Category: U.S. Medical Residency

Choosing a Specialty

If you have not chosen a specialty yet, you may have noticed that it is not as easy as it sounds. You may be drawn to one specialty, but more likely you are torn between a few or even many choices. Medicine is stimulating, relevant and fulfilling in broad specialties such as family medicine but also in narrower specialties such as radiation oncology. What draws you to one may be a lifestyle choice, or it may be a deeper calling. In either case, you want it to be a choice you can stick with for a long while.

What are my specialty options?

The American Medical Association (AMA) provides a database of 11,000 accredited residency programs, and that database is FREIDA. Common specialty choices are:

  • Allergy and Immunology
  • Anesthesiology
  • Cardiovascular Disease
  • Child and Adolescent Psychiatry
  • Colon and Rectal Surgery
  • Critical Care Medicine
  • Cytopathology
  • Dermatology
  • Emergency Medicine
  • Endocrinology, Diabetes and Metabolism
  • Family Medicine
  • Gastroenterology
  • General Preventive Medicine and Public Health
  • Geriatric Medicine
  • Hematology
  • Hospice and Palliative Medicine
  • Infectious Diseases
  • Internal Medicine
  • Interventional Cardiology
  • Medical Genetics and Genomics
  • Medical Oncology
  • Nephrology
  • Neurological Surgery
  • Neurology
  • Nuclear Medicine
  • Obstetrics and Gynecology
  • Occupational Medicine
  • Ophthalmology
  • Orthopedic Sports Medicine
  • Otolaryngology
  • Pain Medicine
  • Pathology
  • Pediatric Surgery
  • Pediatrics
  • Physical Medicine and Rehabilitation
  • Plastic Surgery
  • Preventive Medicine
  • Psychiatry
  • Pulmonary Disease and Critical Care Medicine
  • Radiation Oncology
  • Radiology – Diagnostic
  • Radiology – Interventional and Diagnostic
  • Rheumatology
  • Sleep Medicine
  • Surgery – General
  • Thoracic Surgery
  • Urology
  • Vascular Surgery

This list can be found on the AMA’s website with links providing more training information.

How to Choose One Specialty

There are many ways to choose a specialty, and the advantage of doing it early is that you have more time to plan. First year medical students who successfully decide on a specialty can tailor every medical school decision to that specialty. However, if you aren’t sure as a first-year medical student, it’s better to wait than to try to force a choice too early. Here are a few ways to help you along regardless of whether you are entering medical school or choosing programs for The Match.

Set Goals:

You have to know what you want before you can start looking for it, and many medical students have misplaced dreams about reputation or riches. Entering a specialty because of the pay will not ensure a successful path to residency. Instead, focus on more functional aspects of the specialty such as the population it serves, geographic limitations, and lifestyle provisions. For example, you may find that emergency medicine hours do not suit your lifestyle despite the pay, and family medicine affords you the lifestyle you want to live comfortably and have time for leisure. On the other hand, maybe you want the excitement that the emergency room can provide, and saving lives in traumatic situations is fulfilling. If you want to fight infectious disease, there may be geographic limitations. There are factors in residency programs and the subsequent medical careers that are much more important than how impressive it is or how much money you make.

Gather Information:

Once you know what you want, you should find out all you can about the residency programs available. One way to do this is by attending residency fairs such as the AAFP National Conference or the AMSA Residency Fair. Looking on program websites is another way to find out if they offer what you are looking for, and you can find out if you meet the prerequisites to enter the program.

Ruminate:

You should be fairly methodical about your choice. That does not mean don’t choose from the heart…or the gut, but make sure you verify that with more objective means. Make lists of pros and cons. Research facts about job prospects and the future of the specialty. Get an idea of where you are going to have to live to support a career in that field of medicine. For example, some surgical specialties may not have a lot of prospects in rural areas where hospital resources are minimal. Spend a good amount of time reflecting back upon your goals and making sure your specialty reflects those goals. Then, make sure your heart…or your gut agrees. You should objectively and subjectively feel good about your choice.

Follow Your Passion

Money should not be the driving force behind your medical specialty choice, but it may be a factor. In order to live certain lifestyles and have the means to travel, you will need to make a certain amount of money. However, if you are miserable doing it, you probably won’t last. Physician burnout is a real thing, and even if you think you can hack it, long hours in a position you don’t feel passionate about will wear on you. Instead, choose a specialty in which you have passion. Stanford University has a comprehensive questionnaire to help guide you in your specialty selection. It offers a roadmap for the selection process, but there is no one way to pick a specialty. That is why this choice is worth so much of your time.

Foreign Medical Graduates’ Barrier is Red Tape

According to the Association of American Medical Colleges, the United States will suffer a shortage of 122,000 doctors by 2032, which is similar to past predictions by other organizations. As aging populations with multiple, co-existing morbidities continue to grow, a shortage of this magnitude should be worrisome. People are living longer, and older physicians are retiring. For many Americans, the idea of not being able to see a physician when necessary is unimaginable. However, it is quickly becoming a reality.

