Applying for medical residency in the USA as IMG

Common questions and Requirements for medical residency in the USA for IMG

The most frequently asked questions by medical students are:

How much does medical residency cost?

The cost of applying for residency programs depends on the approach(the number of programs to apply to, etc.), but you must be prepared to pay travel expenses and at least about $ 4,000 in fees. This includes USMLE exams fees, ERAS application fees, NRMP fees, visa fees(if required). You should be ready to pay extra money for gaining some U.S. clinical experience. IMGs also often pay for other medical residency application help services like editing, etc.

What are the requirements for medical residency in the USA?

First of all, you must have graduated from ECFMG eligible medical school. You must pass USMLE Step 1 and USMLE Step 2 CK exams. You must become ECFMG certified before entering a residency program (or even earlier before the start of the application process to increase chances). You must be a U.S. citizen or permanent resident or be eligible for a J1 or H1B visa. Read about the application process in detail below. Also, read about additional requirements that residency program can have.

How long does the medical residency application take?

The whole process will take roughly 2-3 years. This includes 1-2 years for passing USMLE exams and around 1 year from the start of application season to the entering residency program.

How long is medical residency?

It depends on specialty. Internal medicine, family medicine - 3 years. Emergency medicine, Physical medicine - 3-4 yers. Anesthesiology, dermatology, neurology, ophthalmology - 3+1 preliminary/transitional year. Ob-Gyn, pathology, psychiatry - 4 years. Radiation oncology, radiology-diagnostic 4+1 preliminary/transitional year. General surgery, orthopedic surgery, otolaryngology, urology - 5 years. Plastic Surgery - 6 years. Neurosurgery - 7 years.

How do I get a medical residency in the United States as an IMG?

USMLE exams should be passed with high scores on the first attempt. You should be a recent graduate, if possible. You should have hands-on clinical experience in the United States. You should have strong letters of recommendation from U.S. physicians. You should not have gaps in your medical career. You must have great language skills.

Let us consider the match process for medical residency in detail now. Steps 2,3,4,5,10 are specific for foreign medical graduates while other steps are common for all applicants.

Medical residency application as IMG step by step

  1. Work on academic performance

    Work hard on your academic performance during medical school. You will need an MSPE (Medical Student Performance Evaluation) letter and medical school transcript to be submitted during an application process. MSPE is very important and one of the most frequently used factors during the interview selection process.

  2. Start the ECFMG certification process.

    One of the most important medical residency requirements is to be ECFMG certified. All IMGs must be in process of certification or already certified to be eligible to apply for medical residency in the United States. Students often start ECFMG certification process during the third year at medical school. Start the process by verifying that your school and your anticipated year of graduation meet ECFMG requirements here, your school must have a special note from ECFMG. Search your school and check presence of ECFMG note under "Sponsor notes" tab. If your school is eligible, visit ECFMG website and follow instructions to get your USMLE/ECFMG Identification Number. Then proceed with establishing your ECFMG account here. (After receiving your medical diploma it must be submitted to ECFMG. The exact degree and title of the diploma that you must submit can be found with ECFMG reference guide for medical education credentials. Fees for certification are around 2500$. Exact information about fees can be found here. )

  3. USMLE Step 1 application

    As a part of the ECFMG certification process, you will need to pass USMLE Step 1 and Step 2 exams. Most residency programs require USMLE STEP 1 for interview consideration. Of note, passing Step 1 with a good score can help in your search for clinical electives in the United States. Therefore, you should start the application process after USMLE Step 1, unless you are prepared to pass Step 2 with a high score. Two years at medical school must be completed before the start of the application process. For USMLE Step 1 registration, read USMLE application overview to understand how to register for USMLE Step 1 and USMLE exam and USMLE eligibility. USMLE Step 1 score is the most frequently used factor for selecting candidates for interview. Therefore, it is extremely important for IMGs to pass USMLE Step 1 with scores above the average. In addition, the first-time passage is a very important criterion used by many programs. Study really hard to pass USMLE Step 1 with one attempt and a high score. (The overuse of the Step 1 score as one of the main criteria for interview consideration has resulted in a decision to make Step 1 Pass/Fail in 2022. Because of this, first time passage may become more important in 2022.)

