How To Apply To U.S. Residency Programs As An Applicant From An International Medical School

Applying to residency as a U.S. medical school graduate is confusing already. If you’re an applicant from a foreign/international medical school, things get even more tricky with additional steps, costs, and practical considerations/strategies for matching into a U.S. residency program.

Steps for Qualifying to Apply through ERAS (Electronic Residency Application System) as an International Applicant (IMG):

1. Get a USMLE/ECFMG identification number (https://secure2.ecfmg.org/emain.asp?app=iwa). This is required for registering for Step 1, 2, and 3, and also the ECFMG certification (explanation will follow).
2. Pass Step 1 and Step 2 (Clinical Knowledge). *The Clinical Skills portion of Step 2, USMLE Step 2 CS, that was on hold since May 2020, has been permanently discontinued.* For more information, visit: https://www.usmle.org/announcements/?ContentId=309
3. Obtain ECFMG certification (https://www.ecfmg.org/2020ib/2020ib.pdf). This is a set of requirements for medical school curricula, and schools that are approved are listed in the World Directory of Medical Schools (wdoms.org) by graduation years.
   1. This requires submission of the final medical transcript and diploma.
   2. Specific details are outlined in the ECFMG manual (https://www.ecfmg.org/2020ib/2020ib.pdf) re: documentation required, which includes birth certificates, immigration documents (Resident Alien Card, Permanent Residence Card, or U.S. Naturalization Certificate)
   3. If you are not a U.S. citizen or permanent resident, the ECFMG will sponsor you for a J-1 Visa, specifically meant for trainees for a maximum of 7 years.
      1. You must go back to your home country for two years before applying for a different visa.
   4. The alternative is a H-1B visa, which you can hold while you apply for permanent residency. This is sponsored by the residency program, and does not require you to go back to your home country for two years.
      1. Passing Step 3 is required.

Resources for Picking Residency Programs to Apply to

Applying as an IMG requires a significant amount of strategy. Great resources to look at are:

• Charting Outcomes by the National Resident Matching Program (NRMP) (https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2018/06/Charting-Outcomes-in-the-Match-2018-IMGs.pdf).
  • This document outlines a lot of really specific data for each specialty – how many programs you should apply to, interview at, and rank to match, mean number of Step 1, Step 2, and experiences (work, volunteering, research).
  • The numbers for IMGs are higher than American medical graduates, which creates additional expenses in the application process.
• Residency Explorer (residencyexplorer.org)
  • This website lets you put in all of your application stats and will tell you what percentile you fall into for specific programs.
  • The column that’s important for IMGs to look at is the percentage of IMGs at particular programs – you’ll get an idea of if they’re “IMG friendly” or not.

There are a few other considerations:

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

Be honest with yourself about these factors, and also be open-minded. You may find on the interview trail that some priorities you had may not be as important as other ones.

Submitting the Application and Waiting for Invites

All applicants use ERAS, and this requires getting a token to gain access and register. ECFMG will give you one. The actual application is pretty straight forward, and if you have any questions about whether an experience “counts,” chances are, someone else has already asked that question and has gotten good answers – Google it first, then ask later.

You have to assign all of your documents (Step scores, application, personal statement, photo) to each program. This isn’t too difficult to do; you just have to remember to do it.

Headshots: First impressions matter. We’re all human, and unfortunately, how you look and present yourself is a subconscious factor. Spend the extra money to get them professionally taken. The photo is the first thing that pops up (and I’m told it’s rather large), and there’s a certain art to framing your face right. Some photographers may make your head look disproportionately small or big.

Emails: I’d suggest using a professional sounding personal email for ERAS, then setting up an alert for it. Sometimes emails will go directly to your ERAS email, or to the myERAS inbox. Either way, you want to be prepared. I’ve heard of stories where the interview invites goes to Spam and people miss out on spots because they don’t see it until the end of the day. Interview spots fill up fast, so you want to make sure that you answer as soon as possible. It only takes a few hours for spots to fill up.

Letters of Recommendation: Compared to the U.S., a lot of countries use much more reserved language in their letters of rec. This can be a red flag – Americans use really superfluous language, like excellent, outstanding, stellar, etc. Tips for how to write stronger letters of rec can be found here (https://med.ucf.edu/media/2012/05/Writing-Letters-of-Recommendation.pdf?utm_medium=referral&utm_source=r360).

Clinical Experience in the U.S.: This is valued by most programs, and will give you the chance to work with a clinician that can write you a really strong letter. Most U.S. medical schools will allow you do a visiting rotation if you’re still in medical school. Some are free, but most require some sort of fee. This is done through the VSLO (https://students-residents.aamc.org/attending-medical-school/article/students-outside-us-pursuing-electives/).

Register for the Match

This one is probably the most straight forward. All you have to do is register for the National Resident Matching Program (NRMP) (http://www.nrmp.org/) and link your USMLE and ECFMG IDs to them. You’ll submit your rank lists here and let the algorithm do its magic. The NRMP suggests that you rank your programs in order of where you want to go, and that you try and avoid trying to “game” the system.

Actually Going to Interviews

Some programs will provide an informal dinner with the residents the night before, and some programs will even pay for your hotel or give you a discounted rate. Even so, the application and interview process is incredibly expensive.

One way I’ve saved on out of pocket costs is by opening up a travel rewards credit card early, putting on all of your monthly expenses on that, and then paying it off with your normal income. I’ve gotten about $1600 worth of Southwest Airlines travel funds that way, just by using this card for the last two years.

Actually applying is very expensive – I did 39 programs and I had to pay $830 to transmit my application and scores. With 13 interviews booked, I’ve already spent $3000, which doesn’t account for Ubers, food, or sightseeing costs. Oof.

Budget accordingly, and try and find as many ways to save money as you can. The following links are not affiliate links.

• Buy suits secondhand (ladies, check out ThredUp (thredup.com) – I got my suit for $50) or stay on the prowl for deals.
• See if there are alternate ways to get to some cities that are cheaper than flying directly to them. Shuttle services often run from major cities to smaller airports and cities that make it much cheaper to travel (https://goairportshuttle.com/). Go Airport Shuttle can also take you to your hotel for half the price of an Uber.
• If you really want to rent a car, get a quote from autoslash.com/. I can usually book a rental car for an entire weekend for $30-50 dollars, which is usually the cost of renting per day from other sites.
• Airbnbs (www.airbnb.com) in some cities can be much cheaper than getting a hotel, and sometimes you can rent the entire apartment/house for the same price. The trade-off is that you’ll have to Uber to and back from the interview.
• Use rebate programs religiously, like ebates.com/ or www.ibotta.com. You’ll be surprised at how much money you can get back for travel, accommodations, and even interview clothes.

The process can be really confusing at times, but hopefully this helps sort things out a bit! If you have any other suggestions, please drop them in the comments!