There are two ways anesthesiologists can practice as anesthesiologists in the USA without a USA residency.

  • Visiting Professors – International physician anesthesiologists visiting the USA for a short time are limited to a hospital. They are not the American Board of Anesthesiology (ABA) board-certified.
  • Alternate Entry Path Program for Primary Certification – This is an official pathway by the American Board of Anesthesiology and as the name says is a pathway for certification in the USA without a USA residency.

I will break down each and every step to help you understand this alternate entry path program clearly. I have extensive experience in this topic and have seen colleagues doing it. Let’s jump to find out more. I will limit this post to the Alternate Entry Path Program for Primary Certification in Anesthesiology.

By Dr. Rajeev Iyer, MBBS, MD, FASA; Board Certified Anesthesiologist

What is Alternate Pathway for Primary Certification?

The Alternate Pathway for Primary Certification by the American Board of Anesthesiology is a pathway for International Medical Graduates to become board certified and be productive members of the USA anesthesiology system.

I will quote this verbatim from the ABA Website. “The Alternate Entry Path (AEP) program allows international medical graduates who are certified by the national anesthesiology organization in the country where they trained and practicing anesthesiology in the U.S. to qualify for entrance into our exam system for primary certification in anesthesiology. A record of documented achievement in teaching and/or scholarship, rather than the potential for future success, is critical to acceptance into the AEP program, as is the ability of the sponsoring department to provide an outstanding academic environment.”





What are the requirements for the Alternate Entry Path (AEP) Program?

There are two things here:

  1. First, be anesthesiology certified in your home country or any other country
  2. Have clinical experience in USA or Canada

I will explain this in detail below.

  1. Anesthesiology Certified in Home Country: This is any country outside the USA. Typically this is your how country or any other country where you can be certified.

Let me give you an example. If you are from India, you should have completed anesthesia residency in India or from any other country outside India except the US. This could be the UK, Singapore, Australia, etc., or any others.

2. Anesthesia Experience in the USA: This can be through the following paths in USA and Canada. To my knowledge, experience in Canada has to be clinical.

CountryType of ExperienceUSMLE Required
USAClinical FellowshipYes
Research FellowshipNo
Visiting ProfessorNo
CanadaClinical FellowshipNo
Visiting ProfessorNo

Who is eligible for the Alternate Entry Path Program?

Recently American Board of Anesthesiology (ABA) had a press release expanding the AEP program to two different pathways. The ABA has a limit of 4 candidates per hospital/university at any given time. Many years ago, the AEP program had only research experience-based and had a limit of 2 candidates. To me, it appears that the program has been successful and so it has expanded.


 



 


What are the two pathways for the Alternate Entry Path Program?

  1. Clinician Educator Pathway

Candidates trained from the following countries are eligible for this

    • Australia & New Zealand
    • Canada
    • Europe
    • Ireland
    • Singapore
    • South Africa
    • United Kingdom

If a candidate is from a different home country other than the above but trains here, they are still eligible for entry into the Clinician Educator pathway.

I will give you an example. If someone’s home country is let’s say India, China, Pakistan, Bangladesh, etc. and they do anesthesia certification from Canada, Europe, Ireland, or any other country mentioned above, are eligible for this pathway.

According to ABA, these countries have training that is similar to the training in the USA.

2. Research and Fellowship Pathway

Candidates from any country are eligible for this. I will explain these two pathways in detail below.

How do the two alternate entry path program pathways compare?

I have put this in a table format. You can see the similarities and differences. Any questions or if something has to be changed, reach me out at drrajeeviyer@gmail.com

 Clinician Educator PathwayResearch and Fellowship Pathway
Internationally Trained
4+ years (3+ years of anesthesiology-specific training) of post-graduate medical education.
3+ years of anesthesiology-specific training
Certified anesthesiologists practicing in the U.S❌ - Not required
Letter of support from Chair
Letter of support from Program Director✅ - I think this is required!
Applicants trained from Australia & New Zealand, Canada, Europe, Ireland, Singapore, South Africa, United Kingdom
Applicants from other countries❌ - This can be ✅ if trained from above countries
Well established research pathway - publications, funding, etc❌ - Not required
Academic appointment in the department of anesthesiology
Outstanding anesthesiologist
Outstanding clinician educator
Outstanding resarcher❌ - Not required
Submit 4 year plan to ABA
Formal approval from ABA required
Demonstrate excellence in clinical anesthesia
Demonstrate excellence in education
Demonstrate excellence in research and discovery of new knowledge❌ - Not required
Timely evaluations submitted to ABA
Board Eligible
Requires In-Training exams
Board certification
Requires Visa/Green Card/Citizenship
USMLE

Where to apply for the alternate entry path program?