  4. Do clinical elective in the USA (for students only)

    U.S. clinical experience is one of the important medical residency selection criteria. Do not miss your chance to gain hands-on clinical experience in the United States during your final year of medical school. Many hospitals in the USA provide an opportunity for IMGs to have their optional away rotation in the United States during the final year. It is very important to have hands-on (direct patient care) supervised experience in the United States. A clinical elective is the best way to do that. It will be very hard to gain the same level of USCE (US clinical experience) after graduation because of legal reasons. Other important aspects are LORs (letters of recommendation) from these physicians and gain personal prior knowledge of the application process. LORs are the second most frequently used factor for interviews. LORs from U.S. physicians are extremely valuable.

  5. Secure an official observership in the USA (for graduates without any U.S. clinical experience at the time of application)

    Observership can't satisfy program requirements for hands-on USCE but they are easy to find. Observership is better than having no clinical experience in the United States and an obvious benefit especially in order to target a specific residency program.

  6. Register with ERAS

    Most programs use special electronic service (ERAS) to receive applications. First request your ERAS token at ECFMG app (OASIS web app or MyECFMG mobile app). Go to ERAS Support Services -> Request a Residency Token. Usually, tokens for the next ERAS season are available starting sometime in June. You will need to pay a fee for generating a token. Then create AAMC account and go to AAMC MyERAS, and sign-in with AAMC Account. Enter your ECFMG token and accept Terms and Conditions.

  7. Prepare all required documentation

    You will need to apply to residency programs via ERAS with required documentation included. Ensure that your personal statement(s), common application form, and resume are high quality and have no mistakes. Ensure that your LORs and other documents are transmitted by ECFMG. You can apply without all required documentation included, but you must submit documents before each particular residency program deadline. Each program has own system of deadlines for interview consideration, inclusion into the rank order list, H1 visa sponsorship, etc.

  8. Select the right programs to apply to

    ERAS takes fees for each extra program you choose to apply. You should choose the right programs from the thousands available to have the best chance for obtaining a medical residency. Each program has requirements sucha s minimum USMLE scores, years from graduation, USMLE first time passage, type and duration of US clinical experience, accepted or sponsored visas. Residency Programs List helps with selecting programs by minimal requirements and other important characteristics. The most commonly used visa for medical residency in USA is J1 visa sponsored by ECFMG. Many programs can accept this visa but not all. More information about J1 visa can be found here. Less frequently used visa is H1B visa that is sponsored by program itself. More information about H1B visa can be found here.

  9. Pass USMLE STEP 2 exam

    It is highly recommended, but not mandatory, to pass USMLE Step 2 before applying to programs. However, a high Step 2 score is important. Since Step 1 is expected to be Pass/Fail, USMLE Step 2 will be even more important. Many programs wish to see Step 2 before granting interviews, but prefer to see really high USMLE Step 2 scores for IMGs. There is a time limit for passing exams, but it is important to be a recent graduate at the time of application, if possible.

  10. Find externsip (for graduates without U.S. clinical experience)

    Very often graduates pass USMLE exams, but still have no hands-on clinical experience in the U.S. and corresponding LORs. To fill this gap, applicants often search for other opportunities. It is not easy to find an externship after graduation, because clinical electives are not accessible for graduates. Externships are rare. In most cases, clinics provide externship as a source of cheap labor. There are companies that search for eligible candidates, connect graduates and clinics, and take money from both sides. Such externships are not so valuable as clinical electives but together with corresponding LORs, may satisfy minimum requirements for many residency programs.

  11. Apply to selected programs

    You should apply to programs via ERAS before the date when data will be released to programs, if possible. In the 2021 year, it is September 29. A small selection of programs may not use ERAS for application and you may need to apply manually.

  12. Prepare for your interviews

    The only way to get into residency is to be selected for an interview first. This is why it is so important to select the right programs to apply to. Once selected, you may need to practice answering common interview questions. Your interpersonal skills, interaction with faculty and staff during interviews, and feedback from current residents are the most important factors for ranking.

