Applying for Residency as an International Medical Graduate

*This post was originally published on NEJM Resident 360.*

The medical profession in the U.S. has a remarkable international flair. One in four U.S. physicians is an international medical graduate (IMG), and every year around 12,000 IMGs apply for U.S. residency positions. But the path to practicing in the U.S. is not an easy one when you must navigate the requirements without the structural support from a U.S. medical school and the mentorship of peers and faculty, especially with the added challenges of language and culture.

In the fall of 2018, NEJM Resident 360 hosted a discussion on applying for residency as an IMG. Participants asked questions that ranged from clarifying the practical steps required to be eligible to practice in the U.S. to seeking advice on experiences that can optimize the IMGs’ chances of obtaining their dream residency position. In this post, I summarize some of the main points from that discussion and provide an outline of the practical steps required to pursue this path. For even more information, you can access the library of resources available from the Educational Commission for Foreign Medical Graduates (ECFMG).

Why Go to the United States?

The decision to seek training in the U.S. depends on both personal and professional factors. Some common reasons to apply include:

• the quality of training in practice environments with high-quality standards,
• a predictable career path and employment after completing training
• a flexible career structure
• opportunities for board certifications that are recognized worldwide
• completing a U.S. residency is virtually always required to practice medicine in the U.S. and therefore is a path to immigration.

While the reasons are many, make sure you think through your motivation because it is not an easy path. The practical steps are outlined below, and each comes at a high financial cost. However, with determination, it is within reach!

Apply for ECFMG Certification

To be eligible for a residency spot, you must go through a rigorous process to ensure that you are competent to practice in a clinical environment with the supervision provided by a training program. The ECFMG certification process is the standard for evaluating the qualifications of IMGs entering the U.S. health care system. This process assesses the readiness of IMGs to participate in U.S. residency or fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME). ECFMG sets requirements related to IMGs’ medical schools and medical education, as well as examination requirements.

The definitive source of information on ECFMG Certification is the ECFMG Information Booklet and is required reading for applicants. ECFMG issues the Standard ECFMG Certificate to applicants who meet all requirements for certification. Approximately 10,000 IMGs receive certification annually, representing only about 60% of IMGs who initially apply.

The following is a summary of the main steps involved to receive ECFMG certification:

1. Ensure that your medical school meets ECFMG requirements.
2. Apply for a United States Medical Licensing Examination (USMLE)/ECFMG identification number.
3. Complete the Application for ECFMG Certification, including the notarized Certification of Identification Form.
4. Pass the USMLE Step 1, Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS). These three exams are the same examinations U.S. medical students must pass for medical licensing. Step 1 and 2 CK are computer-based exams that are offered at Prometric testing centers worldwide. Step 2 CS is a live, clinical-encounter exam featuring standardized patients and is only offered in U.S. testing centers (requires a trip to the U.S.)
5. Provide ECFMG with your final medical diploma; they will verify the diploma directly with the issuing medical school and at the same time request a copy of your final medical school transcript. This process can take some time, depending on how responsive your medical school is to the verification request.

Consider Visa Options

Unless you already are a U.S. citizen or permanent resident (with a Green Card), you will need a visa to participate in a graduate medical education program in the U.S. Although you need to think about your visa options early, you do not actually apply for a visa until after you have matched into a residency program.

The J-1 Visa for physicians is sponsored by ECFMG and is the most common visa for those pursuing graduate medical education. The J-1 physician category is specifically meant for trainees (you can’t work as an attending or moonlight with this visa) and can be extended for a total duration of 7 years.

• If you are pursuing a J-1 visa, ECFMG will issue a DS2019 form or Certificate of Eligibility for Exchange Visitor Status. This form tells the consulate that you have met J-1 visa sponsorship requirements. The American consulate in your home country decides whether to issue the visa. The Ministry of Health/Health Department of your most recent county of legal residency must sign a document indicating the need in this country for physicians trained in your prospective specialty. J-1 visa applications are usually processed quickly, although some countries have a longer processing time.

• However, this visa comes with a home residency requirement that dictates that you must go back to your home country for at least 2 years before being eligible to apply for any other U.S. visa status. This requirement is important to consider because, although you may plan to go back to your home country when you apply for residency, your plans may change by the time you complete your training in 3-7 years. For example, you may be offered a good career opportunity or meet a U.S.-based partner. If you end up in this situation, you can try to obtain a waiver for the home residency requirement. Unfortunately, the waiver is complicated, competitive, and limits the types and locations of potential jobs.

