Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG®) assesses whether international medical graduates are ready to enter residency or fellowship programs in the United States that are accredited by the
. The rationale behind ECFMG is that there is no accrediting body for international medical schools. Medical education and medical schools throughout the world vary considerably regarding content, quality and duration, and there is no universal standard to determine equivalency.
ECFMG offers a variety of other programs and services to physicians educated abroad and other members of the international medical community. For detailed information on ECFMG certification and ECFMG's other programs and services, click here.
(AAMC), allows medical school students and graduates to apply electronically for first- and second-year (PGY-1 and PGY-2) residency positions in US programs of graduate medical education (GME).
ECFMG serves as the designated Dean’s office for all international medical graduates. As your designated Dean’s office, ECFMG is your primary contact for assistance and information throughout the ERAS application process.
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The ECFMG advisors network connects qualifying IMGs with advisors to provide practical advice and information about applying for GME positions as well as living and working in the US. The program is currently undergoing an expansion. Advisors will be listed in an on-line database, and eligible IMGs will be able to search the database. Eligibility criteria to participate as advisees were recently expanded to include IMGs who are participating in ERAS 2010 and who also have registered for the 2010 Match with the National Resident Matching Program (NRMP) (see below).
The ECFMG(r) Reporter provides IMGs worldwide with timely, objective information on current topics of interest. Previous issues are available on the ECFMG website, and subsequent issues will be posted as they are published. To join or leave The ECFMG(r) Reporter mailing list, go to The ECFMG Reporter
To be certified by ECFMG, international medical graduates must, among other requirements, pass a medical science examination. Step 1 and Step 2 Clinical Knowledge (CK) of the United States Medical Licensing Examination® (USMLE®) are the exams currently administered that meet the medical science examination requirement for ECFMG Certification. You must pass both Step 1 and Step 2 CK within a specified period of time. You can take Step 1 or Step 2 CK in either order, provided you meet the eligibility requirements.
For detailed information on taking Step 1 and Step 2 CK for ECFMG Certification, refer to the ECFMG Information Booklet.
Professional regulation in New York is different than in any other state. In other states, there are free-standing boards that regulate the licensing and practice of the professions. In New York, however, there is a Board of Regents which has the statutory authority to regulate licensure. The Board of Regents has administrative arms, one of which is the New York State Education Department. The Education Department has advisory boards, such as the State Board for Medicine, to advise on issues relating to professional license and practice.
You may be eligible to apply for a limited permit to practice medicine only under the supervision of a New York State licensed and currently registered physician and only in a general hospital, nursing home, state-operated psychiatric, developmental or alcohol treatment center, or incorporated, nonprofit institution for the treatment of the chronically ill. To be eligible for a limited permit, you must have satisfied all requirements for a license as a physician except those relating to examination and citizenship or permanent residence status in the US, or be an International Medical Graduate (IMG) who has met the education requirement and holds a standard certificate from ECFMG.
Limited permits are granted for an initial period of two years and may be renewed for up to two additional years only if you provide written evidence to the New York State Education Department's Office of the Professions that demonstrates progress toward licensure and justifies sufficient cause for such renewal. In no case will a limited permit be extended beyond four years of practice. Applicants for a limited permit must meet the same educational requirements as those applying for licensure.
Q Can a limited permit be issued to work in a hospital without a residency program?
A Yes. A limited permit is issued to individuals who want to work in some role in an Article 28 facility, which applies to general hospitals, nursing homes, certain types of developmental centers, correctional facilities, etc.
Q What is the difference between an MD and a DO degree?
A None. They are equivalent and are not treated differently.
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Visas can be divided into two categories: temporary (non-immigrant) and permanent (immigrant). The permanent visa, known as the “Green Card”, allows you to stay in the US indefinitely and to apply for US citizenship after three to five years.
For current information, visit the US Department of State visa website.
Also check the AMA’s immigration information.
New York “State 30” Program
Each state health department is allowed to act as an interested party in selecting people for federally designated health care professional shortage areas, and waivers of the foreign residency requirement may be recommended. The New York State Department of Health’s "State 30" program annually sponsors up to thirty physicians who hold J-1 visas and who seek waivers of the home residence requirement. In return, these physicians must agree to practice in federally-designated Health Professional Shortage Areas (HPSAs) or Medically Underserved Areas/Populations (MUA/Ps), or serve populations from these areas, for a period of three years. Up to ten of the waivers can be granted to physicians whose work sites are not located in HPSAs or MUA/Ps but who care for patients who reside in HPSAs or MUA/Ps.
J-1 Visa Foreign Residency Requirement
Some non-immigrant visas allow you to work. The most common one for IMGs to enter residency programs has been the J1. The J1 visa requires that at the end of your program you must go back to your home country to fulfill a two-year foreign residency requirement. (The original purpose of the J1 was to train physicians so they could use their training abroad.) This does not mean just leaving the US for two years – it means returning to the country that is listed on your IAP-66 as your country of residence. (The IAP-66 is the form issued by ECFMG that makes you eligible, if you are already in the US, to convert to J1 status; or to obtain a J1 visa at an American embassy or consul abroad, without a petition to the Immigration and Naturalization Service (INS).
If the country listed is no longer your country of citizenship because, for example, you became a citizen of Canada in the meantime, you cannot go “home” to Canada to fulfill the requirement unless you can prove that your original country will no longer let you in.
You cannot apply for US permanent resident status nor change to another non-immigrant status (except for a diplomatic visa, which is rare) until you fulfill this requirement. If you are subject to this requirement, marriage to a US citizen or having a child or sibling who is a citizen will not help. Such a circumstance is irrelevant to obtaining a waiver.
The foreign residency requirement has three categories of possible waivers, governed by the US Information Agency: hardship, asylum, and a request made by an interested government agency. This is where the New York “State 30” program comes in.