One solution to the shortage of physicians in the U.S. is to enable more foreign medical graduates (FMGs) to practice medicine. There are plenty of FMGs trying to advance their medical knowledge and careers by entering the U.S. for a medical residency. There’s also too much red tape for many of them to get through. Limitations on visas and residency slots hamper America’s ability to produce enough doctors to fill this deficit.

J-1 Visa

Most FMGs apply for a J-1 visa. There are multiple requirements to be eligible for this type of visa including:

  • USMLE step 1 and step 2 CK completed and passed
  • ECFMG certification
  • Position in a graduate program or medical school
  • Statement of need from Ministry of Health

After training in the graduate program or medical school is complete, the visa holder has to go back to their home country for two years. This is intended to spread the wealth of their knowledge gained in the United States to their home country. This prevents nations from losing all of their skilled workers and increases levels of global health. It can also present significant hardship for visa holders who may not get a chance to return to the U.S. Following the 2 year return to the home country, FMGs can attempt to change their visa to an H-Temporary worker, L-Intra-company transferee or U.S. permanent resident.

J-1 visa waiver

The two-year return to home country can be waived in 3 circumstances:

  • If applicant can prove he or she will suffer in home country.
  • If applicant’s absence will be a hardship to immediate family members who are U.S. citizens.
  • Sponsorship by an Interested Governmental Agency (IGA).

Once an FMG gets a waiver and a medical license, he or she can apply for a H-1B or immigrant visa.

H-1 B Visa

To get an H-1 B visa, an FMG must have passed all USMLE exams and have an unrestricted license to practice medicine. There is no 2-year home requirement, and the FMG can be employed in the U.S. for up to 6 years. This is the best visa option for FMGs looking to enter the U.S. for a medical residency.

H1-B visa requirements

  • Position in residency or fellowship
  • Medical school graduate
  • ECFMG certification
  • USMLE steps I, II, III passed
  • State medical license if required

The story behind H1-B visas

The purpose behind H1-B visas is to get employers the skilled workers they need for their businesses. Employers petition for a pool of visa numbers, and there is a cap on the amount of visas offered at 65,000 new hires per year with 20,000 extra slots for those who have graduated with a U.S. master’s or doctorate degree. This cap is always met quickly, and the majority of H1-B visas are not in healthcare positions.

Residency Positions

Although medical schools are trying to produce more medical graduates, residencies are not able to create more slots because of a cap set by congress on the number of Medicare-funded residencies. Congress has control of how much money is allocated to teaching hospitals for residencies. The 1997 Balanced Budget Act of 1997 and 1999 capped funding, and at that time, America was looking at a surplus of physicians in the future. Things have definitely changed, but the cap has not been adjusted to make up for the shortage, mostly based on budgetary concerns. Some hospitals privately fund extra residency positions, but the majority are funded by Medicare.

Protecting the U.S.

Much of the red tape surrounding FMG visas has been an attempt to maintain the opportunities for American citizens. However, H1-B visas bring in skilled workers, and studies show that they improve the economy. One study of an increase in H1-B visas predicted that it would create 1.3 million jobs by 2045. Foreign skilled workers and FMGs are not a threat to U.S. citizen opportunity. In fact, Americans need more FMGs training to become U.S. physicians to address the shortage of physicians.

It is clear that the consideration of FMGs has not been paramount to the decision-making of the U.S. government, or else there would be more residency programs and better visa options for FMGs. However, change is coming. The looming physician shortage is scary to all Americans, and it is stimulating people to come up with solutions. One of those solutions will surely be the promotion of more FMGs into U.S. residencies. There are not many suitable alternatives.

Clinical Rotations and Foreign Medical Graduates

What are Clinical Rotations?

In the U.S., the first two years of medical school are typically classroom lectures and book-inspired learning with very little hands-on experience. But applying these skills to real life medical situations is difficult without actual experience. That is why the third and fourth years of medical school include clinical rotations.

Clinical rotations are time spent shadowing physicians and residents in order to see what it’s like to truly experience practicing medicine. Students get to participate in the medical decision-making process, and they gain the invaluable experience about uncertainty and solution-making inherent in medical practice. This may be the first time medical students have dealt first-hand with patients, so it is really an opportunity to understand the physician-patient relationship.

Core Rotations:

Core rotations are not elective, but they may vary depending on the medical school. These rotations cover the breadth of general medicine. They may include family medicine, internal medicine, pediatrics, OB/GYN, psychiatry, emergency medicine, and surgery. The learning opportunities expand as the student progresses through the rotations, and they leave with a greater understanding of their future responsibilities and skill requirements.

