The IMG Insider: Unlocking the Path
to U.S. Medical Residency

As an International Medical Graduate (IMG), gaining a comprehensive understanding of the medical residency application process in the United States is essential. This multifaceted journey encompasses several stages that commence months before the residency officially begins, encompassing a range of crucial preparations, applications, and the residency program matching process.

Let's delve into the key stages:

1. Preparation Stage (Months to Years in Advance)

Decide on your medical specialty (or specialties for some) and build your CV and clinical experience in your chosen specialty.

Medical School’s ECFMG Eligibility

Ensure that your medical school meets all the requirements for ECFMG as listed in the https://www.wdoms.org/. ECFMG certifies the qualifications of IMGs through the ECFMG Certification process. This certification is a requirement for IMGs to take the United States Medical Licensing Examination (USMLE) and participate in the National Resident Matching Program (NRMP).

Financial Preparedness 

The cost of an IMG's journey to becoming a U.S. doctor can vary significantly, influenced by various factors such as the expenses related to the Step exams, the resources utilized, the diversity of USCE experiences, interview preparation services, the number of programs applied to, and travel, among others. Previous applicants have reported spending anywhere from $10,000 to $50,000 in a single application cycle. Given the substantial financial investment, planning your application strategy carefully is wise to avoid unnecessary repeat.

For IMG applicants, this investment holds the promise of significant future returns as they embark on fulfilling careers within the U.S. healthcare system. It offers the prospect of financial stability and numerous opportunities for long-term professional growth and personal satisfaction. One notable advantage is that many IMG residents do not carry the heavy burden of medical school debt, which is a challenge faced by some U.S. residents.

A report from the Association of American Medical Colleges (AAMC) reveals that the median medical school debt among the Class of 2021 reached $200,000, and this figure does not even include their undergraduate debt. This stark contrast highlights the favorable financial position of many IMGs pursuing their medical careers in the United States.

USMLE Exams 

It's essential to align your preparation with your career aspirations and the specific medical specialty or program requirements you intend to pursue. Step scores, particularly Step 1 (Basic Sciences) and Step 2 CK (Clinical Knowledge and Skills), are often used as filtering criteria by some residency programs, especially Step 2 CK, which has a numeric score. Therefore, excelling in these exams can significantly enhance your competitiveness.

Furthermore, although USMLE Step 3 (In-depth Clinical Knowledge and Decision-Making) is typically taken during the first year of residency training, some insiders in the field of residency suggest contemplating this step earlier in your journey. However, it's important to note that the impact of the Step 3 score can vary widely, making it a double-edged sword for applicants. Given the uniqueness of each applicant's profile, seeking advice from an expert is highly advisable to make an informed decision regarding when to tackle this crucial step.

Recommended resources for your exam preparation include UWorld and NBME. We suggest limiting study resources to less than two. Here's a suggested study approach:

A Few Months Before the Exam Date:

• Utilize UWorld.
• Allocate a fixed number of questions to tackle each day.
• Take your time to thoroughly read and understand the explanations provided for each question.

At Least Two Months Before the Exam Date:

• Continue using UWorld.
• Integrate NBME into your study routine.
• Aim to answer a fixed number of questions daily.
• Stay committed to answering a predetermined number of questions, simulating the conditions of the actual exam.

This approach will help you progressively enhance your endurance and refine your test-taking skills, ensuring you are thoroughly prepared for the examination on the actual test day. As you enter the final stretch, typically at least two days before the examination date, it is advisable to engage in light study or completely relax. We recommend reviewing crucial notes, such as biostatistics formulas, growth and development milestones, HLA associations, etc. This practice will help ease your mind, alleviate unnecessary stress, and enable you to approach the exam with a refreshed and composed mindset.

Letters of Recommendation from USCE

The practice of medicine in the United States varies significantly from international medical practices, presenting a distinct challenge for IMG applicants. To enhance a candidate's competitiveness throughout the selection process, letters of recommendation from U.S. Clinical Experience (U.S.C.E.) play a pivotal role. This is especially true considering that Step 1 is simply a pass-or-fail exam. 

According to a report from ECFMG dated January 31, 2024, Intealth™ received a notice from the United States Medical Licensing Examination® (USMLE) program regarding the invalidation of USMLE examination scores for a group of test takers. This action was taken due to a consistent pattern of unusual exam performance linked to Nepal. This is a  developing story as of this writing, and in light of this situation, according to some residency insiders, letters of recommendation from a USCE can now hold the utmost importance in the selection process.  

It's worth noting that American Medical Graduates (AMGs), who are often favored by many programs over IMG applicants, may not be required to take Step 2 CK to participate in the match. This underscores the heightened significance of a strong and comprehensive US Clinical Experience (USCE) profile for IMG applicants looking to distinguish themselves.

Letters of recommendation from USCE constitute one of the three most significant modifiable components in a candidate's profile. Understanding the types of USCE is crucial:

• Observerships: These clinical experiences involve students or graduates shadowing physicians in their daily activities within a hospital or clinic setting. Not all residency programs consider observerships as USCE, but observerships from a university hospital can be a significant consideration in a few cases.
• Electives: Electives are hands-on clinical experiences designed for medical students, typically within a hospital setting. Responsibilities include patient history taking, physical examinations, EMR charting, patient rounds, and supervised procedures under attending physicians or residents.‍
• Externships: Externships, also known as hands-on observerships, entail responsibilities like or less than those of electives and are generally intended for medical school graduates.