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NATIONAL RESIDENT MATCHING PROGRAM
The National Resident Matching Program (NRMP), a private, not-for-profit corporation established in 1952, matches residency candidates to hospital training positions. It allows you to do all your interviewing and then privately decide your order of preference as to where you would like to be trained. At the same time, it allows program directors to rank those they have interviewed. These preference lists are merged by computer at the NRMP and are announced during the third week of March.
Each year, approximately 16,000 US medical school students participate in the residency match. In addition, another 20,000 "independent" applicants compete for the approximately 25,000 available residency positions. Independent applicants include former graduates of US medical schools, US osteopathic students, Canadian students and graduates of foreign medical schools. In 2009, the NRMP enrolled 4,299 programs in the Match, which altogether offered 25,185 positions. A total of 35,972 applicants participated in the Match. Of those, 15,638 were 2009 graduates of accredited US medical schools, and 21,334 were independent applicants.
Programs register year by year just as applicants do. Some programs require you to go through the Match, others do not. You should inquire about this when you apply to a program. There are programs that fill all of their positions outside the Match. Some fill most from inside the Match but offer outside contracts as well. This is an institutional decision, and each hospital sets the rules as to whether or not its programs must use the Match exclusively. (In the same way, every program is autonomous in its decision making process. Each has its own specific requirements, e.g. concerning letters of recommendation, USMLE scores, etc.)
Write your list in good faith. There is no magical way to “play” the Match. Experience has taught that it makes no sense to try to figure out where you will be put on an institution’s rank order list (ROL). You need to simply rank your choices in order of preference. Ranking your “pie in the sky” place first will not damage your chances of getting your second, third, fourth or last choice. You will match with the highest spot on your ROL that has accepted you. The applicant’s list is the driving force behind the Match, and programs must rank more people than they need.
Before you rank a program, make sure you know its institutional and employment policies. A Match commitment DOES NOT supersede an institution’s prerequisites. For example, if you are told at an interview about certain visa requirements with which you are unable to comply after having matched with that program, the Match commitment is not binding.
Read the Match Participation Agreement carefully. Once a participant registers for a match and electronically signs the applicable Match Participation Agreement, the Agreement becomes a binding contract. Failure to comply with all the terms and conditions of the Agreement, whether intentional or not, may result in an investigation and the imposition of severe penalties.
Do you have to participate in the Match?
No. You are perfectly free to take a position offered by a program director during this process. But if you do remain active in the NRMP, remember that there is a mutual agreement signed by both the student and the institution. The student agrees that if he/she matches, the position offered will be accepted. The institution agrees that if the student matches, it will train that student.
FREQUENTLY ASKED QUESTIONS on NRMP are available on their website.
The number of residency positions offered is regulated at the national level, not by individual hospitals and programs. Each specialty has a residency review committee which regulates training. If a program director wants to change the number of residents in his program, he has to appeal to the appropriate residency review committee, complete dozens of forms, make a case as to why his community needs it, etc.
The interview period can end as early as November for programs beginning the following July.
Community service is a plus. If you’ve done any, make sure it’s visible on your application.
A program director will not consider hiring a candidate who has not been interviewed. You cannot be interviewed if you do not file an application for that program. Therefore, you should apply to as many hospitals as possible. The more hospitals you apply to, the more you increase your chances of obtaining an interview.
There are private organizations which, for a fee, assure IMGs a place in a residency program. They may contact program directors or set up fairs.
The general view among program directors regarding the credibility of these organizations is tremendous cynicism. It is recommended that you NOT listen to anybody who “guarantees” you a residency spot unless he/she is a program director authorized to do so, and if such a service costs a significant amount of money, it is not worthwhile to get involved.
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HOW TO APPROACH AN INTERVIEW AT A HOSPITAL
Once hospitals have a pool of candidates, either a selection committee or the program directors themselves will begin to review the applications. As with all jobs, the decision to interview is based upon what reviewers see on those applications.
Applications are reviewed and considered on the basis of how a candidate did in school, scores on the ECFMG exams, job history since graduation from medical school, etc. If you choose to obtain a job while you are waiting for a residency, it is very helpful to obtain employment in a healthcare setting rather than something totally unrelated. This demonstrates to program directors that you are "keeping your hand in" while waiting for a training position and that your interest in medicine is sincere.
When you get an interview, the window is open, not the door. You should frequently review interviewing guidelines and tips. The most important thing to remember:
BE PUNCTUAL AND BE PREPARED.
It is recommended that you know the name(s) of the person(s) who will be interviewing you, something about the hospital (number of beds, primary specialty, etc.), and something about the program for which you are interviewing. Do not be afraid to ask questions.
Be prepared to discuss cases, hypothetical or not. It is possible that you may be brought around the hospital to see how you interact with patients and other physicians. This is the only opportunity a program director has to assess your potential as a physician.
If you are not a US citizen, you will almost certainly be questioned about your visa status. The status of your visa is your responsibility, and a program director usually will not be able to assist you with any visa or citizenship problems. Likewise, a program director may reject you as a candidate if there is any indication that you may have visa problems in the future.
As with all job interviews, leave questions about salary, benefits, vacation, etc. until last in the interview. If the program director has indicated there may be another interview, leave them until then.
While you may be willing to accept almost any specialty in order to obtain a residency, program directors generally look for someone committed to their particular specialty. Be prepared to answer questions about why you have chosen a particular specialty.
If you find you are having difficulty obtaining interviews, try to obtain an appointment with a director — perhaps someone you know, another international medical graduate, or a program director with whom you did interview — in order to ascertain what it is that is causing you problems. Speak candidly with this person. Explain that you have not been receiving interviews or that the ones you had did not go well. Seek advice on what could be improved.
