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AIPG or MLE: All we need to Know before going for USMLE

Author: AshB, Posted on Saturday, December 17 @ 11:49:08 IST by RxPG  

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USMLE Step 1

Well when I got stuck between Indian Pre-PGs and USMLE , I thought I was alone, but with time I've come to realise that there are many docs like me who're in this dilemma, whether to go for AIPG (by this I mean Indian Pre-PGs) or USMLE.

I met a lot of seniors and friends and took their advice and in this process I've gathered a lot of info regarding varying aspects of this eternal question AIPG or MLE??

So in this thread I’ve tried I've tried to compile whatever info i have, including my own views regarding aforesaid aspect. Of course I've used facts and views from other relevant posts as well. I request all to add whatever info is deficient here..

In keeping with the tradition of RxPG, any additions, suggestions, comments are welcome. That would help us get a broad view of the realities we face and help lot of us to decide, what's the right course for us.

But remember, these are my own views and I’ve penned them down just to help out people like me. I may be wrong at a point and I apologise in advance for that.

Lets start with the first and basic question, that is which one is better..

We'll take factor by factor...

1. Home advantage. With AIPG you have an advantage of home country, being close to family - Its very hard to spend years abroad and many students become home sick because you don't find many people with our culture. Students, too much attached to their families might find it very difficult there when you celebrate Diwali/Holi/Eid alone. But then Indians abroad do form their own little groups and celebrate all festivals together.

2. There is a risk of being treated as 2nd citizens at the USA. But then regional, caste and creed considerations do exist in India too and sometimes are grave enough. I know people who had to leave their PG seats when limits of discrimination were crossed. So its not a very strong factor.

3. Risks. In AIPG, Selection means a seat and If u get a seat, u will surely complete a PG. But clearing MLE even up to Step 2 CS doesn't guarantee a residency slot. You may return bare handed or may have to compromise with a branch you don't like, for the whole life.

4. Expenditure. At least in the short run, expenditure for AIPG runs only in few thousands. But for MLE it is in the tune of 5-8 lacs (details later). But again in the long run MLE people earn lot lot more than their Indian counterparts. So it can be considered to be an investment.

5. Visa? Mera no aayega? This is the most critical factor for MLE. You may be denied visa even after getting 99 in both steps, that too for no reason at all. The situation these days is pretty rosy, but we gotta remember the fact that its very very unpredictable. 12 months or so from now when we apply, what the situation may turn out to be, only god knows. So never decide solely on the fact 'My senior got the visa, so will i'. Same is true for vice-versa.

6. Working conditions. MLE definitely scores over AIPG on this aspect. You'll get very good working conditions even at the lowest ranked program at US. No need to comment on the situation in india. Still i'd like to remind you here you'll be faced with lack of infrastructure n lab facilities, poor clientelle, general bias AGAINST medical community, Very frustrating payscales, broken/malfunctioning instruments, filthy hospitals. Conditions in private setup are better but then most people prefer govt jobs. In private sector you earn well only as a consultant, buts it would be 7-10 years at least before you get a consultant job at a good hospital.

A distinct disadvantage in US is that you have to be thouroughly professional. Any laxity and you are always at the risk for litigations (specially true in surgical branches). You should be willing to give best service to the patient there cos pts there are well educated and well informed. Don’t forget that the number of litigations in India is on a sharp rise. Every other day you can read about patients, relatives, local politicians storming and mobbing the hospitals on small so called lapses. Episodes of manhandling of docs is also increasingly common.

7. Earnings.
Do i need to elaborate??? In the US, even during residency (in the tune of $45k per annumn) you earn more than most of us would earn here 5 years post-PG. Its very frustrating when during PG you're given 6K and you have to look towards your parents for support. After PG, you're offered 8k/14k/20k at private hospitals. Or if you do SR-ship (Senior Residency) it runs from 15k-25k at the max.
Post residency pay scales in the US are in the tune of $ 1 lac plus p.a.

