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International Medical Graduates in the United States: A View from an ECFMG Certificant

Zerhouni, Elias A. MD

doi: 10.1097/01.ACM.0000243348.55441.3b
Conference Papers

The author was instilled with a passion for mathematics and physics by his father, who taught those subjects in a small Algerian town. Another indelible influence came during a high school mathematics class when his teacher gave the class a problem to solve. Little did the students know that it was Fermat’s Last Theorem, which stumped them, and before that, every mathematician since 1630. This experience taught the author that failing to get the final answer was part of learning. He became enchanted with imaging techniques and after earning his medical degree in Algeria, came to study at Johns Hopkins. There he received the training he desired in diagnostic radiology.

The author believes science has no borders and would like to see the opportunities that were extended to him in 1975 given to immigrants today. Although the United States produces many graduates in the sciences and mathematics, the nation still has a shortfall and must, he argues, work harder to educate and inspire this country’s youth in addition to welcoming the brightest and most able scientists from around the world. He also discusses the crucial role of the National Institutes of Health in furthering global health by funding international biomedical research and by transforming medicine in the 21st century.

Dr. Zerhouni is director, National Institutes of Health, Bethesda, Maryland.

Correspondence should be addressed to Dr. Zerhouni, National Institutes of Health, Office of Communication and Public Liaison, 9000 Rockville Pike, Room 344, Bethesda, MD 20892-0188; e-mail: (

My story begins when I was 24 years old and had just left my hometown of Algiers, Algeria, to pursue medical training in the United States. During my childhood in my home country, strong role models instilled in me a passion for learning. My father, Mohamed Zerhouni, nurtured my love for mathematics and physics, which were subjects he taught in high school. My own high school mathematics teacher, Mr. Tsuria, was also a great influence.

One distinct memory I have of Mr. Tsuria’s class is the time he wrote on the blackboard the equation xn + yn = zn and asked us to prove that n could not be greater than two. The problem looked simple enough, and we figured we would solve the problem in a few days. Of course, we did not. Mr. Tsuria looked at our efforts, praised some of our good ideas, but said we were still far from getting anywhere with the problem. This challenge continued for a month. We finally gave up, but not before learning many new mathematical ideas and techniques.

Finally, Mr. Tsuria revealed that the mathematics problem was none other than Fermat’s Last Theorem. Little did we know that this problem, which French mathematician Pierre Fermat had scribbled in the margin of a text he was writing, had frustrated mathematicians around the globe since he first considered it in about 1630. No wonder the theorem stumped us. My struggle with Fermat’s problem sticks in my mind because it taught me something totally unrelated to mathematics: It showed me that failing to get the final answer is not really failing, but rather a way of learning to learn more. The exercise had another impact on me: it opened my eyes to the international nature of learning. Here was a problem, first presented by a mathematician from France, which had stumped scholars from every continent. It proved to be a very tough problem, indeed, because it wasn’t solved until 1995 by Dr. Andrew Wiles, a brilliant mathematician from England who was working at Princeton University here in America. This and countless other examples show clearly that ideas, inspiration, and talent have no borders.

Of course, international scholarly exchange has gone on for hundreds of years. During the European Middle Ages, scholars and students traveled from one great university to another, often crossing country borders and enduring many hardships in the process. What really made this possible was the existence of a lingua franca. In those days, that international language was Latin, but today it is English. It is amazing to me to see how many presentations are delivered in English at international scientific meetings, even though English may not be the speaker’s native language.

For me, as for many physicians and scientists who want to advance their training in the United States, a stumbling block was communication—in particular, learning to speak English. When I first decided to pursue acquiring my English equivalency certification, I contacted the Educational Commission for Foreign Medical Graduates (ECFMG), and they sent me a list of recommended books: Sabiston Textbook of Surgery, Harrison’s Principles of Internal Medicine, and many others. My brother, who was traveling to Europe, obtained some used copies of these books. Having also traveled to the United States, he advised me to try to meet English-speaking people and to listen to the radio. I managed to get through the textbooks, although I still was not very proficient at spoken English.

