Residency Training in the US : The Ultimate USMLE Guide for the International Medical Graduate

Completing a medical degree (MBBS or MD) in an international medical school is just the first step in becoming a physician. For many, the next step is to pursue residency training in the United States. There are several reasons why international medical graduates (IMGs) choose to migrate to the US for their residency training. Some common reasons include the desire to be closer to family, a spouse in the US, access to higher-quality training programs, more opportunities for research, and higher salaries and quality of living. The US is home to some of the world’s leading medical institutions and offers a wide range of specialties, making it an attractive destination for IMGs seeking to advance their careers. However, the process of securing a residency position in the US can be challenging, especially for IMGs.

I am currently a third-year internal medicine resident and a chief resident at one of the residency programs in the US. As someone who took on this path many years ago, I wanted to share my experiences and lay a step-by-step manual for someone looking to pursue their residency training in the US.

What Makes an IMG a Competitive Applicant

To be a competitive applicant for residency training in the United States, IMGs must meet several requirements. Scoring high on the USMLE Steps 1, Step 2 CK, and Step 3 exams are crucial, demonstrating your knowledge and ability to meet the standards the US medical school training sets. USMLE exam scores are the only objective data that the programs have to compare you to other international and US medical students who will be applying for a residency with you. Research experience and publications can also be a plus, as residency programs often look for candidates who have a strong interest in advancing the field of medicine.

Obtaining US clinical experience through observerships and electives is also a must. Having US clinical experience shows the program leadership that you know how medicine is practiced in the US and how it differs from your home country where you trained. This becomes especially important if you are an older graduate. Obtaining US clinical experience through observership and electives is also an opportunity to get your foot in the door, build contacts and relationships with physicians in the US, and obtain letters of recommendations. By focusing on these critical areas, IMGs can increase their chances of being selected for residency in the United States.

Step 1: Meet Eligibility Requirements

The first step to securing a residency position in the United States is to ensure you meet the eligibility requirements. These requirements may vary based on the state and specialty you are applying to, but here are some general requirements you must meet:

Medical School Requirements: To be eligible for ECFMG certification, you must first complete all requirements for a medical degree from a medical school outside the United States and Canada, that is listed in the World Health Organization’s (WHO) World Directory of Medical Schools. You must also provide proof that your medical degree is equivalent to a US medical degree.

USMLE: The United States Medical Licensing Examination (USMLE) is a three-step exam that tests your knowledge and clinical skills. You must pass all three steps to be eligible to practice medicine in the US. Here’s a brief overview of each step:

USMLE Step 1: USMLE Step 1 tests your basic medical knowledge and focuses on anatomy, physiology, and pathology. Previously, this was a score-based exam, and IMGs used to study for at least 6-8 months before taking the exam. However, this is now a pass-or-fail exam, and I recommend not spending too much time on USMLE Step 1. I took this exam as a third-year medical student in my home country. However, after completing medical school, many people take a break from medical school to prepare for the USMLE exams exclusively. I would not recommend taking too much break as you do not want to have a large unexplained gap in your CV.

USMLE Step 2 CK (Clinical Knowledge): Tests your knowledge in clinical sciences, such as internal medicine, surgery, and pediatrics. With Step 1 becoming a pass-or-fail exam, Step 2 CK became even more important as an objective measure to judge an applicant. Hence I recommend a few months of dedicated preparation to ensure a high score. At some point, I will write a separate article on how I prepared for this exam.

USMLE Step 2 CS (Clinical Skills): This exam was previously done to demonstrate your clinical skills and English language proficiency. However, since the advent of the COVID-19 pandemic, this exam has been canceled. Now ECFMG requires candidates to complete the Occupational English Test (OET) to complete the eligibility requirements.

USMLE Step 3: This exam is a 2-day examination, predominantly focusing on multiple choice questions in all core subjects such as internal medicine, surgery, and pediatrics, as well as computerized interactive case simulations (CCS). USMLE Step 3 is not a mandatory requirement for obtaining residency in the US. In fact, many candidates complete this exam after starting their residency through the second year of residency. However, I recommend completing this exam and getting a good score before starting residency or finalizing the match list. There are many reasons for this:

1. As an international medical graduate, you must present objective evidence of equivalency to the US medical students who will apply with you. With USMLE Step 1 becoming a pass-or-fail exam, much focus will be on USMLE Step 2. I recommend adding USMLE Step 3 as a vital gold star to your application, and it would be even more impressive if you have a good score.
2. USMLE Step 3 is a requirement for H1b VISA. This VISA has many advantages over the J1 VISA, which the ECFMG supports for residency training in the US. So if you can get trained in a program with H1b VISA, you should consider that and keep this option open by having USMLE Step 3 ready to go before the match results.
3. USMLE Step 3 is in many ways similar to USMLE Step 2 CK, and there is a lot of overlap in content. Hence I recommend taking it soon after Step 2 CK if possible to have better chances of scoring high.
4. Residency in the US is busy! I have seen many residents struggle to find time to prepare for USMLE Step 3 in the middle of their residency. Hence I recommend completing this requirement before starting your residency, if possible.