Elective Rotations

Elective rotations are specified and more applicable to your future hopes and dreams in the medical field. These rotations may cover subjects such as ophthalmology or plastic surgery. Elective rotations typically occur during the fourth year of medical school. Because of this, it is easy to get distracted and focused on residency rather than rotations. This can make it difficult to select rotations, and the help of an adviser or mentor is suggested to keep you on the right path.

Clinical Rotations are a Job

One thing about clinical rotations is that it can be very much like a job, and it should be treated like a job. Even though there is no pay, and you may work long hours, this is very similar to what you will do as a resident and then a practicing physician. The hours and the work environment will be similar, and rotations are a first opportunity to experience “the real world” of a physician.

It would be a mistake to underestimate the importance of rotations, and a medical student should take it seriously. This means dedication, attentiveness, eagerness, and self-care to make sure you are getting everything you can from every moment observing others in the medical field. It is also a chance for networking, and some of the professional connections you make during this time will be life/career-long.

Clinical Rotations and Foreign Medical Graduates

As a foreign medical graduate, U.S.-based experience is a must. It may be helpful to get assistance from an outside source such as FMG Portal to help you get started. Any U.S. experience obtained prior to the Match will help a student get into to more residency programs, as it will look better on applications and during interviews.

Advantages of Clinical Rotations for Foreign Medical Graduates

  • Hands-on Experience: For all medical graduates, foreign or not, clinical rotations add valuable hands-on experience that cannot be replaced by classroom lectures. Students will learn from actual doctors and in the professional setting.
  • Letters of Recommendation: When applying for residencies through the Match, foreign medical graduates will need letters of recommendation from colleagues within the United States. This sends a message to residency directors that your educational background includes cultural acclimatization and that you have experience practicing medicine in the U.S. Healthcare System.
  • Performance Evaluations: Most clinical rotations offer performance evaluations where you will be informed of you strengths and weaknesses in certain areas of medicine. This is very valuable for future studying and in order to know where to get more experience.
  • Pathway to Residency: As a foreign medical graduate, you need local training to be considered for many residency programs, and clinical rotations provide a pathway for that to occur before graduation, so you don’t have to spend time after graduation getting experience before the Match.

The outlook for foreign medical graduates is constantly getting better despite political issues causing problems with visas, etc. There is a physician shortage that must be filled, and the American people and residency directors are consistently looking at foreign medical graduates as hope for a system that is lacking.

One of the ways that you can help foreign medical graduates (yourself) along is by making sure you have the background to show that you will be a formidable physician in the U.S. Clinical rotations are one way to do that. Not only do they give you added knowledge, experience and skills to help you practice better medicine, but they also make you look good to residency directors who may be concerned about your medical school experience. This shows them that not only is your educational background strong, but you have already had success applying it to patients in the U.S.

Residency Match Program Types

When you are considering residency programs, one of the things to consider is the type of program in which you will be seeking. This includes evaluating how you will personally fit into a program, if you got along well with current residents in the program and whether or not you can see yourself their long-term. It is less about how programs rank and the reputation of the program. If it doesn’t feel right during your interview and other interactions with people in the program, then it shouldn’t appear on your rank order list.

Beginning the Match process can seem overwhelming, especially after recently finishing the USMLE-2 exam. It seems like life is one whirlwind after another, and for the foreign medical graduate (FMG), there can be added stress in communication and logistics. With this may also come difficulty over Visa processing or difficulty getting ECFMG certification. It is not easy to maneuver life throughout your transition to PGY-1 (Post-graduate year 1), and one thing that can help is understanding how residency programs are set up. If nothing else, it clarifies a bit of the “mud” when you are trying to navigate the NRMP process.

One thing you may not completely understand is the program types offered through the Match. There are 5 program types available, and they each specifically coded for your rank order list.

How are programs coded?

Each program has a 9-character code that is recognized by the rank order list computer algorithm when you create your list. The first four characters are the institution code. The next five to seven characters are the ACGME specialty code, and then comes the program type or letter. Last is the track number, which is typically zero unless there is more than one track in the program. If there are more tracks, they are listed sequentially.

For example, anesthesiology programs at George Washington University – DC have the codes 1802040A0, 180204C0 and 1802040R0. Emergency medicine programs at the same university have the codes 1802110C0 and 1802110C1. The first four characters remain the same for the university. 1802 is the code for George Washington University – DC. The number 040 is the code for anesthesiology, while the number 110 is the code for emergency medicine. Anesthesiology offers three program types, advanced (A), categorical (C) and physician reserved (R).  Emergency medicine only offers categorical (C). The anesthesiology programs only offer one track, while emergency medicine offers two tracks. The second track is an international track.

You may not think it is important to understand how the programs are coded, but understanding the codes can help you to avoid errors when choosing programs for your rank order list. It also helps to understand that there are different categories of programs for planning purposes. For example preliminary and advanced programs are meant to be ranked together but separately, as the advanced program will be on your primary rank order list, while the preliminary will be on your supplementary rank order list.

What are the categories?

