Questions on today's podcast come to us from Dr. Sagar Shah via twitter - you can follow him @thisissagarshah In a short exchange he asked questions a lot of our IMG clients ask, and I thought the answers would be valuable to a wider audience, so I'll answer them here. There is a lot of good information available online from different sources like the ECFMG, ERAS, etc. so I won't regurgitate a lot of that stuff and will instead give more personal advice.
Any US student who wants to get a bit of understanding may also gain some insight from today's topics. As you may remember from earlier episodes, only about 50% of any given match year over the last 10 years has been US allopathic MDs, IMGs made up about 40% of the pool or may not know, IMGs currently make up about 25% of the physician workforce. Most of those in Internal medicine, psych, pedi - more primary specialties. Regionally, New Jersey, New York, Florida, and Illinois had the highest concentration of IMGs when last polled in 2009 - could have shifted a bit since. The country supplying the most IMGs is India, the Caribbean schools collectively make up a huge chunk - Dominica, Grenada, Netherlands Antilles, then Pakistan, China, Philippines, Mexico - overall 127 different countries granting ECFMG certificates in this 2009 paper. So, a bit of perspective - as a US student you will absolutely work with an FMG in the near future, and as an FMG, you will not be alone when you match into a US residency program. Let's get into the questions:
Dr. Shah asks: Can you give a good strategy for IMGs?
This is a very loaded question with about 50 questions encapsulated into this one - so I think I know what you are asking and I'll try and outline a "good strategy" for any IMG. When we work with clients, each individual candidate is unique - geography, speciality, graduation year, family concerns, US experience, visa status, etc - so it is hard to point a whole group of people in one direction with advice, but there are some highlights:
- Do as well as you possibly can on the USMLE. I can not emphasize this enough. Some foreign schools already have credibility in certain states or in certain programs so that PDs and state licensing boards are familiar with the caliber of graduates that come out of them. Lots don't - so doing well on a standardized test makes you look good comparing apples to apples. Be prepared to do whatever it takes - multiple review courses, thousands of dollars, multiple months off for individual study. SImply put, the higher your score, the better your chances.
- Know your priorities - as an FMG, getting a US residency spot is already a hard process, for you and your family, and it is a hard choice both personally and professionally when deciding what you are going to prioritize. Ultimately you may find yourself needing to choose between practicing any type of medicine in the US vs practicing a specific specialty anywhere on earth. You will often see IM or FM residents in US programs who were Orthopedic Surgeons or Ophthalmologists in their home countries, but they choose to change specialty to practice medicine in the US. On the flip side you see US citizens who go out of the country for medical education, fall in love with Dermatology or Otolaryngology to the point that they remain in their training country to practice that passion instead of trying to get into the hyper competitive US options. Think about these options when deciding what would benefit you and your loved ones the most.
- Be flexible - the saying "beggars can't be choosers" absolutely applies here - apply to a huge number of programs, and absolutely apply to multiple specialties. Consider multiple geographic regions. If finances are a strain, you can focus your efforts, but the reality is that extra 12/16/26 dollar fee to tack on one more program is a drop in a bucket and can get your foot in the door to a six figure salary for the rest of your career - now is not the time to pinch pennies.
- Be realistic - short term - knowing where to apply and how to go about it, and long term as well. Some IMGs end up compromise too much and get stuck in patterns of multiple prelim years, malignant programs, grad school, and other endeavors to try and become more competitive for the match and can paradoxically become less competitive, and really mount up debt. Some test prep courses can be these endless loops of multiple time test takers, who can ace qbanks but not get residencies - end up a tutors, advisors, lab assistants, phlebotomists, foreign MDs are definately not guaranteed anything in the US. Know how competitive you are and focus your efforts accordingly.
- Use your connections - anyone you know - and I mean anyone, previous alumni, any friends or relatives, anyone you rotated with on AI or observership.
- Play to your strengths - whenever the opportunity arises - PS, LORs, interview, make sure you let them know you speak multiple languages, talk about your hands-on experience, paint a picture of IMGs as a group that is hungrier, harder working, more resilient, more flexible - willing and able to move countries to train. As any US students listening may not realize that different countries have regulatory bodies and medical training outside of the US can be drastically different - US students have curriculum that can be evidence based, problem based, well researched, validated tools, etc. learn from an online module, and get excited when an attending lets them throw a few simple interrupted sutures during closing - when students in Mexico for example don't have the luxury of having a note taking service, or even professors who know what is covered on Step 1, but they were first assist in transplant cases with a resident in charge - no fellow, resident, other students fighting for the case.
- Be optimistic - don't believe everything you read on SDN or valueMD or other forums. Plenty of IMGs have jobs. In fact, IMGs make up about 25% of the current physician workforce. This is a subject that hits close to home as personally, I am an IMG, and it is the reason I wrote my book and the reason I started this business was to help IMGs - I think they are a vital portion of the medical workforce and bring elements to US medicine that will continue to drive it forward. "Millennial" generation with note taking services, angry when a professor didn't tell them what question was going to be on a test, upset over anything less than perfect on an evaluation form - nauseating and not indicative of patient care. IMGs traditionally flying blind, fighting tooth and nail for any position available often taking USMLE on their own, with bootleg study review materials, fighting for any leg up, fighting to find material relevant to the USMLE vs deciding between 4-5 books to see which is best. A handful of common US student complaints are about not getting enough away rotations, or the lack of financial support or housing, or getting an evaluation from a resident that an attending signs, or even an attending you didn't really spend time with. Meanwhile IMGs may have clinical rotations in 7 different cities with a loose word-of mouth network of where to live, and shared subway cards, IM in Chicago, then OB in NYC, Psych in LA - and they are grateful for a LRO in English from ANYONE, much less the person who will give them the best letter. Long list of intangibles that IMGs deal with often that departments may or may not know - you have been through a lot, you will get through this too.