After you have interviewed for a particular program, be sure to acknowledge it by sending a short note extending your thanks. If you are interested in that particular program, say so. Be enthusiastic about your interview, the hospital and the program.
If after interviewing for a program you decide it is not for you, give the program director the courtesy of writing and informing him or her. This extends a chance to another candidate to get that slot.
Remember that the interview is the critical part of the whole process. Here are excerpts [LINK TO] from a presentation given by a co-director of residency training and chief of internal medicine at a Long Island hospital. It will give you some perspective on how program directors view the process of applications and interviews, and ultimately how they decide to offer positions. Remember, there are opportunities for people who are able to rise to the top and show their skills and abilities. If you show commitment and a work ethic and learn the system, you will have opportunities and the chance to become a chief resident, a junior faculty member and a leader of medicine.
Comments from a program director’s perspective
My job is not to tell you that the system is fair or will work well for you; my job is to be as honest as possible and tell you about the system and how we as program directors decide who gets an interview and who gets recruited. Understanding the pitfalls, obstacles, etc. will increase your likelihood of ultimately finding a training position.
The first question is what specialty should you apply for? Those where you’re most likely to get positions are in primary care: internal medicine, pediatrics, family practice, psychiatry. The US needs practitioners in these specialties. When choosing programs, you must therefore balance your personal needs and background with reality. You must also consider where post residency jobs will be available.
Another important consideration is to know where to apply. IMGs are more likely to find positions in certain states, such as New York, New Jersey, Illinois. Also, look for programs that have already shown they are IMG friendly. The school you come from is important. You should be aware of people who preceded you from your school. Where did they train? Where were they successful? You will find a more welcoming atmosphere from a program director who had good success with a graduate of your school. (Check the internet, where programs will often list participants, where they come from, etc.)
You have to be aware of trends on a statewide and national level. Applicants honestly committed to a career in primary care are looked upon favorably.
How many hospitals should you look at? There’s no limit. Investigate and learn about as many as you want. How many should you apply to? This will be limited by time and by financial and practical constraints.
When should you gather information and apply? The summer before you wish to start. Program directors begin to worry about the following academic year around July 15 of the year before.
As for the application process, one of the things I must share with you is that there is a frustrating amount of randomness to the whole thing. It is not very scientific, but here’s a pointer: assume that you are being evaluated at EVERY step. From the initial contact, do everything right and everything you can to make yourself seem different from the thousands of other applicants.
Your application package must allow you to rise to the top, to stand out. You are competing with thousands of other people. About one quarter of our applications are thrown out right away because of their quality. This includes poor grammar, typing mistakes, and unclear ideas. This kind of application reflects a certain laxness, a certain approach to medicine as a whole. An application should have perfect grammar and spelling. It’s a good idea to have someone review the application for these issues.
Get everything in on time. We have thousands of applications, and if you miss the deadline date, we are not going to make exceptions.
Your CV should highlight what sets you apart from other applicants. Include experience in your home country, publications, research, teaching, anything academic.
YOUR TEST SCORES ARE VERY IMPORTANT. This is the first way we evaluate applicants, and I cannot overemphasize how important it is to get as high a score as possible. Some programs have a specific cutoff below which they will not even consider someone. DO WHATEVER YOU CAN TO GET THAT SCORE AS HIGH AS POSSIBLE. Put in the hours for test readiness, and be prepared.
Grade cutoff policies are becoming very popular. Programs develop such policies to make life easier for them.
Don’t confuse “dean’s letters” with letters of recommendation. Dean’s letters are not very important, but letters of recommendation are. Letters from the US will carry more weight than those from overseas, but letters from overseas can be important too.
How can an IMG get a good letter? The ideal, though admittedly very difficult to obtain, is to get some experience in a US facility, especially a facility with a teaching program. Any experience in a US teaching hospital will put you at the top of the list, but unfortunately there is no coordinated or standard process to get such experience, and observerships and externships are not advertised.
I suggest you call or write to every institution within driving distance of where you live, explaining that you are a well trained IMG, you have a lot of experience and would like to volunteer to be part of that institution as an observer or extern. Tell them you will work nights, weekends, whatever. Ask friends, network, etc. Even a four week rotation, especially in a teaching hospital, can make an impression on someone and get you that very important letter.
People who have had such a rotation are the kind of people program directors want, and if you have had a rotation in a setting in which regular education takes place, this will really single you out from most of the candidates. Such a letter is powerful and will almost always guarantee you an interview.
The next best thing is a research project in a hospital where you work in a laboratory and obtain a mentor. You can become familiar with the hospital and ask the chief residents if you can observe, etc.
What about an externship in someone’s office in the community? While working in a private office is certainly helpful for you personally and professionally, and will teach you about American medicine, skills and issues, it alone is not such a help to your candidacy. It is assumed that working in an office reflects a friendship or a family connection, and it is not looked at very seriously.
We are looking for letters from people who know you and can comment on your abilities, strengths and weaknesses. If I get a sense that the letter writer knows you and is providing honest information about you, I will pay attention to that letter and invite you in for an interview. But if I get a series of letters from people who write one paragraph, and I get no insight into you and your abilities, I am less likely to do so. US grads also have trouble with deans’ letters. They are instructed that a letter from someone who knows them — even if only an instructor, assistant professor or resident — is much more important than one from someone at a higher level who does not know them.
Some programs require a personal statement and use it as part of the interview process. Even if it is not required, I advise you to write one. It gives you the opportunity to identify yourself as someone unique from the other applicants, and this is the bottom line: you have to separate yourself out as a candidate, to highlight your candidacy, to make yourself appear different, special and unique to a program that receives applications from 1,000 to 1,500 other people. Keep your statement short (one to one-and-a-half pages), and discuss your training, experience, view of medicine, goals for the future. You can talk about your career in your country of origin, the factors that led you to come to the US, why you decided to go into medicine in the first place, a critical incident or patient encounter. The angle you take is not as important as making sure the statement says something unique about you, the skills you can bring to a residency program, and how the program would be better for having you as a trainee. The personal statement allows an interviewer to form an initial impression of you, and a good one may get you in the front door. Once your foot is in the door, you have a chance.