8. Job satisfaction.
Well its very subjective and variable. But most people who are in the field agree that it’s highly frustrating in majority of India. According to them Few reasons why:
* Yours pt has more faith in local quack/ compounder than you
* Pt Compliance is very poor due to illiteracy , poverty etc. But the blame of failure of treatment will always be on you.
* If you prescribe an investigation it’s always unnecessary in pts view
* Indian pts are highly reluctant to pay your meagre consultation fees
* Even after specialising you have to work as a GP because of lack of facilities you can't make specific diagnosis or perform big procedures (barring big centres)
* Pay scales are not commensurate with the quality of your qualification and work
There are hundreds more. In summary, here you feel incapable of applying the hard earned knowledge properly leading to dissatisfaction.
While in US, you get paid well, plus ample facilities at most hospitals n literate pts. who don’t worry about expenses (also due to health insurance) allow you to try to provide the best treatment according to your judgement.

9. MCI Recognition.
MCI doesn't recognise PG from US, so you would be counted as an MBBS in govt. setup, even after residency from US. So your scope in India is restricted to private hospitals. Its a good option but competition among US returned docs is increasing day by day, so it might not be a cakewalk on return from US.

10. Time spent. Well its a big issue at hand. Definitely here you have a chance to get into PG early concurrently with your batch mates. While if you go for MLE, you might be delayed by 2 years. By the time you’ll join your residency your friends myt be in final year PG. But i look at it differently, In india we myt start the race early but what'll be the situation only 5-6 years from now. With the kind of earnings in US you'll have accumulated more money than your friends here, even after deducting what you'd spend for MLE.
Careerwise, as far as i know, a fresh PG from US wil get at pays least equal to, if not more, than an Indian PG after doing SRship for 5 years, of course only in private hospitals.

11. Choice of branch. Well if you are hell bent on surgical branches, reconsider your decision for MLE cos its tough to get them (not impossible mind it). To get them you need very high scores, good LORs (Letters of Recommendation), USCE (US Clinical Experience), some research background etc. Even if you take surgical branch, you might be a bit discriminated (not in all programs), plus Asians are more at risk for litigations. I know a senior who left Surgery within 2 months due to aforesaid reasons.

12. Exam itself.
Well MLE is definitely easier than AIPG. MLE study material is:
* Significantly Less exhuastive
* Less ambigous
* Clinically oriented
* More of conceptual
* Hence involves less cramming
So, if u find cramming difficult, love clinical cases, have spent more time at wards than at your study table, you are more likely to love studying for MLE.

13. Indian PG + prep for MLE simultaneously?
It requires a lot of patience for MLE aspirants specially cos lot of risks are involved at multiple points. Plus its very very tough to prepare for AIPG and MLE simultaneously, both might get spoiled cos remember, in MLE scores are very very important n you can't improve scores once you’ve cleared a step.

Yes, starting PG and then preparing 4 MLE is possible and many people do it but it is associated with following difficulties:
* You gotta prepare for AIPG if you don’t get selected this year, which means 1 additional year.
* During PG its hard to find time to study, of course depends on branch and college
* You won't be able to join any coaching if reqd.
* A small disadvantage is that a few programs prefer recent medical graduates or at least who have passed within past 2 years. This incurs a loss of at least a few more programs which u can apply for.

Now lets take various issues in a bit more detail. I’ll start with finances cos they appear to be very important for most of us.

How much money needed for USMLE?

A rough rough estimate
step 1- 40k
step 2-40k
step 2 CS- 55k
step 3 - 35k
Study material - 30k (excluding coaching)
Online mock tests - 6-12k per step
Airfares - 50k (economy class for one round trip), double if u plan 2 come back to india in between
Applications for residency - 60 k
Coaching at Kaplan for 1 step – 60k (not very sure for individual steps)
Commuting within US for interviews, exams etc – 50k
Sundry (like ISD calls, visits to us consulate, booze etc.) – 40k
Stay in US for 6 months - 200k (If u know someone, at whose place you can stay, it might be much less cos it forms the major chunk of living expenses)
Attorney fees H1B visa processing – about 60k

Total (excluding coaching, online mock tests, H1B attorney fees) = approx. 6 lacs INR
These all expenses are valid if you clear everything in one attempt, otherwise add accordingly.

But remember this is just an investment if you get a residency. You can cover the money in 1-1.5 years.

How much time?
Well that’s pretty subjective again. Still I’ll outline average suggested time frames for a good preparation. These are based on average of 6-8 hours of thorough studies a day (adjust according to your schedule)

Step 1 – 5-7 months
Step 2 CK - 4-6 months
Step 2 CS - 45-60 days
Step 3 - 2 months (I’m not very sure about this)

Now this totals to 15-18 months. But you gotta know a few facts:
* To be able to apply to max no of residency positions you should have cleared all steps (Up to Step 2 CS) by mid-September.
* Interviews are conducted around Jan-Feb period. So its no use even if you complete your steps in Feb or April for that matter. You’ll have to wait till next year’s match. This is the dilemma for many like me who have decided at this point. We can’t be eligible for the match of 2007. We’ll have to wait till 2008, which IS a long time..