The alternate entry path program is offered in universities or hospitals that have an ACGME accredited anesthesiology residency or fellowship or both. This is critical because if there are ACGME accredited programs, that particular university of the hospital will have the necessary infrastructure to satisfy the high standards required by the American Board of Anesthesiology which certifies physician anesthesiologists. This is done through a rigorous training process followed by written and oral anesthesia boards.

You can find these programs by looking into the American Society of Anesthesiologists residency information by State https://www.asahq.org/education-and-career/asa-resident-component/residency-information-by-state. This is a comprehensive list of places with ACGME accredited training that can potentially offer this pathway.

If you can find a program that has candidates in the alternate entry path program either now or in the past you are in luck!

How to apply to the alternate entry path program?

You should apply to the chair or head of the department of anesthesia asking them if they can support you as a candidate for the alternate entry path program. You should specify the achievements you have done in your CV and how you qualify for the program. Highlight how you can bring academic or teaching excellence into the USA from outside.

What are the steps in the alternate entry path program?

I have summarized the steps below.

  • Apply to the program
  • Interview
  • Selected – Congratulations
  • Submit the 4-year plan to the ABA with the support of the Department Chair
  • ABA accepts the plan – Congratulations. I want to warn you that there is a high likelihood of rejection since the requirements are set at very high standards.
  • Start the program practicing as a faculty or clinical fellow or research fellow or a combination of these. My experience has been working as a faculty and this will depend on the CV.
  • Semi-annual and annual reviews
  • In-training examinations
  • Successful completion of 4 years
  • Anesthesia Written Boards
  • Anesthesia Oral Boards
  • Board Certified Anesthesiologist – Congratulations

Am I eligible for the alternate entry path program with 2 years of anesthesia training?

There are some training programs around the world that are less than 3 years in duration. An example I can think of here is the Diploma in Anesthesia which is 2 years of training. The ABA is clear that the anesthesia training has to be 3+ years, so anything less will make you ineligible.

Does the Alternate Entry Path Program require a visa?

In my experience, everyone I know of entering the Alternate Entry Path Program has required a visa. They all have received an H-1B visa. The H-1B visa is a temporary work visa that is offered to people who are professional-level degrees. The difference between H1B and J1 is that H1B does not have the two-year waiver restrictions of J1.

My disclaimer is that I’m not a visa expert and I’m not an attorney and should not be assumed so. However, I’m saying this based on all my personal experience. The H1B people who come into the AEP pathway have successfully transitioned everyone I know of from H1B into a green card and being a citizen in the USA. OF course, this is a complex matter with many factors playing a role in the process.

Does Alternate Entry Path Program require USMLE?

All the details about USMLE can be found on usmle.org. Essentially, there are three steps for USMLE presently known as

  • Step 1
  • Step 2 CK
  • Step 3
  • Step 2 CS which is a simulated patient-based exam is presently on hold due to the current situation and I’m not sure what the next steps for that are.

After Steps 1 and 2, you can apply for ECFMG certification to be certified. 

Now the USMLE is an expensive exam. The general scare is that it is a tough exam. There is a strategic way to prepare and if you have any questions about USMLE do post in the comments below.

You can read all about USMLE on a website called usmle.org and I have summarized some important points about USMLE below.

 Where OfferedVisa Required to Travel Required for Alternate Entry Path ProgramNumber of DaysDuration of Exam
Step 1Prometric test centers worldwide❌ - Travel to USA Optional18 hours with 7 sixty minute blocks
Step 2 CKPrometric test centers worldwide❌ - Travel to USA Optional19 hours with 8 sixty minute blocks
Step 2 CS5 testing sites in USA. Presently on Hold
Step 3 Prometric test centers in the USA 2Day 1: 7 Hours with 6 sixty minute block
Day 2: 9 hours - Questions + 13 simulated cases

Bottom line:

If you have a 3 year+ anesthesia training, a CV that stands out, and you want to move to the USA to become a productive member of the anesthesia community, you may qualify for the alternate entry path program.

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