The Credentialing Document-Part I: Understanding Medical Education

Credentialing is the process by which a physician (doctor) is certified to practice his/her trade at a given institution. It is a systematic documentation of a physician’s training, licensure and medico-legal history that gives credibility to the physician that enables him/her to practice medicine/surgery at a given institution. It constitutes many steps, which must be documented in detail. This is the first of a yet unknown series on the topic: 

1. Education:
   1. India:

                                                               i.      Medical training: Following the completion of high school (12^th standard), most doctors in India go straight to medical college, where they complete a course that consists of three one and a half year terms of the MBBS, each followed by a university level examination. This makes one eligible for the MBBS degree.

                                                             ii.      Internship (India): In order to get the MBBS degree in India, the trainee must also complete a one year internship, which consists of 3 months each in medicine, surgery, obsterics and gynaecology and preventive and social medicine and their subspecialties (if applicable). It is important to document this entire training history, complete with the number of hours spent on each rotation throughout medical training. Some states like California require at least 4 weeks of training in psychiatry and this must be documented. The internship training in India does not count as an internship in the United States and so almost all doctors traveling overseas despite their training will have to re-do an internship there, which is slightly different.

                                                            iii.      Post graduate training: After the MBBS degree, doctors may apply to get into specialty training programmes, also called residency/houseman/registrar etc. This is usually in a specialty such as Internal Medicine, General Surgery, Obstetrics and Gynaecology and Radiology. The training period usually lasts for about 3 years and consists of 6 month “posts”, which maybe at the same or different hospitals. At the end of a specified training period, the physician is eligible to take an examination and get certain degrees. The most common of these is an MD (Medicine/Radiology) or MS (Surgery/ObsGyn), which is administered by the university. There is also a degree called the DNB or Diplomate of the National Board, which is administered by a central board in Delhi. Other degrees may also be obtained along the course of one’s training and in radiology one may get a DMRD or DMRE also. An individual may hold one or all of these degrees/diplomas.

                                                           iv.      Sub/super specialization: This means training in a specialty area of the specialty area. For example, brain imaging (neuroradiologist). Upon completion of this, one may or may not take the DM examination.

1.  
   1. USA:

                                                               i.      College or pre medical education: After 12^th standard (grade), most US people will go to college and spend four years to get a BS or BA (like BSc, BA, BComm etc). Following this, some people may do a masters and even a PhD. It is not unusual that people in the US take medicine as a second career and may have been Bankers, nurses, actors, military personnel before they go to medical college.

                                                             ii.      Medical education: in the US, this is typically 4 years and has no compulsory internship training attached. The degree at the end of this is called the MD which is equivalent to the MBBS in India and different from the MD in India.  Some people may take longer because they combine their MD with a PhD. There is a small number of people who go to medical college after 12^th standard in the US, and will complete the course in 6-7 years as opposed to 8 years or more for most others (4 years BS/BA + 4 years MD). Training during this time is well documented by most medical colleges and these can be obtained relatively easily by writing to the college.

                                                          iii.           Internship: After getting the MD degree, almost everyone does an internship. This is usually in a “clinical” field that has patient contact such as internal medicine or general surgery. Once this first year is complete, the physician may continue with their specialty training. This is different from the Indian internship as it is not required to get the MD degree and is considered post graduate education. The internship may also be rotating through multiple specialties and maybe referred to as a “transitional year”. This is called the PGY1 (post graduate year 1).                                                    

 iv.      Residency: The next 2-5 years after the internship are usually spent in specialty training such as radiology, surgery etc etc. At the end of this, one takes an examination administered by the specialty board (American board of Radiology/Nuclear Medicine/Surgery etc etc) and becomes “board certified”. There is usually no degree applied at the end of this, but we occasionally use DABR (Diplomate of the American Board of Radiology). An individual, if appropriately trained may have many board certifications.                                                           

v.      Sub/super specialty training (fellowship): After specializing in radiology, one may be sub specialized in neuro/interventional/pediatric/nuclear radiology and take an exam to get a Certificate of Additional Qualification (CAQ). Some people may do the additional training and not take the exam and some may be in sub specialties such as musculoskeletal radiology, where these exams do not exist. 

Bridging the Gap: 

Obviously, USA does not recognize all examinations taken in India and vice versa. Since we deal primarily with physicians trained in India, I will only discuss the qualification of the Indian physician in USA.

The first step for an MBBS physician in India to get qualified in the USA is to pass a set of examinations that adjudge them equally qualified as US physicians. These are called the USMLEs (United States Medical Licensing Examinations) and are the same set of examinations that all US medical students take. They consist of 4 parts: Parts I, II (theory) and CS (Clinical Skills, practical) followed by a final Part II (administered by a state board of the applicant choosing (FSMB) but scores valid in all states). The CS examination is a recent addition and some physicians may not have had to take them. The USMLE examinations were previously also known as ECFMG, FLEX, FMGEMS etc. For all foreign medical graduates, the ECFMG (Education Council for Foreign Medical Graduates) is the body that co ordinates the examinations.

Once all the examinations have been passed, one is eligible to enter the workforce. Again, the hiccup is that if you have done specialty/subspecialty training in India, it is not fully credited in the USA and so re training is required. Equivalency can be achieved in the following ways:

1. Apply to a US residency program and repeat the four years of radiology training and then take the ABR exam again.
2. More recently, the ABR will allow one to join a fellowship at a university hospital with a recognized training program* directly after completing training in India and passing the USMLE. Four years in such a training program, either as a fellow or faculty makes one eligible to take the ABR examination.