  13. Register with NRMP

    Residency applicants must participate in the National residency matching program (NRMP) to be matched with a specific program. It is an automatic system based on rank order lists submitted by applicants and programs. Applicants must register at The Match, R3 system. It is possible to find registration opening day and upcoming deadlines here. On registration, you must enter your AAMC id, ECFMG id, and other information as well as pay registration fees. Then, return to your ERAS profile and add your NRMP ID. (Some programs do not participate in the NRMP – these programs are plastic surgery, ophthalmology and urology – each use other matching services.)

  14. Fill the rank order list

    Once you get interviews, you will complete a rank order list of your preferred programs via the NRMP R3 system. Programs fill out a similar list of preferred applicants among interviewed. When all referred programs are entered, you must certify your rank order list as final to be used in the Match. It must be done by the submission deadline.

  15. Match and SOAP

    Based on rank order lists, NRMP releases the list of matched candidates. Usually, it happens on the March 15. It is a happy day for many matched candidates. However, it is often not the end for many IMGs. NRMP also releases the list of unfilled positions and the Supplemental Offer and Acceptance Program [SOAP] begins. SOAP consists of several fast match rounds over roughly 7 days. Most SOAP positions are in preliminary and categorical internal medicine, preliminary surgery, transitional year, and family medicine.

Applying for medical residency as a U.S. graduate - real stories

How to match into competitive specialty or prestigious residency program are common questions of U.S. graduates. One of the best ways to understand the residency application process is to read real stories of the matched applicants.

Dr. L., Family medicine resident application story

Looking back, it feels surreal that only one year ago, I was on the other side of the Match process. As a PGY-1 family medicine resident now, I can feel relief instead of anxiety when I hear “ERAS”. I was fortunate enough to have a good Match season, and I owe it to preparing ahead of time. Preparation may seem intimidating, but it was the last thing I could control to influence how my Match would go. Having a good plan early took away a lot of the stress by not having it build up all at once.

Selecting Programs

Before deciding where to apply and how to rank, you have to determine what your priorities are. Is it prestige? Is it the type of training, whether it be academic versus community program? Is it location, salary, or something else? For me, it was location, full-spectrum training, and acceptance of osteopathic manipulation.

Being in a medical school across the country from where I was from, it was my priority to get back home. I still had family and friends there that I was looking forward to getting back to. This significantly helped me to cut down my list of options. On the spreadsheet, I took out every state that was not around where I wanted to be. I kept some around where I went to medical school since I had built those connections, but my list became a lot more manageable.

Full-spectrum training to me meant being trained in the many facets of family medicine without being completely opposed. Opposed versus unopposed is an issue that affects family medicine training being how broad it is. I did not want to be so opposed that I would feel like I was not doing much, but I did not need a completely unopposed program. I made sure to note other residencies a program would have and ask during interviews about how opposed residents felt. Full-spectrum training also meant having a diverse patient population; I wanted to work with patients of different ages, cultures, and socioeconomic levels since that is how I envisioned my future practice to look like. This ties back to location as having this much diversity would mostly mean somewhere that is more urban. Again, I was able to cut out some programs.

As a DO student who enjoys using osteopathic manipulation, I wanted to be at a program that would allow me to use and practice my skills. That meant I was looking for programs that had DOs as residents and faculty. Osteopathic recognition is a distinction granted to some programs as well, but I was fine with a program without it, as long as I can get the training. Also, with the merger, I would have to face more competition from programs that were traditionally MD. This helped me take out some programs that did not have a history with osteopaths as I figured my chances were low anyway.

How Many to Apply to

One of the biggest questions that no one has an exact answer to is “How many programs should I apply to?”. You will hear so many different answers from different people. I decided to try to take a more data-driven route. The Reddit spreadsheet from the prior year helped as there were people who posted their scores, where they were applying to, how many programs they applied to, and how many interviews they received. Though not completely reliable, it helped put my application in the context of previous applicants and their outcomes. I also used the NRMP Match data to see collectively how people with similar scores and stats fared. There is data on the percent chance of matching based on how many programs ranked for particular score ranges. Again, this is population data so it does not guarantee anything for me, but it gave some guidance.