The H-1B Visa is sometimes preferred by trainees because of the difficulty of obtaining a waiver for the home residency requirement for the J-1 visa. The H-1B Visa is a so-called “dual-intent” visa because it is a nonimmigrant visa that you can have while you apply for permanent residency status. Another advantage is that there is no 2-year home residency requirement. The H-1B visa is also not restricted to training activities only; an employer can also use it legally for other opportunities (including moonlighting). This visa is sponsored by the institution that hosts the training program. As a result, some training programs (both residencies and fellowships) are reluctant to sponsor an H-1B visa because it requires more work than the ECFMG-sponsored J-1 visa and is more likely to be delayed. Many programs will reverse their position on H-1B visas if you talk to them or the international office at the institution. However, to be eligible for this visa, you must pass USMLE Step 3.

• You are only eligible for Step 3 after you have obtained your medical degree, passed USMLE Step 1, Step 2 CK, and Step 2 CS, and obtained the ECFMG certification. As a result, you can only take this examination after medical school, delaying your application for residency for 1-2 years. Step 2 CS and Step 3 are only offered in the U.S. (requiring you to travel to the U.S. on two separate occasions to take these exams).
• If you plan for an H-1B visa, delays may occur. Once you match, you need to apply for a state medical license to be eligible for this visa followed by 2 to 3 months for visa processing. As the residency match happens in March, and residencies begin in June or July, there is little time to get the paperwork completed. The institution that hosts the residency program may choose to pay for expedited visa processing to shorten the processing time to just a few weeks.

The Diversity Immigrant Visa lottery  is one of the few ways to obtain permanent residency (Green Card) in the U.S. without first entering on a visa. The lottery provides residency to a random selection of applicants who are from countries with low rates of immigration to the U.S.

Other visa options may be available for different circumstances. Speaking to an immigration lawyer might be helpful if you think you have a unique situation. Immigration lawyers can also provide you with the most up-to-date information about your visa options.

Select a Specialty

Before applying for residency, you need to choose a specialty. For guidance on choosing a specialty, see the NEJM Resident 360 blog post on How to Choose a Specialty. The primary care specialties (family medicine, internal medicine, pediatrics, and psychiatry) have traditionally been most popular for IMGs, in part because these programs have the most spots and are therefore less competitive. Although some applicants apply for several specialties, this practice is generally frowned upon because it gives the impression that you are not fully committed to any one specialty. If you are applying for a more competitive specialty (e.g., many surgical specialties), consider applying for a preliminary general surgery residency. This is a one-year residency for programs to see how you perform before committing to training you for the entire duration of your residency.

Select Residency Programs

Once you decide on a specialty, you need to choose the residency programs you want to apply to. Many considerations come into play, including answers to the following questions:

• Is geography important (urban vs. rural, East Coast vs. Midwest, etc.)?
• Are you looking for an academic program with a heavy emphasis on research or a clinical program with high clinical volume?
• How important is residency reputation?
• How competitive is your own application?
• Are you moving with a spouse who will also seek employment?

With so many considerations, you will need to assess your options and discuss them with colleagues and mentors who know you and in your field. The AMA Residency & Fellowship Database (FREIDA) is a good resource to help narrow your search and obtain contact information. For internal medicine, the American Board of Internal Medicine (ABIM) also provides residency program pass rates for medicine certification examinations as an indication of how well the programs prepare residents for the board exam.

Submit the Residency Application

All residency applications are submitted to programs using the Electronic Residency Application System (ERAS). To register for ERAS, you need to go back to your old friend ECFMG to obtain a residency token and gain access to ERAS and register.

• Once registered with ERAS, you will provide your resume information in a standardized curriculum vitae (CV) template, enter a personal statement, upload a photo, and submit your examination transcript, dean’s letter, and letters of reference.
• Be sure to include all your experiences in the application, including teaching experiences, membership in academic organizations, and extracurricular activities. This is also an opportunity for you to highlight how your unique background can enrich the residency program if you match there.
• Designate the programs you wish to apply to. Your application will be electronically submitted to these programs.

Register for the Match

Residency applicants also must register for the National Resident Matching Program (NRMP), also known as the Match. NRMP is a separate organization from the ERAS application service and thus requires separate registration. As discussed in more detail below, the Match is where the preferences of applicants and program directors are entered and matched by an algorithm.

Overview of the Process for Applying for Medical Residency in the United States

Optimize Your Chances of Success

While many programs are accustomed to assessing applications from IMGs, some programs may not consider any IMGs or have a higher threshold for interviewing an IMG. Programs may not recognize the name of your medical school, may not know your recommendation letter writers, or may not understand the grading system at your medical school. Therefore, you need to be proactive to ensure that your application is as strong as possible.