There are five categories of programs, and they tell you what post-graduate year they will start in along with the level of training offered.

  1. Categorical (C).

    If the program code has a C as its second to last character, it is categorical. This means it starts in PGY-1 (year one following medical school), and it offers full residency training. At the end of the program, a resident should be prepared for specialty board certification. Common categorical specialties are internal medicine, family medicine and neurological surgery. The length of categorical programs is 3 to 5 years.

  2. Primary (M).

    Primary programs are very similar to categorical programs in that they begin in PGY-1 and prepare the resident for boards. What makes M programs different is that they focus on primary care in that specialty. For example, they may focus on primary care in internal medicine or pediatrics. These programs may only take 3 years.

  3. Preliminary (P).

    Preliminary programs are to be coupled with Advanced programs (A). Common examples of preliminary programs are internal medicine and surgery. In P programs, the skill set learned is broader and covers a variety of disciplines in preparation for Advanced programs. They may take 1 or 2 years and begin in PGY-1.

  4. Advanced (A).

    Advanced programs follow preliminary and complete the full course of training began during preliminary training. Examples of Advanced programs are anesthesiology or dermatology.

  5. Physician Reserved (R).

    Physician reserved programs are advanced programs for physicians with graduate medical education. There are not many positions available in these programs, and they are for physicians that already have prerequisite resident training. These programs begin in PGY-1.

If you are beginning your journey to the Match, you may feel like it is a little premature to start figuring out the details of programs and how they are handled by NRMP to make sure your Match meets your needs and the needs of the program. However, there is a wealth of information and small details that can confuse the process if you aren’t adequately prepared. Casually studying these details will reduce the stress of the Match once it comes time for interviews and ranking.

Strategy, Stamina and Truth: The Path to a Residency

There are many motivating factors that influence one to enter medical school, and some of them are better than others. Your passion for medicine is a good one, and it may be coupled with family pressure or monetary expectations. These are not bad motivations, but becoming a doctor is more difficult than motivation, and if you are preparing for the Match, your path to a Match is far from over. That is why there are a few tools you can use to mentally prep yourself into a successful medical career.

Three Tools for a Successful Match

Strategy

Strategy is basically the planning process. You don’t just go to medical school, get a couple good recommendations, and Match in a residency program. Of course, there are the tests necessary to apply for residency, such as USMLE step 1 and USMLE step 2. However, more importantly is knowing what you need to get into the program you want.

When you entered medical school, you probably had an idea of the direction you would go. Maybe you were interested in pathology or plastic surgery. By your third year in medical school, you should have it narrowed down to one or two specialties.

After you know where to focus your efforts, you need to look at the requirements. What test scores are required to be considered for that residency program? How are you going to study for the boards? Are there sub-internships available? Find an overseas rotation in the U.S. and make sure you are doing it.

Your efforts should be targeted, and the target should be clear. This will make all of your efforts efficient, so you won’t waste time where it doesn’t need to be spent. You don’t need to study 12 hours a day to get into the residency of your dreams. In fact, over studying can diminish retention. So, focus and plan your efforts to a Match.

Stamina

You must already have a can-do attitude, or you wouldn’t have made it this far. From now on, any procrastinating tendencies you have must be disregarded for committed action. This means committed action in all walks of life.

It is natural to find excuses why you cannot or should not do something. When faced with adversity, our natural inclination is to preserve and protect instead of fight until the end. Some physicians will reflect on residency as “not that bad” or “most people could do it if they tried.” This is not true! They are either remembering incorrectly in a fit of nostalgia, or they are one of a handful of geniuses on the planet gifted with unreasonable talent.

Don’t expect anything to be easy, and don’t plan on waiting for anything. If you want to do something to prep for the Match, get started now and keep going.

Truth

There is some hard honesty that must be had during this journey. One of those truths involves self-reflection. If you are holding on to dreams of a surgical residency, but you just don’t fit in with that group of people or are having second thoughts for other reasons, go with your gut! This is going to be your life. Good physicians don’t clock out at 5 p.m. on the dot, and neither do happy physicians. Recognize the places where you fit, and you’ll shine.

It can cost some money to prepare for your tests, but you need those scores to get into your program of choice. Accept the reality that prep courses work, and you’ll maximize every second spent studying. Some courses to consider are Kaplan, UWorld, and Doctors in Training. You may spend thousands on prep, but think about the time and money you’ll save in the long run. A couple thousand is worth it to capitalize on the hundreds of thousands you may have spent on education.

Lastly, be honest about the integrity of the advice you receive. Listen to the person who bombed their step tests, but take any advice with a grain of salt. They don’t know how to get to where you want to be, as they weren’t able to do it themselves. Unfortunately, these people are typically forthcoming with their advice.