After taking all this data into account, I had to be honest with myself as an applicant. Looking at my stats, where do I really stand against the average family medicine applicant of the past? I eventually came to a range of 20-30 needed to match. Since it was a new interview experience being all virtual, I decided to keep it safe and double that number. Eventually, I ended up applying to 50 programs. In the end, it turned out to be a bit excessive, but I felt safe.

Which Programs

Now I had to get my list of potentials shaved down. It was time to take a deeper look at each program individually. For this, I found that Residency Explorer was especially useful. I was able to find information about the kind of training they have, the average hours they work, the salary, and estimated board score ranges.

I also looked up each program’s website and noted significant strengths and weaknesses. More and more, I was getting to know each program and started developing ideas of where I would like to be. Programs that did not fit what I was looking for got cut from my list until I was down to 50. I also rated each program based on my perceived ability to be ranked by “Likely”, “Average”, or “Difficult”. This way, I was making sure my list was not too heavily weighted with reach programs.

Interviews

Read this part on residency interview prep page.

Ranking

The final step. While I was going through interviews, I updated my spreadsheet with notes of how I felt each interview went. This helped me remember what I thought about each program and where I wanted to rank them. I defaulted back to my priorities of location, training, and osteopathic acceptance, but now I can add in another component.

Through the process, I realized how much I valued having camaraderie and fun in the program. The interviews where I got to meet the residents and see that they are actually enjoying the program got a higher rank for me over the ones where I did not meet residents at all. If I had a weird feeling or if the interviews were too short, they were dropped lower. For some programs, I didn't even get to meet the program director which I thought was a bit odd as well, so I ranked them lower.

Final Thoughts

Waiting, waiting, waiting. It felt like an eternity until I found out if I had matched. It took another eternity to find out where. Eventually, I matched into my second choice. I was disappointed not making my first one, but my top four choices were able to hit all of my priorities, plus they had some prestige to their names. I now train at a program within a top hospital system in the country and I get to be by my family and friends. It finally feels like all of that grueling time in medical school was worth it.

Research and preparation got me through the Match cycle. Boards are done, grades are in; there is only so much left you can do. Have people look over your personal statement and application. Make sure you have the best product you can produce. When interviews come, know that you are ready and prepared for them. Programs want to see your interest and are just looking for someone who will fit. It is then your job to be yourself and decide if they fit you.

2. Dr. G.U. Gunner, One Man's Wild Journey to Urology Residency

I've had the tremendous good fortune to meet many distinct kinds of medical students, residents, and attending physicians. Because of the intense challenges we face during our training, we share a bond. Most of us confront similar obstacles, battle with similar insecurities, and feel the same pressure to succeed. Still, for all we have in common, our journeys will be as unique as we are. As I describe how the residency application process unfolded for me, I will highlight wherever I see opportunities to improve upon what I did. My goal is to diminish unnecessary anticipatory anxiety.

Introduction

I graduated from college with a BA in Humanities and a concentration in Health Care Ethics. In addition to the classes which counted towards my degree, I also took premedical courses. I applied broadly to medical schools, both Osteopathic and Allopathic. I had an undergraduate GPA of 3.45 and an MCAT of 32(514). I received only three interviews, but I got into a DO school off the waiting list. The first class at my medical school, gross anatomy, challenged me more than anything I had ever experienced. I spent a lot of tearful nights staring at diagrams or flashcards, unable to recall what I had just spent hours trying to memorize.

I reached a low when I came close to failing part of an exam that involved recognizing a structure I had dissected myself. As I stared at the results of that test, posted on a board outside the anatomy lab, I decided. I started to disregard every single bit of guidance that told me to relax. If a piece of advice made things easier, I would ignore it. If someone told me only to learn structures associated with clinical problems, I ignored them and instead set about retaining everything. My classmates could afford to live well-balanced lives and somehow memorize this material. Not me.

