Author + information
- Romain Didier, MD∗ ( and )
- Edward Koifman, MD
- ↵∗Reprint requests and correspondence:
Dr. Romain Didier, MedStar Washington Hospital Center, 110 Irving Street, Northwest, Suite 4B-1, Washington, DC 20010.
Broad research exposure has become a cornerstone of an academic hospital-based career in Europe (1). One of the ways to acquire this type of experience is through a highly regarded international research fellowship. Living in a foreign country and meeting professionals from around the globe grant fellows the opportunity to pursue research, dedicate time to scientific developments, and gain new perspectives. However, the choice of the destination country is critical in obtaining a meaningful research experience.
Why choose a research fellowship in the United States? During the 2012 and 2013 academic years, 8,588 foreign physicians participated in research or clinical training fellowship programs (2). Many factors favor U.S.-based fellowships, which makes it worthwhile to complete the laborious application process and relocate, even given the difficulties of being far from home.
According to cybermetric indicators (quantity of publications, in addition to the number of external citations regarding the impact of the publications) (3), the United States is currently the highest-ranked nation in the world in terms of global scientific research activity and communication (4). Therefore, these privileged research positions that the United States offers to foreign research fellows are great opportunities to gain experience and publish scientific research.
The United States has many large and populated cities. Often, these metropolitan cities have large, diverse patient populations that are crucial for large trials. Consequently, the quality of research is improved through a large sample size and statistical power.
Because many of the foreign research fellows are not native English speakers, learning or improving their English language skills is a major advantage of their experiences. Enhanced English language skills will improve comprehension and scientific writing, as well as the capacity to communicate ideas in publications and at international conferences. Subsequently, these skills could boost the quality and value of future scientific works. However, the fellowship is not an English school, and a certain level of English is a prerequisite for a meaningful fellowship. One way of determining English skill level is the Test of English as a Foreign Language (TOEFL), which is required in most universities and includes various aspects of language skills. Passing the TOEFL is a good indicator that language will not be a barrier to succeeding in fellowship.
Quality and Diversity
The United States offers a broad range of research fellowship programs. Each program offers unique opportunities to improve expertise in basic science and clinical research in all of the varied fields of modern cardiology. Although some European university hospitals have begun to offer research fellowships within structured, dedicated programs in recent years, the current status of medical education and research training in Europe remains heterogeneous and varies across countries and cities (5).
Understanding multifaceted concepts in a different research framework, including the consideration of various laws, methods, and work styles pertaining to research, gives the fellow a critical perspective on his or her everyday research and medical practice in the country of origin. The rigors of research project protocols in the United States provide a strong framework for improving the quality and structure of future research that can be carried forward in the country of origin.
The humbling experience of sharing practices and expertise from prior training with U.S. fellows/physicians is a great honor and privilege. For example, advanced medical device technologies usually gain the CE mark in Europe at an earlier stage in development than in the U.S. medical device market, so this may give an international fellow the opportunity to contribute his or her experience with these devices to the U.S. medical community.
Working closely with researchers from different regions across the world allows for the exchange of ideas and practices and creates professional and personal relationships for future collaborations, which is possibly one of the most important results of these fellowship programs.
The United States conducts many large-scale studies through national- and industry-supported grants, which demands a real effort in planning and execution on behalf of the fellow. So, how does one prepare and apply to a U.S. research fellowship? Please look to the steps below as possible suggestions.
Select a Mentor
The selection of a mentor at a U.S. center is extremely important for a successful fellowship and is highly dependent on the fellow’s contacts and the contacts of the senior faculty at the fellow’s native institution (6).
Choose Research or Clinical Training
U.S. fellowships offer many opportunities in both research and clinical training. The U.S. medical system, however, does not allow for cross-equivalence with foreign countries (7). Therefore, clinical programs usually last more than 1 year and require additional testing as part of the U.S. Medical Licensing Examination, which includes a broad spectrum of medical sciences and requires significant preparation and financial resources. Each test is approximately $1,000, in addition to a trip to the United States to take the clinical skills part. Yet, research programs do not require U.S. medical licensure and usually can be tailored to the fellow’s interests. However, with a U.S. research fellowship, no clinical practice is allowed.
Consider Research Topics
As with any fellowship, the major research theme must be in accordance with one’s field of interest and future plans to ultimately integrate this broad experience from an academic university hospital with a career in the country of origin.
The cost of living can be relatively high in the United States compared with some locations in Europe—especially in some urban areas. Thus, finding a funding source is a crucial issue, which should be addressed as early as possible. Fortunately, there are many possibilities, because many U.S. centers and organizations offer research scholarships and grants for foreign researchers. Funding might also be available from the country of origin, for example, funding from the fellow’s university or hospital, medical associations, or other private organizations.
Apply for a Visa
The temporary nonimmigrant J-1 visa remains the most common visa offered to foreign physicians (8). This exchange visitor program is defined by the U.S. Code of Federal Regulations (22 CFR §62.27) and is sponsored by the Educational Commission for Foreign Medical Graduates (2). The J-1 application process requires a letter of acceptance, proof of a funding source, medical school transcripts, and diplomas. After the validation of all documents, the Educational Commission for Foreign Medical Graduates issues the DS-2019 form to the candidate, and he or she can then apply for a visa at the U.S. embassy in the country of origin.
