Medical residency in the US – how tough is it?


Lately, some people have been asking me about postgraduate residency programs in the US. Most of them are Nizhnians, but there is one from Volgograd as well :)

Since I’ve wrote about postgraduate studies in Malaysia, Australia, New Zealand, UK etc, might as well I write about the US. Please be reminded that whatever I write here can be wrong, so please verify everything yourself.

  1. Some people think passing the qualifying medical examinations for practicing medicine in the US – USMLE or United States Medical Licensing Examination is already enough to get a residency. While USMLE is the core factor for residency in the US, passing the Step 1, Step 2 CK (Clinical Knowledge) and Step 2 CS (Clinical Skills) of USMLE alone is certainly not enough (the points below explain the not-enough part). The application requires med school insignia (what a pain!). Step 3 of USMLE is usually taken during or before the start of residency.
  2. Exam accessories – of course you need to choose excellent review books for USMLE revision. You also don’t want to miss excellent USMLE-oriented revision programs such as Kaplan and question banks for your practice (Kaplan, NBME, USMLE World, USMLERX etc). People spend differently on this, ranging from $800 – $5000.
  3. USCE or United States Clinical Experience is looked upon quite highly for residency programs to interview their residency candidates. Most programs require a candidate to have at least 2 LORs (Letters of Recommendations) from US physicians. To obtain the LORs, a candidate must take up externship/subinternship/observership program in US hospitals. You need to pay some $$$ for the program. Some clinical and scientific researches give more weight to the IMGs (International Medical Graduates).
  4. Getting into the US – this can be quite tough with the pencil-pushing bureaucrats in the US embassy/consulate. IMGs need at least THREE TIMES of travel to the US before starting residency. One for USMLE Step 2 CS exam which is only available in the US, one for USCE, and one for residency interview. More $$$ down the drain!! Visas are pain in the ass; some may get visitors visa B1, for those unfortunate ones, they will decline you the visa. For residency visa, you’ll have to choose H1B (6 years of employment) or J1 (7 years of education). To obtain a H1B visa, an IMG has to be reaaaaaalll good for the program to sponsor such visa. J1 visa requires some letters from ministry of Health of IMG’s home country saying that the IMG will return home after 7 years of training. Many IMGs opt for J1.
  5. Application process to a residency program- I haven’t fully understood the whole process, but it’s kinda painful for me tho. With all the pre-match, scrambles, NRMP, ERAS, datelines and timelines, interview processes, final applications, ECFMG certifications and shits like that! Gaaaa that’s too many shits in an IMG’s head.
  6. Interviews – IMGs mostly apply a few programs (10-20) for interview. A typical IMG profile is 4-5 years post graduation, have done at least 2 USCEs and have a few LORs in hand (refer above), 85th percentile and above for USMLE Step 1 and Step 2 CK scores, passed Step 2 CS on first attempt.
  7. Specialties - some specialties are definitely no-no for IMGs, such as radiology, ophthalmology, ortho, anesthesia and dermatology. Most IMGs go for Internal Medicine and Family Medicine since American Medical Graduates (AMGs) opt for easier specialties with higher pays to settle their medical school debts. Internal Medicine and Family Medicine residency usually last 3 years. Many IMGs follow with fellowship programs for their subspecialties since the J1 visa is valid for 7 years. So, 3 years of residency + 2-4 years of fellowship = just nice for an IMG to be called a specialist!
  8. Competition – no doubt it’s gonna be very competitive. Some programs are real tough they only pick those USMLE scores of 90th percentile and above for residency interview. Some specialties like neurology, neurosurgery and surgery are much tougher – 97th – 99th percentile only. A highly respected surgeon from a foreign country can end up being a family medicine physician in the US. Not that I’m looking down to family medicine, but specialties like surgery is definitely tough for IMGs to get in.

Ok I guess this is the shortest summary down to the bare minimum I can give you. Mind you, my knowledge about residency in the US is not even 10% from what other IMGs know! I was soooo overwhelmed when I saw people discussing residency in the US in some forums available throughout the world wide web.

Anyways, if you’re inspired to work in US because you see how happy those surgeons are in Grey’s Anatomy or how genius Dr. House can diagnose a patient; perhaps you should change your inspiration.

And for those who are inspired by fame, respect and money; you definitely won’t get any of that! What you get is probably long-hours of strenuous working with yelling supervisors, sacrificing your time and being very far from your family and friends, changing who you are and many other negative stuffs.

Perhaps I should just be a nurse… ;)

For more information visit www.usmle.org and www.ecfmg.org.

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12 comments on “Medical residency in the US – how tough is it?

