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Elisabeth

Photo courtesy of Dr. Elisabeth Billod-Girard

Dr. Elisabeth Billod-Girard practiced as a veterinarian in Austria for 20 years before moving to North Carolina in 2017. She's tried for more than a year to get a seat for an exam she needs to practice in the United States, but the test program is straining under demand.

Dr. Elisabeth Billod-Girard has for 18 months been in fruitless pursuit of a seat for an exam she needs to become a licensed veterinarian in the United States. It's been as frustrating, she thinks, as trying to get tickets to a Taylor Swift show. No, worse.

"You at least know what day the tickets go on sale," she quipped, referring to the megastar's concert ticketing fiasco last year that prompted lawsuits and congressional hearings.

"In our case, we have no idea when test dates will even open," Billod-Girard lamented. "There are hundreds of us waiting, each of us trying to get spots that are snapped up in minutes."

The stakes are also much higher than trying to score concert tickets. Billod-Girard is one of hundreds of veterinarians vying for one of 570 seats offered annually for what's known as the Clinical Proficiency Examination, or CPE.

The CPE is a rigorous three-day assessment that encompasses hands-on procedures such as surgery. It is undertaken by veterinarians who wish to practice in the U.S. or Canada but who were educated at a foreign school not accredited by the American Veterinary Medical Association.

Passing the CPE is the last of four steps laid out by the AVMA's Educational Commission for Foreign Veterinary Graduates to assess foreign candidates' readiness to take the ultimate test — the North American Veterinary Licensing Examination. Passing the NAVLE is required of anyone wishing to practice veterinary medicine in the U.S. and Canada.

How did a clinical exam for foreign-trained veterinarians become a hot ticket? Blame Covid-19. Travel restrictions during the early part of the pandemic slowed the usual demand, the AVMA explained in written replies to questions from the VIN News Service. Once restrictions lifted, demand surged, creating a backlog the organization is still working through.

According to figures provided by the AVMA, before the pandemic, the number of practitioners who registered for ECFVG averaged 282 per year. It dropped to 233 in 2020, the year the pandemic began. In 2023, it reached 640.

More than 2,000 candidates are currently enrolled in the ECFVG program. The first step in the process is registration and identity verification. Next, candidates must pass an English-language test, followed by a Basic and Clinical Sciences Examination (BCSE) and lastly, the CPE.

The cost to complete the ECFVG is around $10,000, not including travel and accommodation costs for testing locations. Fees go toward costs related to the program, which is not a revenue-generator for the association, the AVMA said. 

Frustrations at every turn

Billod-Girard, 55, was educated in Vienna and practiced veterinary medicine in Austria for 20 years before moving in 2017 with her husband to the U.S. The couple, who had met while doing seasonal work on a ranch in Wyoming, desired to return to the country where they first fell in love. Billod-Girard said her husband had no trouble finding a job with a company that makes drawer hinges. However, she did not anticipate the arduous process of obtaining a license to practice.

Billod-Girard registered for the ECFVG in 2022 and has since passed all the tests except the CPE. She's even passed the NAVLE, which she was permitted to take out of order because of the CPE backlog.

Although she appreciates the allowance, she's vexed that she was forced to re-register with the ECFVG at a cost of $120 because she hadn't completed the process within two years. "I think punishing me because I haven't been able to find a CPE seat is very unfair," she said.

Billod-Girard said she and her husband check the test portal multiple times a day in hopes of stumbling across a seat vacated by a cancellation. "Maybe they'll put the spot back in the system, and I can take it," she said.

She's heard of veterinarians in other countries who employ staff to continuously monitor the portal, logging in repeatedly. "I think that's how some people get seats," she speculated. 

However, too many logins can lead to an account being suspended. Billod-Girard has faced the issue herself. "They tell you the best chance to get a spot is to keep logging in and looking, but do it too much, and they'll block you," she said.

The AVMA said account suspensions are a security measure: "Excessive logins or using multiple devices are often an indication that someone may be attempting to gain unauthorized access to the system."

A bigger point of frustration for candidates is simply figuring out when the next block of test slots will become available. The CPE is scheduled in two blocks twice a year. The first runs January to August. The second spans September to December. In January, the ECFVG portal stated that test dates for the August-to-December block would open "soon" but didn't specify a date. 

On Feb. 7, Billod-Girard saw a Facebook post that spots were open. She logged in only to find she had missed the window. Back on Facebook, she read a post from a candidate who said she'd gotten the last spot. "I was 31 minutes too late," Billod-Girard realized. "I was depressed for weeks, just sick about it."

The AVMA explained that it opens registration with minimal advance notice to avoid overwhelming the system: "We have had issues with a large number of candidates trying to register concurrently, resulting in overbooking by the current software platform."

The AVMA indicated that wait times generally are not excessively long for most candidates: "The average time required from the initial application to take the CPE to sitting for the exam is currently eight months."

Clearly, Billod-Girard isn't average. At this point, the earliest possible opening for her to take the CPE is 2025. "If I'm fortunate, I'll have waited three-and-a-half years," she said.

Error Message

VIN News Service screenshot of ECFVG portal

The AVMA recommends that candidates keep an eye online for available test seats, but logging in too frequently can trigger a security lock on accounts, causing them to freeze temporarily.

Sign-ups for tests during the first block of the year are expected to open this summer. Billod-Girard will need to be in the right place at the right time — ideally in front of a computer outfitted with just the right browsers.

That's because the registration portal is not accessible through smartphones or certain browsers. An ECFVG announcement states that "using a mobile device could cause scheduling or payment issues." It recommends Chrome and Edge browsers. 

About the limitation, the AVMA said: "The challenge with using a mobile device is an issue we are aware of and are working to address."