Visa of Step 2 CS?

Toughest question! First I’ll talk about visa for Step 2 CS. Its usually the biggest hurdle. You can be denied visa even after getting 99 in both steps without any obvious reasons. It depends totally on luck. I won’t go deep in technical details. Usually when you apply for a visa, you are given B1/B2 (which one of the two I don’t know) tourist visa which can be given for month to many years multiple entry. All depends on your luck. But the factor which is most important in getting a visa is your ability to convince the Visa Officer (VO) that you will surely come back to India once your purpose is achieved)

The VO believes that every visa applicant is a potential immigrant unless convinced otherwise. The arguments in favour of the fact that you’ll come back may be:
- Your or your parents’ fixed assets in India
- If you are the only son, it’s a plus point
- If you are married and your wife stays back in India. Plus point if you have a child.
- If you have your own hospital, or have a contract with a hospital that you’ll come back and serve it.
- During interview convince the VO that you are attached to your family and culture and wanna come back
- Liquid assets (your own or your parents’). In the tune of many lakhs.

Still if denied, you can reapply. Don’t loose hope. Most of the MLE aspirants do get a visa sooner or later.

If you’ve come back to India after CS, getting a visa for residency interviews is relatively easy.

Visa for Residency?
It is commonly of two types, J1 and H1B.

J1 - Exchange visitor visa- You need to clear up to Step 2 CS.
- Most programs (60-70%) prefer J1 visa
- Sponsored by ECFMG
- You need to come back to India for 2 years (mandatory) after completing your residency. There is a talk of increasing this mandatory period to 5 years. So this is not for people who badly wanna stay in US.
- There are certain conditions in which J1 waiver (ie. No need to serve in India for 2 years) can be obtained. But it is very very tough.

H1B - You need to clear step 3
- Less programs offer H1 cos it has to sponsored by employer itself. They are unwilling to do so much paperwork and bear the attorney costs.
- It is easier to get it converted into green card.
- The H1 cap that we hear about doesn’t apply to docs.
- If you are aiming for this visa the number of programs that you will have as your options will be less.

GRE route:
- You clear GRE and take up courses like Masters in Public health for 2 years or so (some say 1 year??!!, not sure) Give MLE while in US
- Normally you have to pay for your course which entails a expenditure of around 7-10 lakhs
- There are aids/scholarships etc available but not for all, you’ll have to try hard for them
- Plus 2 years more before you can get residency.

No. of Residency seats?
I’m giving approx. numbers:
In USA during past years:
No of US medical graduates per year – 14,500
No of residency slots per year – 22,500
Hence about 8,000 slots are there to be filled by IMGs (International Medical Graduates). But mind it Indians are not the only ones applying!!

No of IMGs who got residency after clearing MLE – 55%
No of students (including us graduates) who got residency(MLE score > 75) = 75%
No of students (including us graduates) who got residency(MLE score > 90) = 90%

Scope after Residency?
Well if get to stay in US, its great. You earn good, life’s good. If you have to come back to India you still earn more than your Indian counterparts of same batch. But mind it its getting tougher these days even for US returned PGs to get good jobs since we are restricted only to private sector.

But since US PG is recognized all over world, you can head towards other countries. Believe me if you are prepared for that the scope is great.

Books to study: (courtesy vineet, georgie n sravya)
1. First Aid - the mother of all preparations
2. Kaplan notes - (Add extra material to it)
3. Anatomy : High Yield (HY) for embryo, neuro , histo and gross
4. Physiology : BRS physio – Add extra points to Kaplan
5. Biochemistry : Lippincott
6. Pharmacology : Lippinott
7. Microbiology : Jawetz (for reference only...)
8. Pathology : BRS with points on Kaplan
9. Webpath/Pathguy for slides
10. Behavioral Sciences: BRS is ok
11. Biostats: NMS
12. Q book kaplans +/- NMS series

And above all, a good discussion at our beloved RxPG!!

Note: originally posted at http://www.rxpgonline.com/postt38318.html

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