  1. You have some reasonably good tips for international medical graduates; however, you are correct that the application and interview process is complex. Examples of criteria seven MN family medicine programs look for in applications are 1 year of US experience (observerships & externships qualify) and no more than two attempts on each USMLE exams. However, applicants only need to apply to one of the seven residency programs to be considered for an interview at all seven.

    • I was looking for USMLE information and stumbled upon your blog. Not many Malaysians are taking USMLE as compared to MRCP.

      I have a question: I graduated from one of the local public medical school but I just found out that my school is not on the state’s medical board approved school list such as Medical Board of California. Does it mean if i pass the exams I am not eligible to apply their residency?

      I think the USMLE Step 1 is much more difficult than my medical school exams. Frankly speaking, I wonder how many Malaysian doctors are able to pass the exams.

  2. Thanks for the good tip for Family Medicine Residency in Minessota. I heard it’s a nice state.

    1 year of USCE is definitely tougher than I thought! With the B1 visitor’s visa limit to only 3 months stay in the United States, an international medical graduate must go back and forth at least 4 times for USCE alone.

  3. Harapan la saye nak gi US!! It seems really tough! Seriusly, being a doctor seems to look very leceh, u hv to take this examla, do that internshipla…and the list goes on. But i suppose when the fact tat lives will be at stake when u r at work, it seems worth it. In the end its all up to passion, ambition and motivation…if u want it, go get it!!! N if u love wat u do, doesn’t matter whr u are, u will be the best!!!

  4. hm…now that it seems impossible for me to work in da UK, US is looking more attractive… :p but i’ll probably stick to NZ since its nearer to home…

  5. Maalini: Many IMGs I know are already in their 30s and have kids. So dont give up hope! And I agree, if you work hard enough for it, sure you’ll be the best!

    delirioustk: The best part is; NZ recognizes USMLE as part of its qualifying exam too! So, if u pass USMLE but never got to US, NZ is enough. You just have to take an extra exam for clinical skills.

  6. Thanks for the great summary. I was the Chief Resident of Morehouse School of Family Medicine in Atlanta, and 60% of our residents were IMGs. In our admission committees, we looked at the following (in order of importance):

    1. USMLE SCORES and attempts

    2. U.S. “Hands-on” clinical experience & acculturation – Up to one academic year (36 weeks); Observerships, externships or research didn’t count as it wasn’t clinical.

    3. Activities since medical school GRADUATION

    4. 3 to 5 recent letters of recommendation from licensed US physicians (< 12 months old), documenting your clinical experience in the US. The more LORs, the better, since not all LORs positively recommend an IMG, or carry a weight necessary to compete with American Graduate competition.

    5. U.S. immigration status – if we liked an interviewee, we sponsored them… no problem.

    6. ECFMG Certification

    7. Passing score on USMLE Step 3, if taken – not a huge factor, but a good one. Definitely not as important as the top 6.

    8. Interview skills and English COMPETENCY – of course, you have to get an interview first.

    According to the NRMP, the following are positive Match predictors:
    1. For all – #contiguous ranks
    2. 2nd for all 4 groups – USMLE Step 2
    3. Step 1 for less competitive specialties only
    4. Research nor # of publications was not a significant predictor of Match
    5. For U.S. graduates – Being a graduate of top 40 NIH research medical schools, PHD and AOA member

    A Comparison of Residency Selection Criteria for 1996 to 2006 (AAMC Central Group on Education Meeting 2007) identified Most important residency secelction criteria to be:
    1. Disciplinary actino in med school
    2. Received a failure in a required clerkships
    3. Failed USMLE Step 2 CK prior to passing
    4. Failed USMLE Step 2 CS prior to passing
    5. Failed USMLE Step 1 prior to passing
    6. Taken extended time to graduate for academic reasons
    7. Applied to more than one specialty
    8. Graduates in lower 25% of class
    9. Grades in required clerkships
    10. Received a failure in a pre-clinical course

    Although the above 10 are primarily for U.S. graduates, the fundamentals are the same for IMGs; therefore and IMG who has an application that looks very similar to a U.S. graduate, he/she will be assessed based on the above criteria.

    Hope this helps during the regular Match, and especially during the annual Scramble.

    All the best – Dr. Mizani

    • Dear Dr Mizani,

      I’m from Malaysia and I’ll be taking the USMLE step 1 this year. I would like to know is it necessary to have U.S. “Hands-on” clinical experience & acculturation? What is the duration? If I do housemanship in Malaysia, is it recognized?

      I really do appreciate it if you would reply as alot of financial planning needs to be done.

      Thank you

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