Most house staff training programs have administrative coordinators. They are valuable members of our team who help us assess applicants. As part of the process, you are going to have to speak to them. Be polite and be professional. Each year about two or three dozen applicants interact with my coordinator in a rude and inappropriate manner. I will not interview these people. If you are unprofessional and inappropriate to my coordinator, I assume that you will be the same with colleagues and patients. On the other hand, sometimes my coordinator will come to me and say she has spoken to someone on the phone whose scores are not that high, but whom she feels very positive about. This will sometimes get someone in the door.
The Match is the fairest way for all concerned to obtain a position and is in your best interest.
Even though you are registered, you will go on interviews where you will be asked if you are interested in coming to an agreement outside the Match. Some of these programs are relatively fair, and some are unfair. There are some where you will walk in, go through your interviews and are offered a spot at the end of the day — but you have to make a decision before you leave. Obviously this is neither ethical nor appropriate, and you should do your best to bargain for time and not be forced into a decision. But you may be put in this position, and you should decide in advance how you will deal with it.
Other programs might give you a few weeks to make a decision. This too puts you in a very difficult position. If you have interviews in November spreading out to January, and the programs you see in November want an answer by December, this might be before you see your top choices in January.
I therefore recommend that you get your interviews scheduled as soon as possible. Since the first one or two are the most distressing, arrange them in places where you are really not interested; make them practice interviews. The interview process is full of anxiety, and your chances of “screwing up” your first interviews are very, very high. In this way you will get a sense of what an interview is like, and if you mess up, there is nothing to worry about.
If you have been to a program in which you are very interested, but another makes you an offer on the spot, call back the program you really want and say, “Look, I’ve been offered a spot, but I really want to go to your program, what advice can you give me?”
Everything else is secondary to the interview. This is your chance to sell yourself in person, and you can dramatically change the way you appear on paper. Be polite, never arrogant. Explain how your skills, experiences, insights, personality and commitment will make you successful and why the program will be strengthened by having you as a member.
Is it a problem if you’re shy? Yes and no. You should be yourself. If you’re shy and quiet, there is no need to come across as obnoxious and overbearing. Think in advance how you’re going to sell yourself and what you’re going to say about your ability to make that program better. For example, say, “As you can tell, I’m a shy and quiet person, but my work ethic is strong, as is my ability to get along with other members of the team; patients feel comfortable with me…” Articulate your goals for the future and your desire for residency training. Not saying enough could cost you a position.
Learn as much as you can in advance about each program and hospital at which you interview. You need to be able to speak intelligently about them. This tells the interviewer you’re interested in the program and gets the energy going.
It is deadly to have no questions. In about a third of my interviews I sit and ask questions while the candidate shows no interest. I ask if there are any questions, and the answer is no. It is a turnoff if you stare blankly or say no. This makes the interviewer think you have no interest, there’s no spark. So even if you know the answers, ask some good questions, e.g. re libraries, computer resources, teaching programs, curriculum, the future in the field. Ask how many graduates of the program have passed their boards? gone on to fellowships? to practice in the community? What has been the success rate of IMGs in the program? Ask about the educational focus of the program, the lecture schedule, the rounds, the quality of the faculty. Ask academic questions and make the interviewer think you are intellectually inclined and looking for the best place from an educational, not a lifestyle point of view. All this makes the program director believe you have a focus on education and understand what residency training is about.
If you have the opportunity when you set up an interview, ask if you can come to morning report and join house staff rounds. This gives you a chance to observe interactions between faculty and house staff as well as to show your interest, and it will help you better compare programs you have seen. But do not “hang out” outside the office. About fifteen or twenty people do so each year, asking questions of all who enter. This is bad. If you want to speak to house staff, ask the coordinator or chief resident to set things up. (And by the way, if I see you smoking outside, that costs you one or two points.)
Sleep well the night before, relax, and go in with the mindset that two processes are going on: a program is interviewing you, and you are interviewing a program that has to please you and prove they have an education and house staff of which you would like to be a part.
You will be evaluated by how you present yourself, so dress and groom well. Every year we have people dressed inappropriately, with sneakers and without ties. This makes an awful first impression which will greatly diminish any chance that applicant has.
Usually you are first brought into a large room with about twenty others. Don’t come too early, for this can be nerve-wracking. However, allow a little time, and you can share experiences, learn what is going on this year at interviews, who is offering positions outside the Match, which programs are giving pressure interviews, etc.
You will then be greeted by the program director, chief resident or coordinator, who will give a short overview of the program. This is not much pressure for you, but PAY ATTENTION, even if you have to fake it — you are being seen by the speaker.
Be aware that there are some programs that will administer an actual test. Some tell you up front, some do not, and some make decisions about whom to offer spots based on this test. Other programs are more relaxed, but all want to get a sense of you as a person.
Part of the day will be spent with house staff. (If not, you definitely should be concerned.) You want to make a good impression on the house staff, because they give feedback to faculty. Sometimes applicants feel the house staff is their "buddy," but this is a mistake. Be careful how you present yourself.
This is when you ask the real nuts and bolts questions, such as, “What’s the work like? How many patients does one carry? What’s it like to live and work in this environment? Where have recent grads gone?” These questions are different from those you ask the interviewer. It’s fine and perfectly appropriate to ask a resident, “Do you ever get any sleep when you’re on call? Or do you work like crazy?” But DON’T ask this of the Chair of Medicine.
