Dr. SHS. adult neurologist and a clinical neurophysiologist.
My path has been different from the usual path that International Medical Graduates (IMGs) take but this path is something, which not many people are aware of. I am sharing my experience with my fellow IMGs and USMLE aspirants so that they have a better understanding of this whole process and they do not repeat the same mistakes which I did. My story and struggles may help and inspire others in achieving their dreams. Also, read about USMLE preparation.
I graduated from medical school in Pakistan in 2011 (quite an old graduate, I know).
In Pakistan, we have to do a one-year mandatory internship before receiving the full license to practice medicine.
I completed my Internship in 2012. Passed Step 1 in early 2014 with a score of 261.
Step 2 CK in 2015 with a score of 266 followed by step 2 CS, which I gave in Houston, Texas, and passed with flying colors.
I applied to residency, basically just with my scores, and got just a couple interview invites. I was disappointed and eventually have not appeared in the interviews at that time. I got the ECFMG certification.
Keeping my US dream aside, I pursued my training in Internal Medicine in Pakistan, followed by core training in neurology, which I completed in 2019.
I passed my neurology exit exam in 2020.
In Pakistan (and in many other countries), you need to pass the exit exam (similar to the US Boards) to get a degree and work as a consultant.
In the meantime, I pursued a two-year fellowship training in clinical neurophysiology at Aga Khan University, which ended in December 2021.
During my residency and fellowship, I did some research work and published around 15 papers in different national and international journals. When I was doing my fellowship, one of my colleagues from cardiology got a fellowship in cardiology imaging in the US. This gave me a much-needed spark that I should also look for fellowship opportunities in the US.
I asked my colleagues and schoolmates, who were working in the US. I also approached my senior neurologists in the US that allowed me to join their WhatsApp group where I communicated with many Pakistani neurologists working in the US, who I never knew before. I also searched on different websites (including Reddit and various USMLE forums). After all the research, I came to know that fellowship opportunity is available if you have completed your core residency in your home country but having an ECFMG-certification is a requirement. Step-3 is not mandatory but most of the programs do ask for Step 3 and it is better to pass your Step 3 if you want to maximize your fellowship opportunities. Now some fellowships are easier to get, for instance, nephrology or non-ACGME accredited fellowships, which remain unfilled as compared to some other fellowships, e.g. interventional cardiology, where the competition among the US residents and trainees is high. Another thing that greatly helped my colleagues is a clinical experience (observership/electives) in the same program. They worked there, made social contacts, and it helped them in getting the fellowship. So once you have done your homework and have shortlisted your programs where you can match realistically, a brief clinical experience in that institution and department is essential in securing a fellowship spot.
How fellowship is different from residency? And why this path is not usually followed? It is because of the fact that after the fellowship, you cannot practice in the US. To be eligible for US board certification and practice independently, you have to complete your residency (again) in the US. So this pathway is kind of a reverse one, where you are doing the fellowship first, followed by residency training. If you do not intend to repeat the residency, then after completing the fellowship, you have to go back to your home country. Uncommonly, but it is possible that your faculty during the fellowship is so much impressed from your work and happy with your performance that they may ask for some special exemptions for you to work in their institute without doing a US residency, even with this exemption your options are limited and you cannot work outside the institute that has asked for the exemption.
Some fellowship specialties enter into a fellowship match (similar to the NRMP residency match). Some specialties participate in the San Francisco (SF) match, while other fellowships do not participate in any program and you have to email the Program Directors individually. For example, if we talk about the fellowships in neurology, the movement disorder fellowship enters the SF match and it is a non-ACGME program. The neuromuscular fellowship has its matching program, only limited to the single super-specialty, while most of the fellowships do not take part in any match program.
Taking advantage of my ECFMG certification, I applied to 20 movement disorder fellowship programs, was interviewed by six programs, and got selected at the University of Virginia at Charlottesville. I am not alone who is getting selected for a US fellowship after completing a residency in their home country. In the last two years, following seniors and colleagues from my institute have also joined the fellowship programs after residency in Pakistan: A cardiology colleague was selected for a fellowship in cardiac imaging; A neurosurgeon was selected for a fellowship in pediatric neurosurgery; A senior of mine, an orthopedic surgeon, completed his fellowship in orthopedic oncology;
The point is: If you couldn't match for the US residency or you did not apply for the US residency and instead completed your residency in your home country, you still have a chance to get a fellowship and pursue your dream of training in the USA.
