In India, it is quite an achievement to graduate from medical school, given that many students come from modest socio-economic backgrounds.

It’s an even higher hurdle for foreign medical graduates to turn that degree into a license to practice medicine in the U.S.

“For a [foreign medical graduate] to come to this country, they have to be among the best students in their native country,” said Anupam B. Jena, an Indian American who is an associate professor of health care policy at Harvard Medical School. Jena is also a physician at Massachusetts General Hospital in Boston.

The standards for acceptance into a U.S. residency program are high for international applicants. An international medical graduate (IMG) describes a U.S. citizen or green card holder who obtained their degree outside the U.S., while a foreign medical graduate (FMG) describes a foreigner who completes a degree in their country of origin.

Indian FMGs in the U.S. are composed of India’s topmost students, Jena said.

So how does someone with a Bachelor of Medicine, Bachelor of Surgery (MBBS) and a Doctor of Medicine (M.D.) and a post-graduate degree from an Indian institution practice medicine in the U.S.?

It starts with gaining certification from the U.S. Educational Commission for Foreign Medical Graduates, which measures whether FMGs are prepared for a residency program in the U.S.

Graduates must next complete the U.S. Medical Licensing Examination (USMLE). The exams determine an IMG’s or FMG’s medical knowledge and skills in line with standards and practices in the U.S. The USMLE website describes it as a three-step exam that evaluates an applicant’s basic medical and scientific knowledge, clinical knowledge and clinical skills. It takes years to achieve medical licensure, but must be accomplished within seven years.

Costs to attain medical licensure through the USMLE vary with each stage of the examination, but it totals about $4,000.

“The biggest hurdle is getting admission into a U.S. residency training program,” Jena said.

Many Indian medical students participate in internships, unpaid or paid, in the U.S., where they shadow physicians and learn more about U.S. health care and medicine, he said.

Jena urged Indian doctors to apply to at least 30 health care programs in the U.S., to ensure at least five to 10 interviews for employment.

Applicants travel to each hospital for in-person interviews, said Rachana Gavara, an Indian American obstetrician-gynecologist at New York-Presbyterian (NYP) Hospital who studied medicine in India and immigrated to the U.S. in 2000.

“There are certain specialties which are much easier for foreign medical grads to get into like internal medicine, psychiatry, pediatrics, family medicine,” Gavara said.

“Some specialties, like the neurosurgery, dermatology, radiology orthopedics, burns and plastics are very competitive,” said Gavara, who was a post-doctoral fellow at Cornell University for three years.

Medical licenses are issued on a state-by-state basis by a medical board, so a doctor would apply in the state in which they intend to work. Licenses must be renewed every two years.

With those milestones achieved, and after completing residency training in a U.S. program, medical practitioners can practice independently in the U.S.