Stubbornly ignoring a lot of excellent advice, I did nothing but study. I lost ten pounds in 30 days. Still, I came away with a good grade. After anatomy, the remaining curriculum came much more naturally to me. And the incredibly intense study habits I had adopted paid some dividends. By the end of year 2, I stood near the top of my class. Once more, ignoring the school counselor's advice, I decided to take both the USMLE and the COMLEX exams. I took three board preparation classes, and I had no goal other than scoring as high as possible on the first step of my boards. I had taken no time to pause and reflect on what career I wanted to pursue within medicine.

Choosing a Field

My first clinical rotation, Urology, brought me into the operating room for the first time as a participant. The relaxed atmosphere of the endoscopy suite stood in stark contrast to the surrounding rooms. The whole environment surprised me. None of the dour intensity from the medical library clung to these people the way it did to me. During this rotation, I learned my USMLE Step 1 score. 252. Based on practice exams, I had anticipated a score about twenty points lower. The other students rotating with me shared their scores with me. When they learned my score, they treated me differently, and I felt aloof. I brought reading materials into the OR and, to my later horror, 'corrected' a resident while he spoke attending physician.

I didn't have time to wallow in regret over my lack of interpersonal skills. My very next rotation, General Surgery, provided an entirely new opportunity to outwork my peers. In this way, the defiant attitude born out of profound anxiety following an anatomy exam hardened into part of my personality. For better or worse, I possessed the necessary intensity to be the first person to arrive and the last person to leave. I spent every free second reading and studying. The surgical residents liked me. I cannot even describe the teeter-totter emotions from struggling so brutally one month to feeling appreciated the next. After scoring well on my shelf exam, I received an honors mark on my general surgery rotation. Amid that elation, defiant as ever, I made it my goal to match Urology.

Building a Resume

I practically interrogated the staff in the Dean's Office until I knew how my school calculated rotation grades and constructed a Dean's letter. I used that knowledge to my advantage, selectively choosing the doctors responsible for my performance evaluations. After more honors rotations, I sent a few emails to a Urology resident at our home program. He gently discouraged me by suggesting that I pursue a career in a medical field better suited to my personality. I politely acknowledged his feedback. I heard about a monthly academic conference, and I showed up to as many of these as possible. I sent out an email to several members of the faculty regarding participation in research. I heard back about a benchwork study investigating the effect of a drug on the Androgen Receptor. I went to the lab several times to help, and I made sure I could describe the project if someone asked.

Before long, I finished my third year. I achieved honors or high pass in almost every rotation, but this reflected excellent planning and diligence more than excellence as a rotating student. In hindsight, I cannot believe how little I grew as a person. Still, time passed, and I remained laser-focused on strengthening my CV. Many students receive help scheduling rotations in their chosen field (so-called 'Audition Rotations). The thought of asking for help from a guidance counselor never even entered my mind. Instead, I found a web forum focused on the Urology Match. I selected my away rotations, 2 Osteopathic and 1 Allopathic. I read about the importance of my performance at my home Urology rotation as a fourth year. The performance while rotating at the beginning of my third year did not set me up for success. I needed to demonstrate personal and professional growth. I braced myself for a 30 day "perfect performance."

30 Days

I showed up an hour early for rounds for the first week. Another student appeared 45 minutes early; "my main competition," I thought to myself as I shook his hand. Three more students, all desperately trying to match into Urology, arrived 10 minutes before rounds. I stuffed my pockets full of supplies, and I volunteered for everything. I ensured I was first to arrive and last to leave by coming in early and intentionally angling for late cases. My plan guaranteed me extra time with the residents. When one of the residents happened to begin typing up a case report, I had the opportunity to ask whether I could help. That resident assigned me a task to do in whatever spare time I had after leaving the hospital. Before the month ended, I had authored a case report and submitted it for publication in a prestigious journal.

