Twenty years on.

One of the problems of moving to the USA to practise medicine is taking "finals" again. I don't mean the exam for an Educational Council for Foreign Medical Graduates (ECFMG) certificate, which is a one-day affair taken in the familiar surroundings of London or Edinburgh. Without the ECFMG, of course, one's chances of getting a visa to live in the USA are next to nil. But actually to practise as an independent and fully functioning doctor something more extensive is demanded. One can sit these further tests only after burning one's boats, migrating to the USA, and risking all on the three-day "trial." Each State has its own regulations but all, except Alaska and Florida, take a satisfactory performance in the Federation Licensing Examination (FLEX) held only in the USA as evidence of competence. Unlike Britain, where the MB ChB degrees or royal college diplomas are themselves registerable as evidence of competence, the MD degree in the USA does not give automatic entry into the ranks of practising doctors. In addition to having the MD a newly graduated doctor has to be successful in a three-part National Board of Medical Examiners (NBME) examination or FLEX, the latter having strong clinical emphasis in each of its three parts. Usually the NBME is taken by native US graduates and FLEX is favoured by the many foreign medical graduates who come to the USA to find fortune if not fame. The FLEX is extremely thorough and lasts three days, starting at 0830 and ending at 1730 with an hour for lunch and one 15-minute break during the morning and afternoon sessions. I took the exam at the beginning of December 1975 at the McCormick Place Centre in Chicago, which is a huge, draughty, hanger-like exhibition hall overlooking Lake Michigan and Meigs Field aerodrome. The 500-odd candidates were a colourfully international crowd with only a few from Britain. The place was so cold that most people sat in their overcoats and the proctors refreshed themselves at frequent intervals from hot vacuum flasks.