This is an update: When I wrote the first part, I had not yet completed my fellowship. Now that I have finished my two-year Movement Disorders fellowship in the US, I can share what actually happened and whether this pathway was worth pursuing.
Without hesitation, I would say yes. Looking back, pursuing a fellowship in the United States was one of the best professional decisions I have made. It changed not only my career but also my confidence as a physician.
The fellowship gave me in-depth training in movement disorders under outstanding mentors who were exceptional clinicians as well as teachers. My workload was very manageable. The fellowship was entirely clinical, without overnight calls, my weekends were generally free, and I had enough time to read, learn, do research, attend conferences, present my work, and spend quality time with my family. Coming from a residency in Pakistan, where the workload is significantly heavier, it was a refreshing and enjoyable experience.
People coming for fellowship usually have families and they are worried about finances and living expenses. The salary I received was of Resident year 5 and 6 was sufficient to comfortably support my wife, my children, and myself during our stay in the US. More importantly, my family thoroughly enjoyed the experience. They adapted well to life there, made wonderful memories, and by the end of the fellowship, they actually wished we could stay longer.
Professionally, the impact was tremendous. Even before completing my fellowship, I was offered a faculty position at one of the leading universities in Pakistan. After returning home, I realized how much my training had changed my clinical practice. I was fortunate to be recognized as one of the few fellowship-trained movement disorder specialists in the country. Colleagues began referring more complex patients, my clinical opinions carried greater weight, and I found myself managing cases that I would have previously considered challenging. The greatest difference, however, was my confidence. I knew why I was making clinical decisions, and that confidence came directly from the quality of training I had received.
Looking back, I also believe I could have successfully completed a US Neurology residency had I chosen to stay. The workload was considerably lighter than what I had experienced during my residency in Pakistan, and the fellowship gave me the confidence that I could adapt to the system. In fact, while I was still a fellow, my department offered me the opportunity to stay and join their Neurology residency program. They also expressed interest in retaining me as faculty after residency because they already knew my work and abilities. I eventually decided to return to Pakistan for family reasons, not because I lacked opportunities to stay.
Another important lesson I learned is that a fellowship gives you a significant advantage if you later decide to pursue residency training. It allows faculty members to know you personally, assess your work ethic, and build confidence in your abilities. Those professional relationships can open doors that are difficult to access through the traditional residency application process alone.
After completing my fellowship, I was granted a full unrestricted medical license in the state of Virginia. This means that I am legally eligible to practice medicine in Virginia. However, having a state medical license and being American Board certified are two different things. Since I have not completed a US Neurology residency, I am not board certified in Neurology, and this remains a limitation for employment in many hospitals because insurance companies often prefer or require board-certified physicians.
The encouraging news is that alternative pathways are now becoming available. Some academic institutions can hire international fellowship-trained physicians as faculty members, and after working in that position for a few years, they may become eligible to appear for the American Board examination without repeating residency. Similar pathways are also being developed in several other specialties and subspecialties.
During my fellowship, I personally saw several examples of physicians who followed this route. One of my colleagues did Movement Disorders fellowship, at the same time as I, was hired as an attending neurologist without repeating a US Neurology residency. She did have one advantage in that she was a US citizen, whereas I required visa sponsorship. I also met physicians from other specialties who had completed residency in their home countries, pursued fellowship training in the US, and were subsequently employed as attending physicians without repeating residency. One neurosurgeon completed three one-year fellowships (two in the US and one in Canada) before joining a hospital in Washington as a neurosurgery faculty in a University program, while another physician who had completed Internal Medicine in Pakistan finished an Infectious Diseases fellowship in the US and was hired as an attending physician. These examples show that although this pathway is uncommon, it is certainly possible under the right circumstances.
Finally, do not hesitate to contact fellowship programs directly. Every program has its own eligibility criteria and policies, and these continue to evolve. A simple email to the Program Director or Program Coordinator can often clarify opportunities that are not obvious from the website. Many applicants never ask, and in doing so, they miss opportunities that are actually available.
If you have the opportunity to pursue a good fellowship in the US, I would strongly encourage you to consider it. Even if you eventually return to your home country, the knowledge, clinical exposure, research experience, professional network, confidence, and career opportunities that come with US training are invaluable. For me, it was an experience that transformed my career, and one for which I will always be grateful.