It is very difficult to get a sense of the medical capabilities of a person being interviewed. So chances are good you will be asked to discuss a case you have recently seen. Nothing looks worse than a candidate hemming and hawing and admitting he/she has not recently seen a case. Have two cases prepared. If you haven’t seen them recently, make believe you have, linking up recent literature to something you saw a while ago. Present them in formal style, allowing about five minutes for each. Be very articulate and animated (“...recent articles say such and such, the literature says so and so...”). One case should preferably be outside the specialty of the person interviewing you. In this way you can look good, you can speak medically, and you can talk with some authority without having someone tear you apart.
A minority of programs will ask you questions. Frequent questions nowadays concern your views on changes in health care in this country and how this compares to your country. We are impressed if you can articulate an understanding and insight into what is going on as well as your thoughts and how you perceive your position. If you prove too unaware, that would be a negative. This is something for which you can prepare.
After the interview process, send letters to the coordinator, the program director and everyone you met, thanking them for their time. It is always good to have that kind of letter on file. We really do remember such letters when we rank candidates or discuss offering positions outside the Match. Honestly, I must reiterate that the whole process is somewhat arbitrary, and a complimentary letter might make you number 115 rather than 124 on my list. You should do anything you can to make yourself special and stand out from the crowd.
Here is something else to bear in mind. After the Match, I get calls, even if my program is not listed, asking if I have open positions. So prepare in advance. In February, pick out five programs, call them, and tell them that you’re sending them your whole information packet — application, letters, etc. — in the event positions are available and you are available after the Match. Then your packet will be on file, and you can call, tell them they have your information, and ask if you may come in for a shot at the position. Chances are you will be called for an interview.
This goes for July as well. There is a small window between July 1 and August 1, though there is no organized way to find them. So my advice is that on June 1 you write to ten programs and tell them, “Here is my completed packet. Please keep this on file in case positions open up. I’m willing to come on a day’s notice.” This gives you an inside track — a program director would much rather go to files already on hand than advertise a position.
The last thing I want to mention is that many people list research and publications on their CV. If you advertise that kind of experience, it is very important to be able to talk about it. Very often someone comes in and says they did research and publication, and when I ask them to discuss it, they are not really able to, explaining it was a number of years ago and they do not remember that much about it. This negates that whole aspect of the CV. If anything is on your CV, be prepared to talk about it.
FREQUENTLY ASKED QUESTIONS on APPLYING
Q When is the right time to begin applying?
A Each program sets up its own dates, but most begin taking applications during the summer or around Labor Day. You should begin looking into programs around the preceding May. The cutoff date for receiving applications is between December 1 and January 1. Most programs will interview through January. Those with unfilled positions after the Match will open up their application process again. It is recommended that you have sets of materials ready to go.
Q I applied for a residency last year and did not get one. I am now applying again. Should I reapply, or do program directors keep last year's applications?
A Unequivocally, old applications are not kept. Do not assume that any program has last year's applications. You must repeat the whole process: applications, letters of recommendation, supporting documents, etc.
Q Can I apply at the same time in the same hospital for two programs?
A Nothing prevents you from doing so. In most hospitals those programs would not communicate, and one would not know of your application to the other. If the programs somehow knew, this could be a problem, for each could construe it as a lack of real interest in their program. But if it were for a good reason, e.g. you must be in a certain city because of a spouse, family, etc., it would be appropriate to let the hospital know this.
Q What about applying for both a categorical and a preliminary internal medicine program in the same hospital?
A You should let the department know you are doing this and explain it in an appropriate way. Do not remark that you really want to do orthopedics, but if you’re stuck you plan to apply to a three year internal medicine categorical as a backup. A more appropriate explanation is that you really want internal medicine, you love that hospital, and if you can’t get the three year program, you would like to train there for one year.
Q What is an appropriate number of letters of recommendation to send to program directors?
A Three are standard, four are not a problem; but don’t send six or more, that’s overkill.
Q What is the purpose of a “dean’s letter”?
A Basically to make sure there have been no screwups, no big problems. So if a dean doesn’t know you very well, don’t worry about it. What we’re really looking for are letters from people who can attest personally and at first hand to your medical abilities.
Q Should letters of recommendation be sent by the medical school?
A Either by the school or by the person writing your recommendation. Letters should be sent from the source.
Q Are those from an earlier date acceptable?
A They are acceptable, but depending on the time elapsed, they may be a negative for you. An older letter implies that for the past number of years you have not done work in the medical field from which someone could write a letter about your performance and abilities. Letters a year or two old generally pose no problem, with the exception of letters from medical school deans.
Q Would a letter from a director of nursing services be helpful?
A Any letter that gives a sense of your personal qualities, work ethic, knowledge, ability to relate to patients, etc. is helpful and cannot hurt you. However, it will not be looked upon favorably if none of your letters comes from a physician.
Q Does a higher degree or diploma affect your chances of being accepted into a program?
A Yes, it would favorably affect your application.
Q How important is research?
A It depends upon the quality of research and the individual program to which you’re applying. If it’s a university program with a culture of research, then it’s very helpful. But if you did two projects at medical school without publication, it won’t make much difference. Lack of research is not a problem except at “hotshot” high pressure places.
Q Will research enhance my chances of getting a residency?
A Yes, especially if you publish and/or receive a strong letter of support from someone in that laboratory.
Q What is a program director’s attitude towards a couple applying for a match in the same program?
A It depends on the program director, but there is no need for qualms about applying as a couple. Be open with it. It would be rare to have that seen as a negative.
Q Is a primary care program a better choice than a categorical position?
A The best advice is probably that you choose the program that best fits your needs and educational goals. If you are convinced you are going to go into a community where you are going to be a generalist, apply for primary care. If you want to train fully in internal medicine and then have the opportunity to train in hematology, pulmonology, rheumatology, then go for a traditional categorical position.
FREQUENTLY ASKED QUESTIONS on INTERVIEWING
Q What specific questions might be asked at an interview?
