Dr. Levey has written an insightful article [1] on a subject with which many of us as program directors have struggled, sometimes against considerable odds. Although we noted among most beginning foreign medical graduates the deficiencies described in the article, we were particularly concerned about their deficiencies in time management, synthetic reasoning after acquisition of data, and the ability to execute standard American algorithms of patient evaluation and management.

After a survey showed nearly unanimous agreement on the need for pre-training, we initiated a program incorporating most of the article's suggestions and numerous other items. A vital aspect of our month-long program was a period during which the new interns were placed on a ward service with reduced workloads under the supervision of university residents. We were surprised to learn of many unanticipated patterns of thought and practice that only day-to-day exposure to and tutoring by highly trained American residents could show. All of the foreign medical graduates who participated were thrilled with the program, particularly with working with the university residents, and believed it should be required.

A major obstacle to our program is the requirement of a license to avoid the "unlicensed practice of medicine." The Educational Commission foreign Medical Graduates is unable to sponsor J-1 visas for blocks of more than 12 months, and the Illinois State Licensing Board could not offer assistance either by facilitating the licensing process or by offering a category permitting pre-training essentially as a student, but without actually being enrolled in a medical school. Unfortunately, legislative action is required in both Congress and the State Legislature to untie the hands of these agencies. We intend to convene a working group of program directors in Illinois to advance this process. If successful, similar programs could commence soon after the Match, and most of our foreign medical graduate residents could remain in synchrony with their American colleagues, something we and they believe to be most desirable.