ECFMG Application Process: As listed here, ECFMG certification can be obtained through many different pathways. In brief, the ECFMG application process typically involves passing the USMLE Step 1, Step 2 Clinical Knowledge (CK), and OET examination. You must also provide official transcripts from your medical school, medical school diploma, and any postgraduate medical training you have completed. Some pathways also require you to have a medical license in your home country and have your medical council attest to your medical registration being in good standing. Once you have completed these requirements, you can apply for ECFMG certification through their online services portal OASIS.

ECFMG Certification: The Educational Commission for Foreign Medical Graduates (ECFMG) is a recognized organization that certifies international medical graduates who wish to pursue residency training in the United States. ECFMG acts as your designated “dean’s office” when you apply for residency training in the US.  Certification by the ECFMG is mandatory for IMGs who want to participate in the residency match process through the NRMP. Keep in mind that ECFMG certification is only valid for seven years from the date of issue, so it’s essential to plan your residency training application cycle accordingly. By obtaining ECFMG certification, IMGs take the most crucial step towards pursuing residency training in the United States and advancing their medical careers.

Step 2: Clinical experience

You may need to obtain clinical experience in the US to demonstrate your clinical skills and knowledge. This can be achieved through observerships or electives. Observerships are short-term shadowing opportunities where you can observe medical professionals in clinical settings. Electives are clinical rotations you can take during medical school. With the COVID-19 pandemic, many IMGs are finding it difficult to find such opportunities. However, many programs continue to require their applicants to have this experience. Having this clinical experience in the US has three main benefits:

1. If you can secure such an opportunity at a residency program, you can get in front of the eyes of the program leadership. This allows you to “audition” in front of the leadership and make an impression, becoming a potential residency candidate when application season begins.
2. Including at least three letters of recommendation with your residency application is mandatory. Most candidates obtain letters of recommendations from US faculty members when they do their elective or observership clinical experience.
3. You can build meaningful mentor-mentee relationships with US faculty members through these experiences. They will be able to help you come application season by giving you invaluable guidance and sometimes even making phone calls to support your application.

I will write a separate post about how I found electives and observerships when I applied back in 2018 and how you can, too, in this current climate.

Step 3: Research the Residency Programs

At this point, I imagine you know which specialty you are applying to. Most IMGs choose to apply to IMG-friendly specialties like Internal Medicine, Family Medicine, and Pediatrics. Familiarize yourself with the different types of residency programs offered in the US, and research the ones that align with your interests and career goals. Make a list of programs you are interested in applying to, and be sure to check each program’s eligibility criteria thoroughly. I used AMA Freida Residency Database to research programs that are less competitive and accepted IMGs in the past.

Step 4: Apply through ERAS

Use the Electronic Residency Application Service (ERAS) to submit your residency applications. ERAS is a centralized online platform that makes the application process easier and more convenient. When you apply, ensure that your ERAS CV is comprehensive and error-free. Have someone proofread your application thoroughly. Make sure the other supportive aspects of your application, such as your personal statement, are well-written and edited.

Step 5: Prepare for the Residency Interviews

Interviews are an essential step in securing a residency position. Start preparing for interviews by brushing up on commonly asked questions and preparing responses in advance. We have a separate guide on how to ace your residency interviews.

Step 6: Attend the Residency Interviews

Attend residency interviews, either in person or virtually, as per the program’s requirements. Use the opportunity to ask questions, learn more about the program, and showcase your skills and knowledge.

Step 7: Rank Programs

After interviews, use the National Resident Matching Program (NRMP) to rank the programs in order of preference.

Step 8: Match Day

On match day, find out if you have been matched to a residency program through the NRMP.

Step 9: Secure Visa and Obtain the Necessary Documentation

If you are matched, start the process of obtaining the necessary visa and documentation to begin your residency program in the US.

In conclusion, securing a residency position in the United States as an IMG requires great hard work, dedication, and preparation. It was a long journey for me personally, starting from 2016, when I passed my USMLE Step 1, to finally matching in July 2020. From meeting the eligibility requirements to attending interviews and securing a match, staying organized and focused throughout the process is essential. Do not hesitate to reach out to your friends, seniors, and alums from medical schools who have taken this journey before you, as they will be able to assist you better. There are multiple Facebook forums and WhatsApp groups where applicants exchange information.

Please leave comments below if there are any specific questions that you have that I can answer. Remember to take care of yourself during this time. It can be stressful and challenging, but with perseverance and determination, you can achieve your goal of becoming a physician in the US. Best of luck!