A “Tell me about an interesting medical case you have seen recently, or one that was important to your career.” “Tell me about your strengths and why we should consider you for this program.”
Q Can you ask an interviewer if the program is on probation?
A Yes, it is perfectly legitimate to ask if the program is fully accredited, if there are any restrictions, sanctions, parole, etc. Programs are required to tell you they are on probation.
Q How important are test scores?
A Some programs clearly have a minimum. A minority of programs will share among each other (but not with applicants) information on minimum scores under which they will not interview. Most programs like higher scores, and that’s a criterion, but there is no absolute basement where you don’t have a chance.
Q Medical School?
A If a program director has had experience with other trainees from your school, and they all did well, passed their boards and went on to good careers, he would be more sympathetic to that school.
A If you are one of the ten percent of applicants who has had the chance to work in a teaching hospital and obtain letters from US faculty, this is a VERY IMPORTANT part of the application process.
A A great equalizer. Once you get your foot in that door, scores, schools, even letters are not as important as the impression you make. This is your chance to sell yourself. Let the interviewer know why you’re special, why you’re different, and why you’re going to be a good person for that program.
Q How does a program director view an applicant who has been in a specialty in his own country, e.g. ophthalmology, but now decides to change to primary care?
A They probably understand that ophthalmology will not be obtainable in the US. If you’re applying to internal medicine, do not try to hide your past, but change it into a strength. Explain how you can bring your specific skills (e.g. ENT, orthopedics, etc.) to a training program. Say you know you won’t be able to train in ophthalmology, but speak about how as an ophthalmologist you managed diabetic patients and watched their vision deteriorate. You therefore feel you have gained an insight into diabetes which would help you provide better care to your patients. This approach can be used with any specialty. E.g. your experience as a vascular surgeon showed you the endstage results of uncontrolled diabetes, and you now realize the way to treat this disease is not to operate on people in their sixties but to teach them to eat the right diet and to exercise in their twenties. The same goes for having been an orthopedist; you can now see that instead of hip replacement at age sixty, it’s better to counsel exercise and calcium during the twenties. Use your prior experience as a strength that will make you a better primary care doctor and that will benefit the program.
Q I was awarded a fellowship to study acupuncture. I feel this is a sensitive issue. While some people may find this interesting, it may disqualify me by orthodox program directors. Should I include this in my CV?
A It is hoped that program directors would not be so close-minded as to see an experience in expanding one's horizons as a negative. Your CV is very important. It is looked at carefully, and it is looked at for gaps. If you decide you do not want to list a medical training period for two years, and there is a two year gap, this is a cause for concern. Each succeeding year that a trained physician has left medicine increases the difficulty of returning. People who have had three or four year gaps have historically had more problems as PGY1s than those who have had continuous exposure or immersion in the medical system at some level.
Q Can I ask a program director about my chances on his/her list?
A Yes, depending on how you phrase it. During the interview, you can choose to say you really like the program and will rank it number one, but they shouldn’t ask you where you are going to rank them. DO NOT ASK where they are going to rank you. If a program director volunteers this information, that’s fine. If the program asks you if you are interested, your answer is always, “I love your program, I’d like to come here, I’d like to train here.” All your post-interview letters should say the same; there is nothing wrong with doing that. After the interview, you can call and say you like the program, you would be very happy at this program, and could you please find out what your chances are. Be aware, however, that you can’t always trust the answer. It’s in the program’s interest to say they liked you very much and that you should rank them, because it’s in their interest to have everyone rank them. Also, if it’s the beginning of the interview process, you might be the best candidate so far — but there are many months to go.
Q Should you rank a program if you felt the interview did not go well?
A If you want the program, you should rank it. You never can tell what the outcome of an interview will be.
FREQUENTLY ASKED QUESTIONS on RESIDENCY PROGRAMS
Q Is there a way, other than word of mouth, that we as candidates can grade programs?
A Board pass rates for some specialties are public information. This is an important outcome issue you should be aware of. Programs with high board pass rates are better than ones with low rates. Also, find out where people have gone for fellowship training programs and where they have gotten jobs.
Q What is the meaning of board certification?
A It is a process that occurs upon completion of residency training. Either a written or both a written and practical exam are given to certify your mastery of knowledge in the specialty. It is a goal you’ll want to ultimately pursue, but it’s not relevant at this time.
Q Are older applicants (over 40) at a disadvantage?
A Yes. This will not be admitted or written down, but there is a bias. Will the applicant be able to keep up with the rigors of residency? Accept being a junior member of a team and reporting to someone who could be 20 years younger? Do your best to turn this weakness into a strength. In a personal statement stress your practice experience: you have taken care of people, you are experienced and have expertise, you will bring a perspective and maturity that someone fresh out of medical school would not be able to bring. Point out that you have realistic expectations of training and understand you will be a junior member of a team, and you are willing and ready to do that.
Q Is there an official cutoff date for year of graduation before which you will not be considered?
A There is no national, state or specialty requirement, and every program can make that kind of decision. There is, however, a concern about how much time was spent out of the medical profession between graduation and entrance into a residency program. Have you kept up your medical skills? A one year gap is not that severe, but it is very important that you come prepared to honestly answer with some specific medical experience: externship, preceptorship, conferences, reading medical journals. Remember that if you mention the latter, you will be asked to talk about something you recently read, e.g. in the New England Journal of Medicine. If you make such a statement, you must be able to back it up.
Q Is it easier for a resident of New York to get into a New York program?
A No, that’s irrelevant.
Q How can you find out which preliminary programs go with which specialty programs?
A When you start to apply to specialty programs, they will recommend the preliminary programs which you should consider in order to enter their residency.
Q If an IMG has trained elsewhere for a number of years and then comes to this country, can credit be received for that time?