When selecting a USCE, several factors should be considered. It's advisable to understand the exposure students will receive, ensure that preceptors do not take on an excessive number of students per rotation (at least no more than six students per rotation to guarantee ample learning opportunities for each student), and, most importantly, confirm that students are not asked to write their own letters of recommendation. The latter is often viewed as a red flag by selection committees in some programs.

A strong letter of recommendation should be highly personalized, emphasizing specific interactions with the student and highlighting their outstanding clinical skills observed over a rotation of at least four weeks. It's important to recognize that not all letters of recommendation (LORs) are created equal, are typically merit-based, and that LORs are not guaranteed by all preceptors. The content of the letter holds immense significance, with a minimum of 80% dedicated to commending the student's expertise in electronic medical record (EMR) usage and their direct or supervised patient care, as well as their personal and professional intangibles. Generic letters are typically deemed insufficient and are unlikely to significantly impact the recommendation process. Regardless of the letterhead of the letter, the content of the recommendation bears much more weight for consideration.

Furthermore, proactive communication with the attending physician is necessary when requesting a letter, providing the author with at least four weeks to write the letter. For IMGs, it is highly advisable to secure at least four strong and personalized LORs from U.S. doctors affiliated with your USCE. Specialty-specific LORs relevant to the specialty you are applying for are particularly beneficial. All LORs should be uploaded within the first week of September to avoid any unnecessary issues in the application process.

Personal Statement

The personal statement is a platform where you can share your unique journey towards becoming a doctor. It allows you to unveil an intriguing aspect of yourself that might not be readily apparent in your ERAS CV. Writing this statement may take several months for some individuals, with multiple revisions, but it's crucial to ensure it is concise and tailored to align with the specialty and program you are applying for. It should be free from grammatical errors and written in clear and proper English. The personal statement enables program directors and faculty members to gain deeper insights into your personality and to recognize your potential as a prospective resident.

The PS is required by ERAS to be one page only, with 750-850 words, and a suggested format would be:

• 1^st paragraph: Begin with a captivating opening on your initial attraction to medicine, highlight two (2) to three (3) unique/transformative qualities/interests, and complement it through a personal experience/story.
• 2^nd paragraph: Cite specific and concrete experiences that drew you to the medical specialty. Connect and highlight relevant experiences, learned skills, motivation, and achievements.
• 3^rd paragraph: Share your USCE journey and how it solidified your interest in pursuing a medical residency in the U.S. and becoming the best version of yourself in your chosen specialty.
• 4^th paragraph: Summarize your key points and showcase the intangible qualities that set you apart. Demonstrate how your unique background and experiences bring diversity to the program. Outline your career goals and show the program fits into your long-term goals. End with a strong and memorable closing statement.

Writing a strong personal statement is one of the topics discussed and explained better during the monthly online town hall session of the students of USCE MATCH.

ERAS CV

The ERAS CV differs from a traditional CV as it is tailored to meet the specific requirements of the residency application process. It contains sections and information relevant to medical professionals seeking a residency position. Understanding the nuances of this format can be challenging, so we recommend watching instructional videos on YouTube that provide a step-by-step guide.

Key components typically include:

• Profile Information
• Medical Education
• Clinical Experience, USCE specific to your chosen specialty is preferred.
• Balanced Research Experience
• Extracurricular Activities (community service or leadership roles)
• Academic/Professional Honors/Awards
• Publications/Presentations (if applicable)
• Professional Memberships (if applicable)

2. ERAS Application Process (June-September)

ERAS Registration

Register with the Electronic Residency Application Service (ERAS), which typically starts in June and is a centralized application service that streamlines the residency application process. 

Program Selection

Thorough research is essential when it comes to selecting programs to apply to. Your list should ideally include a mix of reach, match, and safety programs. It's imperative to research each program's specific requirements and preferences, ensuring that your choices align with your qualifications. Being realistic and strategic in your selection helps manage program selection fees ranging from $2,000 to $10,000, depending on the number of programs and specialties selected.

A well-considered program selection should take into account factors like the program's friendliness to international medical graduates (IMGs), visa sponsorship options, proximity to friends and family, etc., which can facilitate stronger connections to the program. Useful resources for program research include Residency Explorer and the Freida Database.

To further assist applicants in this process, we offer a mentor-mentee service where you can network with current residents who can share their match journey experiences, including insights on carefully selecting programs to apply to and hearing their best practices. This personalized guidance can be invaluable in making informed decisions.

MSPE and Transcript Upload

Work with your medical school to ensure the timely submission of your MSPE (or Dean’s letter) and transcripts to ERAS.

3. Interview Invitation Period (October-January)

Qualified candidates are notified and invited for interviews by residency programs. Multiple interview opportunities are ideal and increase the chances of finding the best-fit program. During this phase, it's suggested that candidates leverage all available networks to maximize their chances of securing interview invites. It's important to note that historically, interview invitations can be extended in multiple waves, typically occurring from October to January, so maintaining a positive and optimistic outlook is essential, even though it can be a stressful period for many candidates.