Learn from the mistakes of others, but seek out advice from people who have been successful. They know how to get over the hurdles of residency. Hopefully, they are willing to share. You don’t need to know how not to pass the USMLE or how not to succeed in an interview. The accounts of people who have failed may contain a few useful do-nots, but they contain no how-tos. The tips from successful applicants will be much more valuable.

You are getting so close to becoming a physician, but you still have a long and tough road to travel. With strategy, stamina, and truth, you will be able to reach the end of that road with a career that was meant to be, and one which you will be able to enjoy. Success is not just about money and prestige…but you can have it all in your medical career if you listen to yourself and plan accordingly.

Preparing for Residency after The Match

Once The Match is over and you have found your residency program, there are only a few months before you start your life as a bonafide medical resident. The feeling is overwhelming, and you are probably still feeling the inertia of placement. This is not the time to spin out of control with excitement an eagerness. Although post-Match time is a time for planning, it is also a time to take care of yourself. Here are a few tips to help you manage life during your time in limbo between The Match and your residency:

  1. Relax:

You’ve done it. The interviews are over. Not only have you picked your residency, but they’ve picked you too. It is especially difficult to relax as a Foreign Medical Graduate (FMG) because the Match is more difficult. The momentum change from the Match to a few months of “regular life” is difficult for the brain to process. Here are a few tips:

  • Sleep: Making sure you have a good sleep schedule is essential for your success as a resident. That may seem impossible with call schedules, but it is doable if you make it a priority. If pulling an all-nighter, make sure your free time prioritizes sleep over recreation…and sometimes over studying. Not prioritizing sleep could make all other efforts futile.
  • Exercise: Long hours and lack of sleep don’t make a person want to exercise, but it will help the mind and the soul. People who exercise are healthier and less-stressed. With that said, any opportunities for outside exercise should be taken.
  • Meditate: Everyone needs time for themselves, and the new resident is no exception. Yoga, meditation, or even people watching can give the body the self-appreciation it needs.

  1. Connect:

While relaxation may be an important thing to consider, so is making or maintaining relationships. Personal and professional relationships prevent burnout and provide opportunity.

  • Current Residents: As an FMG, it is very unlikely that you know the area where you will be a resident. Nobody is a better information source than current residents. Not only is it a great opportunity to make friends, but they know the best places to live and eat. They also can give advice on the details of the residency that you cannot get during The Match.
  • Support System: You should also keep in touch with your friends and family even if they are abroad. Keep them informed of your schedule as much as possible, so you don’t end up isolating yourself because of a busy schedule. Ultimately, you will build strong relationships during your residency, but you don’t want them in lieu of losing old relationships. Explain to them the truth about time constraints, so nobody feels left out.

  1. Maintain:

Yes, relaxation is important but not at the expense of your hard work. The few months before residency can provide time for yourself that may not be available during residency, but that doesn’t mean it’s time for a vacation. Brush up on your skills and keep your training and education fresh by continuing to study.

  • Advanced Cardiac Life Support (ACLS): You may already be certified, but observing critical care can provide a good segue into care provided as a resident. Take any opportunities to observe, and you’ll be that much more ready to start.
  • USMLE Step 3: You can only apply for step 3 of the USMLE after graduating medical school, so you may be taking this test after The Match. This means more studying!
  • Medical Journals: As a physician, learning is never finished. Medical journals should always be on the “to-do list,” as it will keep you up to date and cutting edge.

One of the biggest risks after matching into a residency program is lacking direction. Prioritizing yourself, your connections, and your education will keep you from becoming stagnant and stressed about starting the last step on your way to becoming a fully-autonomously practicing doctor.

Taking care of yourself means taking care of your personal needs as much as your professional needs. That is why things like sleep, exercise, and mediation are essential to your regrouping and preparation for residency. It is easy to become isolated during this time out of a lack of direction but also out of a lack of prioritizing relationships. Success in life is largely dependent on relationships, and cultivating relationships helps maintain friends and family while building professional networks. Lastly, physicians should all consider themselves lifelong learners, and the time between the Match is no exception. Read, study and observe to maintain and build additional skills prior to residency.

There is no such thing as an easy residency, and during this time you will be stressed, hungry, tired, and overwhelmed. That is why the time between the Match is crucial for a successful residency. It is a break from the impossible workload of the medical graduate, but it is not a time to forget about your priorities.

Rural Health Opens Opportunities for Foreign Medical Graduates

According to the Association of American Medical Colleges, the U.S. will face a doctor shortage of around 100,000 by the year 2030 if something is not done to increase new residency positions.

The shortage is happening because of an ever-growing population but also because the amount of new medical school graduates allowed into residency programs has not kept up with the pace of population growth. Why would anyone restrict residency positions in a time of projected shortages? The answer is all about the budget and how much the government will fund positions in teaching hospitals.

Thankfully, 2019 has presented some hope for residents with the introduction of the “Resident Physician Shortage Reduction Act of 2019.” This bill would open 15,000 funded residency positions within the next five years.