A There is a procedure through the American Board of Internal Medicine whereby a program director can request that an applicant receive credit for time spent outside the country, and potentially reduce training to two years. In general, this is for a special research or faculty appointment. It would be unusual for someone who trained abroad but has nothing special in their CV to be able to reduce their training in the US.
Q Do training programs provide guidance specific to IMGs?
A Some medical schools are willing to advise IMGs, but in general they are not going to have a commitment. Many programs do invite their July 1st interns to serve externships prior to their start date in order to see how the system operates. However, the biggest problems facing IMGs tend not to be medical issues, but rather the whole logistics of how to work in American hospitals, how to take care of forms, how to make the system work.
Q Is it detrimental to your chances to change programs?
A If left unaddressed, applying for a program in a new specialty could be a negative. To make it a positive, it should be explained (e.g. in a personal statement). Give a reasonable discussion and insight into your views, and follow this up during the interview, explaining your change in perspective.
Q What recourse is there for someone terminated from a program within two or three weeks?
A Such termination, which does happen on occasion, would occur if it was felt there was danger to patient care. All programs are required to have an institutional internal review and appeal mechanism and to provide due process. There is not much you can do outside the institution after the internal appeals have played out, especially if there are recurrences and documentation of attempts at remediation. If there was no due process, that’s a different issue.
Q How can one find out which hospitals accept IMGs?
A Word of mouth. There is no list, no publication. You have to ask around, share information. Also, target programs that did not fill last year or in the past. Look at programs that are least desirable to US students: public hospitals in cities; places like North Dakota.
Q What areas, besides New York City, are familiar with IMGs and can provide first rate training?
A In New York State, high quality training programs are found at the University of Buffalo, with a consortium of hospitals, e.g. the Veterans Administration Hospital and Millard Fillmore; State University of New York Health Science Center at Syracuse; and Highland Hospital in Rochester. New Jersey has about a dozen or more training institutions that are very dependent on IMGs. The University of Newark (UMDNJ Newark) is a first rate institution which has had trouble recruiting due to its geographical area; it has had great success with IMGs. Also, community hospitals in New Jersey: Livingston, Montclair, Mountainside, Neptune, Rahway, etc. In addition, Chicago, Illinois and Maryland have traditionally welcomed IMGs.
Q If you pass the ECFMG and just miss the NRMP deadline, what are your chances of getting a residency?
A The chances are small, but not zero. There is usually a window period between July 1 and August 15, the first six weeks of the academic year, during which openings may develop. This may be due to people not showing up or not honoring their commitments, or to problems that cause someone to leave. If you are unsuccessful in obtaining a position, or the timing is such that you are unable to get into the Match, it is advisable that by June 1 you make sure you are available and your paperwork is in order. Pick out six to twelve programs and send them a complete package of application, certificates, letters of recommendation. Complete applications might be placed in a backup emergency file where the program director can quickly look if an intern is lost. Once you get past the summer, it is very unusual for a position to open up.
Q How do I find out if any programs begin in January or any date other than July?
A Directly from the program. Check websites. For internal medicine, for example, look at the Alliance for Academic Internal Medicine (AAIM) site. Positions offered through the Match are expected to start in the summer. The only reason they start mid year is because someone left, or it is peculiar to a specific program. It is not the rule. So listen around, network.
A WORD ABOUT PROGRAMS ON PROBATION (PAROLE): All programs in the US have to be accredited by their specialty residency review committee. Those that have not complied with rules and regulations may be put on probation by these committees. Look cautiously at programs on probation. There are a lot of technical reasons for being in this position, and US grads stop applying to a program the moment it goes on probaUBMITTING YOUR RANK ORDER tion. It’s easier to get into such a program, but do your best to get into a fully accredited program. Do not rush to go outside the Match into a program that’s on probation. On the other hand, it’s much better to get into a program on probation than not to get into any at all, and probably at least 50% will become fully reaccredited. There will be no black mark upon you as an individual if the program folds, and you will at least have had some experience and connection with a faculty.
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SUBMITTING YOUR RANK ORDER LIST
For comprehensive information, including deadlines, check the NRMP website.
Your rank order list (ROL) is your declaration of the programs with which you sincerely want to train. You state which program is your first choice, second, third and so on. Programs fill out their rank order list of who is their first choice, second, third, etc.
You may apply to any and all specialties you desire. You rank programs to which you have applied and interviewed in your preference order. At the top of the list should be your “reaches for the stars;” mid range is for programs you want and are pretty sure you could get; low range is for “safety” programs, those you are sure you could get. You will be matched to the program highest on your list that offers you a position.
You may submit as many program choices as you like. Between 25 and 35 are recommended. The average rank order lists ten to twelve programs, but realistically that’s too few. Remember, the more applications you send out, the better your chances.
Programs can follow different tracks, and these can be mixed on your rank order list. The different tracks within internal medicine, e.g., are transitional, preliminary, categorical, and primary care:
Transitional programs do not lead to an end by themselves; they are the equivalent of the old “rotating internship” where you alternate every couple of months, e.g. from obstetrics to surgery to internal medicine. It counts as a year of training, but may not count as a year of board eligibility for medicine, and if you want to stay in internal medicine you might not acquire enough credits to step right into a PGY2 spot. A transitional program can be a good backup for an IMG who doesn’t get into another program. Being in a transitional program is better than being in no program at all.
Preliminary programs have the same sort of goal. They are for people going on to radiology or anesthesiology who need a year of internal medicine training, and they will generally grant enough credits to go smoothly into a second year training position in internal medicine. For IMGs, a first year preliminary spot is a nice entree and is clearly better than nothing; but if you have the option between preliminary medicine or categorical medicine, go for categorical.
Categorical programs are three year positions and, dependent upon your satisfactory performance, you will be able to train up to board eligibility in that program.