However, not everything went so well. The intense level of stress and the enormous pressure I placed upon myself affected me. I waited for weeks for time with the program director. When the time came, the program director was determined to see my response to acute stress. I shadowed him for an afternoon in his office. At the end of the afternoon, he asked me to sit across from him in his office. He asked me a string of tough questions about an obscure topic. I did my best to answer, but most of my responses were versions of "I don't know." I tried my best not to let my discouragement show outwardly. Earlier, I had started to ask him about a letter of recommendation. He deflected the issue and promised to return to it later. Now, as I sat in his office trying to project a calm demeanor, he circled back to my request.

"I suppose you will need a letter of recommendation then, right? Do you see this?" He gestured to an envelope lying on the corner of his desk. "Do you know what this is?" I shook my head no. He told me it was the letter he had just finished writing for "one of the best students we've seen in years." I looked and saw the name on the envelope. It was my competition, not me. I felt myself smile, "I've enjoyed working with him these last few weeks, nice guy."

A few silent seconds passed, and I thanked my program director for the opportunity to follow him this afternoon. I held out my CV, some other details about me, and an envelope and offered them to him. I still needed that letter. I cannot describe the profound deflation I felt when he refused to take the papers from me. He crossed the desk to shake my hand, and I did not want to take his offered hand. But I did.

"Why don't you write the letter yourself? I'll sign it if I think it's good." He smiled briefly and ushered me out of the room. I left his office in a state of profound confusion and made my way back to the resident call room. I sat down on the couch there. After a few quiet minutes, one of the residents knowingly turned around and said, "How was it?"

Not great. I explained what had happened. "What the heck am I supposed to do now?" Every resident I asked had a different take. I left for home, anxious to hear my fiancé's opinion. We decided to write a glowing letter and dare him to sign it, and we did just that.

On the second to last day of the rotation, I looked back on the 30 days. On at least three separate occasions, I had annoyed one of the residents. One time involved doubting someone's ability as a tennis player. Why on Earth would I do something like that!? But the worst thing I did, happened on the second to last night of the rotation. At the end of a long day, the clock read 8:45 pm as the Urology team finished their portion of a combined case with GYN Oncology. As we left the room, I remarked to one of the residents that I felt tired. I will never forget the resident's reply. "I don't ever want to hear a student complain about being tired. Talk to me after you have been on-call." I apologized as well as I could.

Letters and Personal Statement

I gave my program director a copy of the letter he requested I write for myself. With the help of my wife-to-be and plenty of internet research, I wrote myself one heck of a letter, and I had no idea if he would sign it. I also approached another attending with whom I had worked closely and requested an additional letter from him. After leaving that rotation, I spent a weekend with a practicing Urologist I had met through my future Father-in-Law. I asked him for my third letter of recommendation. I asked the surgeon in charge of my third-year general surgery rotation for my fourth and final recommendation.

Next, I crafted a personal statement over the next month during the next month in a Rural Medicine clinic. I made sure to show rather than tell in my writing. Specifically, I described stories from my life and training that highlighted my strengths. I finished my statement by illustrating my vision for my future. I didn't stop until I had something that brought tears to the eyes of my wife-to-be. However, she may have been a bit biased in my favor.

Away Rotations

I scheduled Urology away-rotations at two DO programs and at one MD residency. I won't bore anyone with a detailed discussion of these months, but I will offer a few lessons I learned. I recommend doing an away-rotation at no more than one institution. I wish I had treated my "aways" with the same level of urgency I reserved for the fourth-year rotation I did at my home program. I did not, and this reflected poorly on me. I came in late one day during one of these months. And I did not prepare anything unique for a conference presentation I needed to give at another place during another. I still can't believe I gave a "canned" presentation using a clinical case from a different hospital. Later, as a resident, I watched as students who presented patients from other rotations doomed themselves. Don't be like me.

Interviews

Read this part of the story on residency interview preparation page.

Conclusion

Medical school and the match process create massive levels of anxiety. The experience made me a stronger person and reinforced a defiant streak within me. But I made things infinitely harder than necessary. I took too little time to reflect on my chosen career path. Instead, I based my decisions on resentment and even spite. I missed a crucial opportunity to learn how and when to ask for help. That is a lesson I had to learn repeatedly throughout a brutally difficult residency. I hope that everyone reading this can learn from my experience, avoid the same mistakes, and even enjoy the process.