One of the shortages bills like the Resident Physicians Shortage Reduction Act plan to address is the rural physician shortage. A Becker’s Hospital Review article states that 20 percent of the U.S. population lives in rural communities, and the doctor shortage is revealed in their ratios compare to this population. For every rural physician, there are 2,500 rural residents.

Why is a Rural Physician Shortage a Health Crisis?

One might think the rural physician shortage is not a significant problem. After all, people do go to urban areas to shop, and they choose to live at a long distance from health care services. However, many rural communities are poor communities, so they have difficulty with travel costs. Additionally, many elderly persons live in rural communities, and they may face transportation difficulties as they age out of the driving population.

More importantly, people are unlikely to seek out cost-saving preventive health services if they are not conveniently located. They may also put off subsequent visits meant to monitor chronic health conditions. Telemedicine has attempted to bridge some of this health care gap for rural areas with telemonitors and telehealth services, but often rural communities have technology knowledge gaps and limited access to these services.

If you have ever lived in a rural community, you might understand the importance of the local physician. Everyone in the town depends on him or her for everyday health needs, and if that person retires or moves, it can stress the entire community. There needs to be motivation for physicians to train and work in the rural health care sector in order to decrease this disparity.

What Does this Mean for Foreign Medical Graduates?

For years, there has been tension between people who want to support U.S. medical graduates and those who recognize the need to fill the doctor shortage with foreign medical graduates (FMGs). As the physician shortage continues to grow, the benefits of FMGs are becoming recognized. In the past few years, there have been articles  noting the abilities of FMGs rather than only the need for them to fill the shortage. Ultimately, the U.S. is realizing that they need FMGs in order to deliver proper healthcare to all of its residents and visitors. Now, they just have to make it easier for them to get residency positions and practice in the U.S.

Rural J-1 Visa Waiver

The Rural Health Information Hub is an organization that supports the improvement of rural health services across American, and they have one page on their site dedicated to information about the J-1 Visa Waiver, an opportunity for foreign medical graduates to remain in the United States.

With a J-1 visa, a resident must return to his or her country following residency and then apply for a H1-B visa, which will allow them to work in the U.S. If a resident is willing to work in a rural community, they can apply for a waiver, and this allows that resident to stay in the U.S. to work. This is a mutually beneficial situation for rural community members who need a quality physician and the FMG who will have much less red tape to get through.

Saving Lives by Improving Access

Studies show that people who live in rural areas are more likely to die from everything from treatable chronic diseases to accidents where they cannot reach timely access to care. Increasing the number of rural physicians would help to improve these numbers.

As a FMG, you may be wanting to work in an urban area with access to high-technology and physicians who are working with the best resources available. However, it can be difficult to dodge all of the red tape that it takes to get to stay in the country after residency. Considering working in the rural area for a short while will not only give you a unique experience, but it will also allow you to practice in the states immediately after residency instead of postponing your career until you can apply for your H1-B visa.

Rural health is not only an opportunity for Foreign Medical Graduates to stay in the United States following their graduate education, but it is also a chance to save lives. Rural communities do not have access to the resources of the city, and one resource that can be brought these underserved areas are physicians.

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FMG Portal: Assisting FMGs to become U.S. Medical Residents

Becoming a physician in the United States as a Foreign Medical Graduate (FMG) requires some hands-on medical experience within the states. That is why FMG Portal has dedicated its services to helping FMGs through every step of becoming a practicing physician in the U.S. We do this by offering connections to clinical externships, clinical electives, clinical clerkships, clinical rotations and clinical observerships. We also offer assistance with CVs and Visas, so there is no kink in your pathway to a U.S. Residency.

Services

Getting U.S. experience is the impetus behind most of FMG Portal’s services, and it does this by connecting you with programs that provide differing levels of experience. Many of the services, such as clerkships vs rotations are the same if not similar, but knowing specifically what they are will help the FMG to understand what they are seeking.

Clinical Externships

Externships are only available to medical graduates, and they do not qualify for medical school credit. They give FMGs the hands-on experience that will be required by many residences in which applicants apply. Some externships cover specific specialties, which can be very beneficial during the Match process if you are looking to join a certain medical specialty.

Some of the other skills that may be learned in an externship are how to write SOAP notes, participate in diagnosis teams and learn how to use an electronic health record (EHR). While FMGs may have already learned adequate diagnosing skills during their medical training abroad, hands-on experience within the U.S. allows them to learn any nuances that could hinder the medical process by being performed in a manner inconsistent with U.S. healthcare system norms.

Clinical Electives

For foreign medical students, clinical electives are a good opportunity to get hands-on training, and FMG Portal has connections with multiple teaching hospitals. This allows the student to get to work closely with attending physicians in a U.S. healthcare setting.

Foreign medical students who have clinical elective experience in the U.S., especially in their desired specialty, have a much better chance of getting a residency match. Not only does it show experience in the U.S. healthcare field, but it also allows for the opportunity to get U.S. letters of recommendation.