Importance of Family
Family is of the utmost importance. Without familial support, success in fellowship is very difficult; therefore, the fellow should seriously consider his or her family’s needs. These needs include housing, a job, or continued education opportunities for the spouse and appropriate schooling for any children. The entire family must be prepared to spend a set amount of time in a foreign country, possibly delaying their own personal goals for the ultimate benefit of the research fellow’s career. However, this experience can offer many rewarding opportunities and unique experiences that will enrich the lives of all of the family members.
At the end of the fellowship exchange program, a fellow’s accomplishments may differ from his or her original expectations. A fellow’s goals should be determined by his or her career plan and the demand for specific research developments in the country of origin. For some physicians, publishing must be a priority, and for others, acquiring clinical or technical skills is fundamental.
Ultimately, once the fellow finds a location that will provide the tools and guidance necessary to conduct research, a transatlantic experience in the United States, including personal development and collaboration, will positively aid in the improvement of the fellow’s future practice and career. Ideally, this experience will, in turn, enable the researcher to have a solid research framework and a successful career in medicine. After fellows return to their country of origin, they can share their experiences with their European colleagues and collaborate with international researchers to initiate programs based on their experience abroad.
RESPONSE: Crossing Borders: A Revealing Personal and Professional Experience
To become a cardiologist today, most European countries offer structured fellowship programs. The European Society of Cardiology has published a core curriculum summarizing the knowledge base and skills that such a program should include (1), and many national medical societies have adapted their recommendations. Thus, almost everywhere in Europe after 2 to 3 years of training in internal medicine—the common trunk still required as a basis—and 4 years of cardiology training, the board in cardiology can be obtained.
Why, then, move abroad? This is the very question I asked myself at age 30 years when I was considering the opportunity to train in the United States. The United States, it was said, is the country of science, and if you want to make a career, it is the place to go. But, go where? After talking to supervisors and colleagues, I decided to get the information directly onsite. I purchased airplane tickets for cities around the United States, interviewing at 7 academic centers. Eventually, I decided to choose the Mayo Clinic, although Rochester, Minnesota, did not appear to be a particularly exciting place to live. Indeed, Paul M. Vanhoutte’s laboratory at this prestigious institution caught my attention. Also, the endothelium, then a neglected structure of the cardiovascular system, was the center of its interest, and I felt that this was what I wanted to pursue.
However, it was not only this new frontier that turned out to be must stimulating; it was also the positive atmosphere, the feeling that we all could discover unknown aspects of cardiovascular regulation, and as if the prophecy was self-fulfilling, we did. For a Swiss person, having grown up in a culture of skeptics, this positive attitude lifted my spirits and facilitated scientific productivity.
Later, in the clinical service, I had a similar experience. I was told to learn echocardiography over a 6-month period. At home in Switzerland, a single staff cardiologist had monopolized the technology, and no structured fellowship program existed. This was a door opener as well.
However, this experience was not only medical, but cultural as well. To live on another continent with a different mind-set—a country of immigrants from all over the world—was equally enlightening. The fact that achievements counted more than origin or personal relations was a further motivator.
Is the United States still the mecca of science and medicine today? The European continent, which lost its leading role in science during the devastating Second World War, has certainly recovered. Indeed, some of the European scientists and institutions have become worldwide leaders, and the European Society of Cardiology has clearly reached the level of its U.S. partner societies. Some, particularly smaller, countries have developed an impressive scientific productivity as assessed by Nobel Prize Laureates, citations, and patents per capita, but overall, still almost one-half of scientific papers originate from institutions in the United States.
So, is it still worth it for a European to train in the United States? The answer is a clear yes. Certainly, most things are also offered by the finest European universities, with structured widespread availability of fellowship programs. However, it is the experience of crossing borders, living the American way of life, the ease of interacting with colleagues and supervisors, as well as the careful mentoring of fellows that is unique. In short, the opportunity to see many things from a different angle can still make a difference.
The authors wish to thank Dr. Ron Waksman, Dr. Augusto Pichard, and Dr. Sarkis Kiramijyan for help with content development and editorial guidance.
Dr. Didier receives support from the French Federation of Cardiology.
- American College of Cardiology Foundation
- Borchgrevink H.,
- Scholz B.
- ↵Educational Commission for Foreign Medical Graduates. 2013 annual report. Available at: http://www.ecfmg.org/resources/ECFMG-2013-annual-report.pdf. Accessed January 26, 2015.
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- ↵Ranking Web of World Hospitals. Cybermetrics Lab, Consejo Superior de Investigaciones Cientificas (CSIC), Spain, July 2014. Available at: http://hospitals.webometrics.info. Accessed January 21, 2015.
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- ↵Educational Commission for Foreign Medical Graduates. ECFMG certification fact sheet. Available at: http://www.ecfmg.org/forms/certfact.pdf. Accessed January 26, 2015.
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