I registered for the ECFMG exam, which was in Paris. That was one of the first plane rides I had ever taken. It was during an internship rotation in medical school, and I had to sneak out to take the test. I got some friends to cover for me but really angered the faculty, who didn’t like the fact that I was skipping out on my classes and responsibilities. I remember that the exam was in a sports facility, and two or three hundred people from all over the world were there. The test was very tough, and I had been told to expect to take it several times before getting a passing grade. The oral comprehension part was particularly hard for someone struggling with English.

I had a radiologist uncle in Algiers, who was another strong role model in my life. When I got the news that I had passed the ECFMG test, I read the letter to him. He could hardly believe the news. No one in Algeria had ever passed the exam, much less on the first try. My medical school dean had promised me that if I earned my equivalency he would contact the dean of Johns Hopkins School of Medicine, Dr. Russell Morgan, whom he had met. At the time, radiology was not a well-developed specialty in Algeria, and one of the best training grounds in the world was at Hopkins. I was good at mathematics and physics, and I had some experience with engineering, which I did to make money during summer breaks in medical school. I was an odd case, for sure, but Dr. Morgan, a radiologist himself, took a chance on me. He needed a research assistant, and although the dean told him I knew little English, Dr. Morgan wrote a letter to the chief of radiology at Hopkins and convinced the radiology department to take me on for a few months as a visiting fellow.

I arrived in the United States on December 10, 1975. I had obtained a tiny scholarship of $369 per month for a period of three months. I was newly married; my wife and I had just graduated from medical school a few months before. Although I could read English, I still couldn’t speak it very well, and when I arrived the radiology faculty advised me to take some English courses. I really was not planning to stay in America, and I told them that I didn’t come to learn English, but rather to get some experience learning cutting-edge radiology. They were extremely accommodating and paired me with a medical student, a man who quickly became my friend, and some time later, one of my scientific collaborators. We attended all the department lectures, and through his mentorship and this period of near-complete language immersion, I learned enough English to get by in about six weeks.

My next lucky break came, ironically enough, when my initial funds began to dry up. I considered applying to different training programs to continue my studies, because I was becoming increasingly convinced that radiology had a bright future. As a last resort, I spoke with the chief resident at Hopkins, offering to work night shifts in the emergency room to help pay my way. He agreed, and that’s what I did—working seven nights on and seven nights off in the emergency room, while continuing my other work during the day. I believe in the idea that “chance favors the prepared mind,” because during this moonlighting work, I uncovered a patient’s hip fracture that would have otherwise been missed. I developed a reputation in diagnostic radiology and ultimately got an offer to enter the Hopkins residency program. This was professionally satisfying, but also a personal relief because my wife and I had a newborn and expenses were quickly building up.

In my last year of residency, I was elected to be chief resident. This appointment was really a surprise to me since, in those days, foreign medical graduates were not often offered this kind of opportunity. What had started as a few months of learning radiology was turning into a research career in the United States. I did not take these opportunities for granted and worked very hard, doing research and publishing papers. Within two years, I was offered an assistant professorship in the radiology department at Hopkins.

During my time in America, I have found mentors and possibly the finest medical training that anyone could want. I have also been fortunate to find many people, instructors and friends, who were encouraging and sympathetic and who inspired me to learn more not only about medicine, but also about the values in academia. Throughout it all, the most patient one was Nadia, my wife. We graduated from medical school together, but she put her career on hold while I established a foothold in research. In 1979 it was her turn to take the Federal Licensing Examination, which she passed. When she was offered a residency position at Eastern Virginia Medical School, I took a faculty job there. Later, we came back to Hopkins, where I remained until being honored with a request from the President to serve in my current position as director of the National Institutes of Health (NIH).