Clinical Clerkships

Clerkships and electives are terms that may be used interchangeably, as they are very similar. In some curricula, they are compulsory. However, U.S.-based clinical clerkships offer a unique opportunity for foreign medical students to participate in healthcare delivery with experienced physicians. This will not only aid the student in passing their USMLE tests, but it will also give the opportunity for cultural adjustment. Cultural adjustment may not seem like a huge component of U.S. healthcare experience, but it greatly aids in communication, which can enhance an interview.

Clinical Rotations

Rotations are very similar to clerkships, and again, the names can be used interchangeably. The word rotation is significant in U.S. rotations because it implies that a student rotates through different specialties in their final year of medical school while supervised by a physician in order to obtain a well-rounded medical education.

Clinical Observerships

Observerships are established when an FMG gets to observe a specialty by participating in a 2-4 week program. This is meant to allow the FMG to get an idea of how the American culture of healthcare works, and it allows the FMG to establish connections along with witnessing firsthand how the medical care is provided in the particular specialty.

Other Services

Visas

Immigration laws are constantly changing with the current administration, and this can make applying for visas difficult and confusing. That is why FMG offers assistance in this endeavor, so you can focus on the more important matter of your education and residency placement.

CVs

Having a thorough CV is essential to residency placement, but it can be difficult to pare down a full resume to fit the needs of a certain specialty. Our experts can take out the unnecessary details in order to highlight the parts of you that will make you appeal to your residency program director.

ERAS Application

The ERAS application is obviously one of the most important parts of the Match, and filling it out properly could mean the difference between consideration and simple rejection. FMG Portal’s staff can help you fill it out properly, so you don’t miss your change based off of a minor issue.

If you are a Foreign Medical Graduate or a Foreign Medical student looking for resources to get Matched and become a successful physician in the U.S., FMG Portal has the skills, resources, and the connection you have tohave to get you there. As an FMG, you must prove the quality of your education through ECFMG certification, CVs and applications that show that you are the type of resident a program would want to have educated under them.

Don’t travel the FMG road to medical practice in the U.S. alone. Get help where you need it with FMG Portal.

2018 Trends for non-U.S. IMGs in the Match

When you are ranking programs for the Match, it is best to go with your heart. That is, try to join a specialty that you are passionate about. It will help you to be successful and lessen your chances of burning out. However, you may be passionate about more than one program. This is understandable, and that it why it is helpful to pay attention to statistics and what other non-U.S. international medical graduates (non-U.S. IMGs) have done to get Matched.

Rank Order List

Ranking programs for the Match should be based on passion, but it should also be smart. For example, the NRMP’s 2018 Match report indicates that longer rank order lists tend to produce a larger percentage of Matches. For non-U.S. IMGs, it may be difficult to find a long list of programs that are likely to accept you for one reason or another. You may feel like some programs are a long shot or that it is a waste of time to rank them. Get this thought out of your head. If there is a chance, and you wish to enter the program, get it on your list. Once you have to start paying extra to add to your rank order list (20 unique programs before extra fees on primary rank order list), you might be more selective. But if your list is short, add those long shots!

USMLE Scores

There are many factors that determine whether or not any medical graduate is considered for a residency program during the Match, and one of those factors is USMLE scores. High USMLE scores are obviously a positive element of your overall application, but lower scores do not eliminate your possibilities of a Match.

In USMLE Step 1, non-U.S. IMGs who Matched had higher scores than those who did not in most specialties. However, this was not true in the orthopaedic surgery and plastic surgery specialties. In step 2, the same was true except in OB-Gyn, orthopaedic surgery, plastic surgery and vascular surgery (see NRMP’s 2018 Match report).

Other Factors

Other factors that may determine whether or not a non-U.S. IMG is chosen for a residency program during the Match are work experiences, research experience, publications, volunteer experiences and Ph.D. or graduate degree.

In competitive programs such as dermatology and neurological surgery, non-U.S. IMGs that Matched had more research experience than those who did not Match. Publications had varied success for all IMGs, but it is worth noting that non-U.S. IMGs had 6.2 publications on average compared to 2.9 for U.S. IMGs. Similarly to publications, there was no clear trend of successful Matches based on work experience. Volunteer experiences were higher among Matched IMGs among both U.S. and non-U.S. IMGs. Having a Ph.D. was a factor for the Match for non-U.S. IMGs, but graduate degrees were often reported more among the non-Matched.

What Does this Mean?

Clearly, the results of the 2018 Match report are varied, and the take home message is that everything matters, but none of the factors will eliminate you from consideration as a non-U.S. IMG. This is why other recommendations are as important as these trends in order to be successful during the Match.

What are Other Recommendations?

