s visa status. The ECFMG will sponsor a J-1 visa, but these usually require that the FMG return to their home country and not return for a minimum of two years after they have completed their training. There are other visa options such as an H-1 visa that would facilitate a long-term stay, but these are very difficult to obtain. Although the visa process is very relevant for non-US citizens, it is a complex topic and outside our scope of understanding.

Outside of continuing on from fellowship to staff anesthesiologist at the institution where residency or fellowship was completed, the only other common avenue to practicing in the United States as a foreign-educated and trained anesthesiologist would be getting a Faculty Appointment. These positions are generally reserved for those who have made significant research or clinical contributions to the specialty making them a highly desirable addition to a US institution. Even under these circumstances, the ECFMG requirements outlined above are still necessary in order to practice in any State in the US.

The process to become eligible to train or work in the United States as a Foreign Medical Graduate is difficult, but it is possible. Most of us have trained with and been taught by foreign-educated or trained anesthesiologists at some point in our training. Their dedication to the specialty and hard work navigating the appropriate requirements has contributed to our development and growth as anesthesiologists. Although daunting, we hope that this can help provide you as trainees with some of the tools necessary to consider a future in anesthesiology in the United States.

  • Anesthesiology Subspecialty Fellowship
    • ECFMG Certification
    • Complete USMLE Examinations Step 1, Step 2 (CK & CS)
    • Complete USMLE Step 3 prior to starting clinical training
    • Trainee (Limited) State Medical License – Can only practice in academic institution of training
      • Non-ACGME & ACGME approved fellowship both require a Trainee (Limited) State Medical License
    • J-1 Visa sponsorship provided by ECFMG once requirements met
  • Employment
    • US fellowship-trained anesthesiologists
      • The Trainee (Limited) Medical License required for fellowship training can often be used to continue employment at the institution where one is fellowship-trained.
    • Faculty Appointment – Foreign medical education and training
      • Academic position reserved for accomplished anesthesiologists that have made significant clinical or research contributions to the specialty.
    • American Board of Anesthesiologists Certification
      • To be board eligible, one must have their Full (Unlimited) State Medical License
      • Varies by state but often requires multiple years of clinical practice in the US.
      • Most institutions (academic and private practice) and states require ABA board certification to be considered for employment.
      • This is a very involved, multi-year process outlined on the ABA website

2 replies

Bipin Kuttiyanickal Ravi
Hi Sir /Madam My name is Bipin kuttiyanickal Ravi ,working as senior anaesthesia technician in Kuwait Govt Hospital 10yrs experience . Actually I want to know about what are the mandatory for work in USA ,reasonly my HCPC registration finished. I kindly request you to guide me how to work in USA.
1 month ago
Dr.Srirangapatna K.Premnath
Dear Kyle Robinson I am a qualified Anaesthesitist still working in Ireland as a consultant. Although I have reached 69 years I want to work few more years. I hold following qualification 1) Bachelor of science 1971 2) MBBS 1977 3) Diploma in Anaesthesia 1986 4) FCA RCSI 2006 5) EDAIC 2016 6) ECFMG /VQE 1983. I wish to work as a Staff Anesthesiologists in USA, pls advise me . Thank you Regards Premnath 25/12/2021
1 year ago

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