As I reflect on my personal journey, it leads me to three observations related to the importance of internationalism in science. The first observation is that many academics have said the United States is not producing enough scientists, technologists, engineers, and mathematicians (STEMs). I would like to see more young Americans, native-born or immigrants, entering science careers. The problem, however, is not only in universities, but also in primary and secondary education, where the emphasis on science is not nearly as strong as it should be. This is a national problem that is finally attracting attention and much-needed financial resources. NIH is fostering programs to raise awareness of the importance of science education among youth and especially among minority groups. I am glad about this, but we have to do more.

My second observation is that our appetite for scientists in the United States is greater than our supply: We very much need young people from abroad in our universities because we are not producing enough young STEMs to teach and work as research assistants. Although China and India may be turning out many engineers with undergraduate degrees, the best training for advanced degrees is still in the United States, and many young foreign graduates still want to come here to study and teach. We should welcome them as I was welcomed in 1975. Many of these potential scientists will do as I did: They will stay in America, put down roots, and enrich our scientific mosaic in ways that are very difficult to predict. Moreover, if the scientific enterprise—not just medical research—is to be influenced by new ideas, discoveries, and even breakthroughs, we need all the help we can get. I think immigrants will continue to participate greatly in the building of our scientific infrastructure in this new century.

My third observation is that scientific ideas and talent, as they flow across borders and boundaries, should not all travel toward one point, ie, to the United States. Because science is an international enterprise, it is important that we continue to support global research. Indeed, diseases do not obey border rules. In 1988, about 10% of American scientific articles had at least one coauthor from abroad. By the turn of the century, that percentage had grown to almost 25% and continues to grow.1 NIH has been taking the lead in funding international biomedical research. In basic research, American investigators and their colleagues abroad, supported by NIH, have made significant advances in studying gene variants that may predispose people to type 2 diabetes, in leading the way to creating the haplotype map of the human genome or HapMap (the HapMap is the second generation of the human genome map and will be very useful in finding gene variants worldwide that effect health and disease), and in conducting research to develop vaccines to protect against emerging viruses, like avian flu. In clinical work, American and foreign scientists have been collaborating on how to meet the challenges of HIV/AIDS, malaria, and tuberculosis. Local physicians and scientists, mainly in the developing world, are playing a significant role in devising the needed therapies for these and other diseases—therapies that will be locally and culturally acceptable.

On a final, important note, NIH is transforming 21st century medicine, and this effort will have an impact on global research. We are leveraging our research resources and infrastructure with scientists everywhere in order to make medicine more predictive, personalized, and preemptive. Through the application of new molecular knowledge, we will be able to identify disease susceptibility long before symptoms arise. We will be able to do better job at matching treatments to individual patients’ needs. This is particularly appropriate in diverse cultural contexts, where not only genetic but also behavioral determinants strongly affect treatment outcome. We must work toward being preemptive, so we can reduce the personal and economic costs of end-stage disease. Our medicine of the future will rely on the strategic use of shared tools and collaborative scientific teams—many working from all corners of the earth with the shared goal of reducing suffering and eliminating disease.

Because transforming medicine will be a truly collaborative exercise, learning modern society’s lingua franca is the most important task for foreign medical graduates who seek to nurture their intellect and grow their professional skills here in the United States. English was the fourth language that I learned—after French, Arabic, and German. This was challenging, but absolutely essential for my success here in America. Language immersion requires a good amount of courage, but it’s often the most efficient way to learn. I think today’s diverse culture makes this job less painful than it used to be. Ethnically diverse communities can offer much needed support during the development of communication skills.

I referred to my own experience as a kind of journey. Science that knows no borders is also a great journey, involving many ideas and, most important of all, individual creativity. If, as I have argued, the United States does not have enough scientists, we must work harder to educate and inspire this nation’s children. I hope young people will continue to be inspired by mentors like my father, my uncle, and Mr. Tsuria, and I look forward to the ECFMG’s continuing to help physicians from throughout the world pursue their journeys in medicine and biomedical science.

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1 National Science Board. Science and Engineering Indicators 2004. Arlington, Va: National Science Foundation; 2004:42.
© 2006 Association of American Medical Colleges