Primary care programs in internal medicine generally provide increased emphasis on ambulatory care, generalism, outpatient care in orthopedics, ENT, dermatology — subjects that are not taught in traditional medicine training programs, but that are important for people who are going out to practice medicine in the community.
There are also about 2000 PGY2 programs which will not begin the following July, but a year from July. These advanced positions are referred to as "S" programs, and they require one year of preliminary preparation. If you rank S programs in this year's Match, you will also be asked to rank compatible first year programs by submitting a supplemental ROL, and it’s not a bad idea to apply to first year programs in the same city. It is possible to be matched to an advanced program and not to a first year one, and you then might have to scramble for a first year position. If you are ranking advanced programs but would also take a preliminary position, those preliminary positions must be on your primary ROL.
It is also possible to submit rank order lists as a couple. Two people can be linked and matched to residencies in the same geographical area, even to two different specialties in two different hospitals. On this ROL, where both partners have to match as a pair in order for a match to be made, an individual can list the same program many different times. One partner can even select a “no match” (and try for the scramble) in order for the other to get a certain position. The couples Match is student friendly and works extremely well.
When filling out the ROL, list the program you most desire first and proceed down your list until you have listed programs which you will accept but are not your primary choice. Do not list a program you will not accept. You are obligated to accept the position with which you match.
It is very important that you have the correct code numbers for each program listed on your ROL. Be sure to use current information.
REMEMBER: If your list does not arrive on time, you will be eliminated from the Match.
How does the Match work?
The computer program starts at the top of your ROL and works its way down — you will match with the highest spot on your ROL that has accepted you. However, if you have not ranked a program, you cannot match there; if the program has not ranked you, you cannot match there.
If you have not been called for interviews, if you do not submit a ROL, if you have not passed all the exams necessary for ECFMG certification, or if you have not paid all your fees, YOU WILL BE WITHDRAWN FROM THE MATCH.
GOING OUTSIDE THE MATCH
Many IMGs feel a great deal of pressure to accept the first residency position that is offered. Be positive about yourself and the process. While you are certainly free to accept a position outside the Match, have confidence that you have something to offer a program director and that you can succeed. If you do choose to accept a residency offered outside of the Match, be sure that you have withdrawn from the Match by the deadline for submission of rank order lists. You should be mindful that the majority of IMGs enrolled in the Match do obtain a residency they have ranked through the Match.
THERE IS NO DOWNSIDE TO REGISTERING WITH THE MATCH — IT OPENS UP THE MAXIMUM NUMBER OF DOORS.
When selecting programs to interview and include in your rank order list, you have many choices to consider in terms of location, quality, whether your spouse may train at the same facility, etc. Much of this information is available through the AMA's Fellowship and Residency Electronic Interactive Database Access (FREIDA). FREIDA has long been acknowledged as the best source for the most thorough information on all graduate medical education programs accredited by the Accreditation Council on Graduate Medical Education. The information is based on surveys submitted by programs. Users can search through the list of over 8,600 programs using a variety of criteria to isolate the exact information they need. It’s not quick, but it’s very comprehensive.
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Additional Important Links
American Medical Association (AMA)
The national arm of the federation of organized medicine, the AMA unites physicians nationwide to work on the most important professional and public health issues.
AMA International Medical Graduates pages
The International Medical Graduates Section (IMG) represents and promotes the interests of physicians who graduated from medical schools outside of the US or Canada. Thirty-five thousand members strong, all AMA members who are IMGs are automatically members of the AMA-IMG Section.
AMA Immigration Information for IMGs
For visa information.
Educational Commission for Foreign Medical Graduates (ECFMG)
Assesses whether IMGs are ready to enter residency or fellowship programs in the US that are accredited by the ACGME.
National Resident Matching Program (NRMP)
Provides an impartial venue for matching applicants' preferences for residency positions with program directors' preferences for applicants.
New York State Department of Health
Functions and responsibilities include promoting and supervising public health activities throughout New York State; ensuring high quality medical care in a sound and cost effective manner for all residents; reducing infectious diseases and chronic disabling illnesses; directing a variety of health-related homeland security measures in conjunction with the New York State Office of Homeland Security.
New York State Education Department – Office of the Professions
New York's system of professional regulation encompass nearly 750,000 practitioners and over 30,000 professional practice business entities in forty-eight professions. Purpose is to protect the public and the integrity of the professions through managing licensure and registration, professional discipline, public and professional education and information.
United States Citizenship and Immigration Services
The government agency that oversees lawful immigration to the US.
US Medical Licensing Examination website
Assesses a physician's ability to apply knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills, that are important in health and disease and that constitute the basis of safe and effective patient care. Exams consists of three Steps.
Because individual medical licensing authorities make decisions regarding use of USMLE results, physicians seeking licensure should contact the jurisdiction where they intend to apply for licensure to obtain complete information.
Iserson's Getting Into A Residency: A Guide for Medical Students, Seventh Edition
Kenneth V. Iserson, MD
Helpful hints on making the right choice.
Survey of Resident/Fellow Stipends and Benefits (AAMC)
The Association of American Medical Colleges survey gathers data from hospitals and medical schools that issue checks for resident stipends. Individual institutions are not identified and summary statistics are generated only when five or more institutions in a subgroup have responded to the survey. The data collection and dissemination process complies with the Antitrust Guidelines promulgated by the US Department of Justice and the Federal Trade Commission in 1994.
AMA – Residency Position Resources
Sources of information on open residency and fellowship training positions:
Offered by the Association of American Medical Colleges, FindAResident is a powerful, web-based search tool to help you find open residency and fellowship positions. Supplements the Electronic Residency Application Service (ERAS) and is ideal for finding unfilled positions, especially if you experienced an unsuccessful match through the National Resident Matching Program (NRMP) or Scramble.