Letter of Interest

Starting as early as late November and continuing into the first two weeks of December, we recommend sending a well-structured and personalized letter of interest (LOI) to your preferred programs that have not yet extended interview invitations. While this approach may not guarantee an interview, it can positively influence the program's perception of you as a candidate and increase your chances of being selected for an interview. (Feel free to reach out to USCE MATCH for a suggested template.)

During this time, residency programs frequently face a significant influx of applications, particularly in highly competitive specialties and esteemed institutions. To handle this high volume of applicants, programs spend extra faculty hours, and some may utilize filters and specific selection criteria. Unfortunately, this process can be disheartening for candidates with certain red flags in their applications.

Residency Mentor-Mentee Session

To help applicants overcome this challenge, USCE MATCH offers a mentor-mentee service that enables candidates to connect with matched residents. This service allows applicants to gain valuable insights, learn from their predecessors' experiences, and access best practices. This additional support layer proves exceptionally beneficial, especially for candidates with limited professional networks and some red flags.

It's worth noting that, according to input from a few residency insiders, a direct recommendation from a current resident within the program can often significantly increase the likelihood of receiving an interview invitation. This underlines the importance of networking and leveraging personal connections during application.

Residency Advocacy Campaign

Additionally, USCE MATCH provides a residency advocacy campaign for all deserving applicants who have completed a USCE rotation with us. This campaign involves endorsing selected applicants based on merit directly to the residency program, and in the past, it has shown promising results in assisting applicants in securing interviews and positions.

4. Interview Season (October-February)

Post Interview e-mail

Interviews are a two-way process where both the applicant and the program assess each other to determine the best fit. Receiving an interview invitation is a significant milestone in the medical residency application process. It indicates that the program has reviewed your application and believes you have the qualifications and potential to be a good fit for their residency position. However, your overall interview performance is extremely important in evaluating your suitability for your residency position and can single-handedly determine your matching success. After the candidate’s every interview, sending a personalized thank you letter at least two days after the interview is recommended while the interactions with the program are still fresh in the interviewers' minds. It is also important to respect the program rules on sending post-interview communications.

The interview phase is of paramount importance, and it's necessary not to underestimate its significance. Even highly qualified applicants can face challenges and, in the worst case, get unmatched if they don't perform well during interviews. Conversely, candidates who may be considered average on paper but excel in their interview skills can secure a match. 

The National Resident Matching Program’s (NRMP) survey identified several key factors that program directors consider when evaluating and ranking residency candidates. The interpretation of this data means that the candidate’s academic profile, Step scores, ERAS CV, summary of USCE, Personal Statement, and LORs are vital components that can help secure interview invitations. However, the applicant’s interview performance can make a crucial difference in your ranking and ultimately define your match result. 

The Match Formula

Remember this formula:

• 1^st step: Candidate’s Profile = Interview Invites
• 2^nd step: Candidate’s Interview Performance = Rank (High or Do Not Rank
• = Match Result

Interview Master's Course

Investing in professional interview preparations, especially with an experienced and trusted partner like USCE MATCH, is a brilliant and strategic move. It is a one-time investment for a benefit that is useful for a lifetime. It's a proactive step that can significantly enhance your interview performance and help you avoid the need for a repeat application, ultimately saving you time and stress in the long run.

5. Ranking Season (February)

Rank Order List Submission: Submitting the Rank Order List to the National Residency Matching Program (NRMP) by the deadline.

Letter of intent

After completing interviews, the candidates and the residency program make the rank list based on their preferences. It is recommended that an applicant proactively sends a tailored letter of intent based specifically on their experience (ask USCE MATCH for a suggested template). This can help remind the review board about the candidate’s profile and describe their interests in the program. The applicant should indicate if they will rank the program high or rank them as their top choice. It's important to show honesty in every aspect because some programs can easily communicate with each other. 

The Rank Formula (Town Hall Discussion)

USCE MATCH hosts an online session for its applicants, offering expert guidance, valuable insights, and advice on formulating a recommended ranking list for their preferred residency programs as well as the SOAP. This informative session is typically scheduled during the final weeks of January or at the beginning of February.

6. Match Day (Results are usually e-mailed)

Residency Match (usually on the 2^nd Monday of March): The NRMP matches applicants with residency programs based on their preferences and the program's preferences. 

Match Results: (usually on the 2^nd Friday of March): On Match Day, applicants find out which residency program they have been matched with.

Consider SOAP: Supplemental Offer and Acceptance Program (SOAP) occurs immediately after Match Day and is a mechanism to fill any remaining unfilled residency positions. If you don't secure interviews during the regular Match process, consider participating in the SOAP to access unfilled positions. Utilizing NRMP, ResidencySwap and Freida to check for unfilled positions and strategizing when to send cold e-mails, is recommended.

It's important to note that the specific timeline and requirements can vary by specialty and program. Be sure to check the individual program's application timeline and requirements and the latest updates from the NRMP and ERAS.