High proportion of retakes

One large reason for the heavy test demand is that 75% of candidates fail at least one portion of the exam on their first try. That puts them back in the line for the test — at least, the portion they need to retake — with a retake fee of $1,450 per section. 

The CPE is administered at two locations: Mississippi State University College of Veterinary Medicine and Viticus Group in Las Vegas (formerly known as Western Veterinary Conference Oquendo Center).

Typically, the test is given 10 times a year at Viticus and four times a year at Mississippi State. Additionally, both sites offer special sessions for candidates retaking anesthesia and surgery portions of the exam, which have the highest failure rates.

In 2023, to help address the backlogged demand, an 11th round was added at Viticus. The AVMA said the extra seating had a significant effect, boosting the proportion of ECFVG candidates completing the program by 30%.

"The ECFVG will continue to work with the testing sites to assess the options for providing additional administrations of both full and retakes for the CPE," the AVMA said.

Approximately 55% of the 570 seats available each year for the CPE are reserved for retakes. Candidates who fail four or more of the seven sections must retake the entire exam. Those who fail three or fewer sections have two additional retake opportunities within a limited period. This leaves roughly 256 seats for new candidates.

The AVMA stated that, on average, candidates take seven months to pass the CPE from the time of their first try. Many take longer, however. 

One candidate in the retake stage is Dr. Roberto Silva Moreira. He left Brazil for the U.S. in 2017 and works as a veterinary technician in New Jersey while pursuing his veterinary license, a process prolonged due to the time it took the AVMA to add the program he attended to its directory of veterinary colleges, a resource used to assess ECFVG applicant eligibility. Silva Moreira said his initial wait for a CPE seat was one-and-a-half years.

His experience trying to secure a test spot was similar to Billod-Girard's. "I was checking every day, multiple times a day, because once they open the seats, they go within half a hour," he said.

Silva Moreira took the exam last August and failed the surgery and food animal practice sections. His mistake in the surgery portion was not following protocol for maintaining sterility. "I was dismissed before I even cut the animal," he recounted.

During the section on food animals, nerves got the best of him. "I just couldn't think and didn't explain things," he said. "But I understand now, and I get it."

Silva Moreira was able to retake the food animal segment in October and passed. He's scheduled to retake the surgery section in May, marking a nine-month gap since his initial attempt. "I couldn't get an earlier spot," he said. "... It's difficult when you have to wait almost a year to take one portion of this exam."

Adding to his frustrations, Silva Moreira faces having to re-register for the ECFVG if he does not pass the exam. He received an email from the AVMA on April 2, notifying him that he must pay $120 by June 10 if he needs to register a third time for the program.  

Some candidates try to maintain an upbeat attitude about the experience. On Instagram, Dr. Mariana Pardo, a critical care specialist who earned her veterinary degree in Chile, shared her 13-year journey in the ECFVG program and encouraged fellow CPE takers to tell their own "stories of resilience."

"I took this test this past week," she said in a post dated July 2022. "I failed anesthesia and was removed from the exam. ... Regardless of whatever you have failed at, make sure to mourn it (some tears for me), keep your head up and try again!"

Last May, Pardo failed the anesthesia section a second time. She explained on Instagram: "I forgot to wipe with alcohol after each chlorhexidine scrub when prepping for my IV [catheter]. I knew that's what they wanted, but I'm sure between the stress and normal habits, it slipped my mind, and I was asked to leave the exam.

"... I completely let the feeling of defeat in and willingly sat in that feeling for a solid 30 [minutes]," she continued. "Self-pity doesn't suit me, but today I welcomed it in."

Pardo completed her emergency and critical care residency at Cornell University in 2018. She practices in New York, having acquired a license via the state's professional program review. The unique pathway grants licensure to graduates of non-U.S.-accredited colleges, provided the program's curriculum meets state standards, and they pass the NAVLE. "I know how privileged I am to be able to have a license in the state of NY and to be able to work as a criticalist. I know many that do not have that luxury," she wrote on Instagram. 

Still, Pardo is committed to completing the CPE and plans to retake the anesthesia section on Dec. 5, a spot she said she secured through "stalking the ECFVG website." By phone, she told VIN News that passing the exam is essential for her to practice anywhere else in the U.S. She also views it as a significant personal achievement.  

"If a specialist who's been trained in the U.S. can't pass this test, I can only imagine how hard it is for someone who has just stepped on U.S. soil," she said. 

Does Canada do it better?

Securing a seat for the CPE may be less difficult in Canada. Rather than using the ECFVG system, foreign-trained veterinarians register with the National Examining Board, which is part of the Canadian Veterinary Medical Association. The NEB supervises Canada's three-part licensing exam process, which encompasses the same tests — BCSE, CPE and NAVLE — as in the U.S.

Unlike the ECFVG, the NEB is transparent about the opening dates for CPE testing windows. For instance, an announcement on its website last year specified that registration for the CPE April 2024 testing window would commence on Dec. 1, 2023, and conclude on Feb. 1, 2024.

Last month, the NEB also introduced a CPE waiting list, enabling candidates to register for the CPE on a first-come, first-served basis, albeit with conditions. Upon registration, candidates are obligated to accept the seat offered or lose their position on the waitlist and be charged a $250 administrative fee. The NEB ensures that waitlisted candidates are notified of a seat offer at least eight weeks before the scheduled exam date.  

The waitlist operates on a first-come, first-served basis and stops accepting entries after reaching an undisclosed capacity, said Lori Ahronson, communications manager for the Canada Veterinary Medical Association.

Asked why the ECFVG doesn't offer something similar, the AVMA said establishing a waitlist is beyond the capabilities of the program's existing software but could be on the horizon: "We are evaluating new software platforms capable of automating workflow, including the capability to create a date-sensitive CPE waitlist."