International medical graduates (IMGs) account for 25% of the United States physician workforce. The main pathway for IMGs who wish to be licensed as orthopaedic surgeons in the U.S. is to complete a Residency Program. However, there are many prerequisites in order to apply for residency.

Passing the first two steps of the United States Medical Licensing Examination (USMLE) series are the initial steps towards obtaining certification. The USMLE consists of three steps designed to assess the ability to apply a broad spectrum of knowledge, concepts, and principles to evaluate basic patient-centered skills.

• Step 1: USLME Step 1, a multiple-choice exam, is designed to test how well the examinee applies basic science concepts to clinical scenarios.
• Step 2 (two separate exams): The USLME Step 2 CK (Clinical Knowledge) is a multiple-choice exam designed to determine whether the examinee possesses the medical knowledge and understanding of clinical science essential for the provision of patient care under supervision. The USLME Step 2 CS (Clinical Skills) is a separate hands-on exam that tests clinical and communication skills through the ability to gather information from standardized patients, perform a physical examination, communicate the findings to the patient, and write a patient note.

Note: These exams can be taken in any order, but it is strongly recommended they are taken in the order listed above. All physicians (domestic graduates in U.S. and international) are required to pass these exams.

After passing USLME Step 1, Step 2 CK, and Step 2 CS, an IMG is qualified for certification by the Educational Commission for Foreign Medical Graduates (ECFMG). Medical transcripts and a medical degree are also required for this certification. The ECFMG sets the standard for evaluating the qualifications of IMGs before they enter U.S. graduate medical education (GME).

Once a doctor is ECFMG certified, they are eligible to take USLME Step 3, the final examination the USLME sequence. This multiple-choice exam assesses the ability to apply medical knowledge and the understanding of biomedical and clinical science necessary for the unsupervised practice of medicine.

ECFMG certified IMGs are also qualified to apply for hospital residency. With a limited number of residency positions available each year and an abundance of applicants, many IMGs apply to multiple programs and multiple specialties to increase their chances of securing a position. The general method to apply for residency programs is through the Electronic Residency Application Service (ERAS)and the National Resident Matching Program (NRMP). Steps for applying include:

1. Residency-Match Application
   • CV
   • Reference Letters
   • Photograph
   • Personal Statement
2. Interviews with Program Directors and/or selection committee for new residents
3. Ranking of programs (both the student and the residency programs will rank each other after the interview process and the computer will put the rankings together through a query)

After completion of specialty residency training, an orthopaedic surgeon is eligible for board certification by the American Board of Orthopaedic Surgery. This means that an orthopaedic surgeon has met the specified educational, evaluation, and examination requirements of the Board. This process requires successful completion of a standardized written exam followed by an oral exam focused on the surgeon's clinical and surgical performance over a 6-month period.

In addition, some orthopaedic surgeons may choose to further their training through a fellowship. Fellowship training is an orthopaedic subspecialty and sometimes has a research component involved with the clinical and operative training. For a list of ACGME accredited fellowship opportunities and unlimited access to a continually updated directory, visit the Postgraduate Orthopaedic Fellowships directory.