Despite the ECFMG certification process, some residency program directors may be uncomfortable with foreign education. This may be due to some deeply held bias (which is unfortunate), but it is more likely that program directors are not able to decipher exactly how you were educated abroad. There are different standards across the world, and your education may be more extensive than U.S. medical schools, but program directors need to know that it was at least as good as U.S. medical school.

Study Match trends to increase your odds of success.

That is why U.S. experience (observership programs) and recommendations are crucial for the Match. Residency program directors want to know that you can work in the U.S. healthcare environment. They want to hear it from you, and they want to hear it from American peers who can testify to your abilities.

It is also very important to do well in your interview, and this may be the most important part of the Match process. Your language ability, your confidence, and your personality will need to fit the program. You may have excellent scores and a full CV, but if you lack any passion or interest, it is unlikely that you will be chosen. Making yourself interesting may include talking about hobbies outside of medicine instead of the residency program. Be prepared to talk about yourself as a normal person, not only a residency candidate.

Yes! It is stressful to consider everything that matters when applying to residency programs. The number of non-U.S. IMGs entering the Match is declining, but the numbers being Matched is at a high point compared to the last couple of decades. The reduction of non-U.S. IMGs may be due to Visa issues or rumored difficulty getting Matched, but the numbers show that if non-U.S. IMGs are ranking residency programs, they are increasingly finding residency programs.

January Agenda: Rank Order List

As 2019 approaches, it is time to consider which residency programs you’d like to attend, and this decision is integral to successful placement in the Match. On the one hand, candidates need to consider residency programs where they feel they’d be a good fit and be able to pursue their medical career successfully. On the other hand, candidates also need to pick programs where they will be successfully matched.

A word of caution: don’t pick residency programs simply because you think you’ll be matched. There are worse things than not getting matched, and you’ll get another chance to be matched through the Supplemental Offer and Acceptance Program (SOAP) where unmatched candidates fill unmatched residency program positions. The Rank Order List should reflect your best picks, not your safest.

Janurary 15th marks the opening day of the Rank Order List entry, which is located on the website of the National Resident Matching Program (NRMP). You should list programs in your order of preference, with those you most want to attend listed first.

Things to consider when ranking programs:

Which program did you simply like the most? This questions does not necessarily mean the program seemed the most challenging or that you would fill a provider gap in your future area of practice. It is more about where you would be a good fit. Did you get along with the people running the program? Did it seem to progress at a desired pace? Is there a good support system? Whatever you are specifically seeking in a residency program should be considered when ranking.

How was the interview? Was it amazing? Did you make connections? Did the interviewers seem receptive, or did you feel unaccepted. Especially for Foreign Medical Graduates (FMGs), this can mean the difference between a successful and an unsuccessful Match. Those who are FMGs should also be considering how the program handles the inclusion of all residents, so an FMG is not set aside as a viewer more than a doer because of cultural or language barriers.

Is the program competitive? Can you succeed at this level of competition? This would include considerations such as your USMLE scores and any education gaps you may have experienced. Especially for FMGs who may have had a different medical school curriculum, this can really impact success.

Is the program good from a logistics standpoint? Is it located in an area that will be acceptable for you to live for a while geographically? Does it pave the path to the medical career you are seeking?

Are the current residents happy? Physician burnout is real, possibly more than ever. Make sure the current residents are satisfied with their residency program. You don’t want burnout to begin early, and a good residency can provide a resident with the tools necessary to avoid it in the future.

It is recommended that you rank around 10 residency programs, but you won’t have to pay additional fees until you reach 20. It is also recommended that you have a qualified person look at your list and discuss any opinions about questionable choices. A mentor or a current physician may be a good choice.

Once you have your Rank Order List Complete, you must certify it in the R3 system. This must be completed by 9 p.m. Eastern Time February 20th 2019.

There are two other things that should be mentioned about Rank Order Lists:

1. If you did not interview with any residency programs, you won’t be able to generate a Rank Order List because no residency programs will be considering you as a candidate. It is not the ideal situation, but don’t forget that this does not mean the end of your residency hopes for this year. There is still SOAP in March.

2. If you are having a lot of difficulty deciding whether or not you should rank a program because you aren’t sure if you’ll be Matched, you can communicate with the programs, and they can reach out to you. Letters of intent may or may not have a positive influence on the Matching process, but they are allowed. Additionally, programs may reach out to you, but it is not recommended that you let this influence your Rank Order List. There is a Communication Code of Conduct that should be followed during this time, which highlights confidentiality and eliminates unnecessary communication.

Remember, your interview days were the time to fully vet each residency program, and your choices should be made based on the positive and negative qualities of the program, not whether or not you think there is a good chance you’ll be selected.

There are differing opinions on how Rank Order Lists should be created, and each person has a different experience based on personalities and professional backgrounds. For FMGs, there may be programs that are friendlier toward foreign education, but again, this should play a minimal role in your selection.

Match week is in March with Match Day falling on March 15th, so if you are in the Match as a Foreign Medical Graduate, your journey is almost complete!