Here are some tips for optimizing your chances of success:

• Have good grades: High scores on the USMLE examination and your medical school tests can only be helpful. Some institutions use USMLE cut-offs (particularly Step 1 scores) and may not look at applications with low USMLE scores.
• Prepare your letters of recommendation: Make sure that you have clinical faculty members who are willing to write you strong letters of recommendation. American letters are often more positive in tone than those from other countries. For example, describing a candidate as “a good clinician” is a red flag when adjectives such as excellent, outstanding, stellar are more common. Therefore, explaining this difference to your letter writers could be helpful and consider providing examples of U.S. letters (for examples, see Tips for Writing Strong Letters of Recommendation and Writing Letters of Recommendation for Residency).

Obtain clinical experience in the United States: Most residency programs value true clinical experiences from the United States. This will also give you the opportunity to request and submit a letter from the faculty member who supervised you and who is familiar with expectations of U.S. residency programs.

If you are in medical school, most U.S. medical schools offer a visiting student or clinical away elective. Some programs are free, but most require a fee. Your best bet is to search the Web for “visiting students” or “clerkship” and the name of the medical school that interests you. Most programs have a dedicated site with information for prospective students. Often, the hospital where you rotate is likely to offer you an invitation to interview for their residency program, so take that into consideration. Keep in mind your competitiveness as a candidate. If you are competitive for the top-tier program, then a rotation at a top-tier institution will be a helpful. If not, you may want to consider a rotation at a less competitive program. Make sure you prepare for your rotation. If you will be doing a rotation in infectious diseases, then read up on infectious diseases topics beforehand so you can impress the faculty during your rotation.

If you are no longer in medical school, then your opportunities for clinical experiences in the United States are much more limited. Very few medical schools or hospitals allow visiting physicians, but you may be able to use your medical school alumni network or other contacts. One option is the American Medical Association (AMA) Observership Programs. If you can only do an observership, some ways to show your skills include offering to help the interns by calling consulting services; give daily 5-10 minute presentations on questions that come up on rounds; accompany the interns during admissions and ask to present these admissions during rounds; and write up case reports, case series, and review papers. 

• Ask mentors to advocate for you: A personal call from a mentor that knows you well can help get your application looked at by the residency program director. Use this sparingly because you don’t want to overwhelm your mentor or the residency program, but asking the mentor to advocate for your application with one or two programs is reasonable.

• Consider doing research: Doing research is a good way to improve your application, at least for programs that are focused on developing future researchers. If you do research at a U.S. hospital, it may also be a way to get a foot inside the door. Your research mentor may be able to provide you with clinical opportunities, and may know the residency program director and advocate for you. However, if you spend many years doing research, residency programs will be worried about the steep learning curve of reintroducing yourself into clinical medicine. In addition, community-based programs may not value research experience as much.

• Advocate for yourself: You can reach out to programs to ask for early decisions because of international travel or coordination with other interviews. It is usually best to contact the program coordinator (contact details are in FREIDA) rather than the program director because recruitment season is a busy time of year. You should also make sure that the program downloaded your application (which you can track in ERAS), and you can contact the program for updates if you have not received an invitation or a rejection.

Interviews

Once you receive a request for an interview, see the NEJM Resident 360 blog post on Applying for Residency for information and guidance on the interview process.

Program Ranking and the Match

After interviews, applicants rank programs in the NRMP’s Registration, Ranking, and Results (R3) system. As noted above, you must register with the NRMP (the Match). Applicants submit a list of programs where they wish to train, ranked in order of preference. At the same time, program directors submit a list of applicants, ranked in order of preference, whom they have interviewed and wish to train. The final preferences of applicants and program directors, as expressed on their rank order lists (ROLs), that determines the Match outcome.

• Registration for the Main Residency Match opens September 15 through the third week in February. You will owe a late fee if you register after November 30.
• Ranking opens on January 15.
• Results of the Main Residency Match are released the third week in March.

Eligible applicants who do not match to a program can participate in the Supplemental Offer and Acceptance Program (SOAP), in which positions left unfilled after the matching algorithm has been processed are offered to eligible applicants. NRMP provides resources on participating in the Match, as well as data and reports on results of the Match that can be helpful as you consider your options and your competitiveness.

Once you have a spot in the program, you will apply for a state medical license and a visa and start packing! Good luck!

Ole-Petter Riksfjord Hamnvik, MB, BCh, BAO, MMSc is an endocrinologist and educator at Brigham and Women’s Hospital and Harvard Medical School in Boston. He is a core faculty in the HMS endocrine course; the program director for the endocrinology fellowship program at Brigham and Women’s Hospital; the education editor for the NEJM Group; and he is also involved in several continuing medical education courses.