Dr. Shah asks: What is more important for IMGs - research work, or electives and observerships?
- Clinical, clinical, clinical. Research is important, but to frankly answer this question, I have to emphasize clinical patient care. You are looking to get into a program to take care of patients, so show them you can take care of patients - the more involved the better. Get an LOR out of the experience, and if possible get it at a hospital you want to train at.
Dr. Shah asks: What are the common mistakes made by IMGs when applying to residency programs?
- Prior to applying - Not doing your homework - not using connections, not looking at the specifics of visa paperwork, how to get one, which ones you need, if a program will sponsor it. State specific in some cases, program specific.
- Commonly overestimate their value - look at your scores, look at your application, you will not get ortho - there is a difference in being optimistic and being delusional - miracles may happen elsewhere, but don't bank on it in the Match.
- Commonly underestimate their value - in the current landscape, there are still not enough US grads to fill all of the available spots - your life, happiness and career are not worth too much compromise. Bad program, on probation, abusing residents, poor education, poor employment opportunities - that will be a bigger stain on your record than your foreign school - at the next level you are always judged by the most recent level - you are no longer a *** grad, you are a *** resident.
- Common mistakes during the interview I have seen - focusing too much on justifying academic performance - many foreign schools work on strictly objective, merit-based rewards - highest score gets the highest spot. I encourage all of our IMG clients to remember the social component - telling families they lost a loved one, discussing cancer diagnoses, end of life care, navigating health system beliefs.
- Nuances of the english language lost in translation - miscarriage vs abortion, obesity vs fat, spanish culture.
- Forgetting that this is a job to learn - when coaching US clients we usually work on US lifelong student changing a mindset from student to employee - need to work on projecting leadership / confidence / reliability / autonomy that go with patient care, and dampen the submissive, passive traits. IMGs I see a lot of the opposite - well established physicians that may carry respect / klout to a degree that need to change mindset to a more traditional learner. Programs don't want to but heads with someone for multiple years who is coming in and telling them how to do things or how they used to do things back home - you are there to learn from these people, learning pt care, learning communication, learning procedures - even if you have performed 200 knee replacements back home, you are interviewing to be an intern next year - wound vac changes, bowel disimpaction, perhaps someone half your age being your superior, etc - show THAT aspect of your personality.
For our last question today, Dr. Shah asks: Looking at the current scenario can an IMG with a green card get into Radiology residency?
Yes - do your homework, be flexible, be realistic, know yourself - all of the above apply. Know that they are not going to hand it to you, and you are going to have to work for it, but be optimistic. FIrst I would make sure I was a competitive applicant - are my scores well above average? Would my application as a US student be competitive? Look at "Charting outcomes in the Match" - diagnostic radiology - step 1 235, step 2 240 - Data shows while most applicants matched at 240 and above, 14 of these "independent applicants" matched with 200 or less.
If you were a client, I would polish your application - make sure your strengths come across as strengths, and any red / yellow flags are addressed. CV polished, appropriate experiences highlighted, perfect multiple PS, LORs appropriately uploaded. Etc.
Create a spreadsheet, look at every website to determine if they are "IMG friendly", or call them all - or even outsource that. When I was applying freelancing was taking off, I hired a virtual assistant call every program coordinator I was interested in and ask bluntly about cutoffs and multiple attempts, IMGs - whatever your specific situation. If you were my client, that is something we can arrange for you.
Once you have your list, polish your application - would tweaks in your PS add to your application? - geography specific or school specific - are you familiar with a professor's works, research,etc. Mention these specifics so they stand out once you clear the initial hurdles.
Then, apply to every single one you can afford.
That would then generate a handful of interview invitations, I would walk you through how to communicate with programs, how to best schedule, and we would practice radiology-specific mock interviews with explicit feedback on body language, diction and word choice, confidence, how to tell your story given different interviewer styles or different question types to make sure you are your best self to these handful of people in a handful of hours. We would help you create your rank list, and sit back and wait patiently. There are some other pre and post communication nuances we could coach you through if they arise.
As a backup plan, take that same list of programs, and apply across the board to preliminary medicine (or surgery) programs with radiology departments you want to train at - if you don't match in radiology, you will at least have a US residency spot as a foothold. I would show you how to structure your rank list to set you up to rank at any radiology program first, then fall to your top choice IM program. During that year, spend every free moment with the radiologists and let them know your interest. Radiology reading rooms - trauma call in the ED - hang out with the residents, and talk with faculty if available - let them know your interest bluntly and that you will be applying next year. To a US residency program, a year spent in US clinical medicine is better than 5 years at the best hospital in any other country, research, perfect step scores, etc. You would now be Dr. Shah, intern at *** IM program. Keep up with radiology CME websites / trending news - be able to discuss specifics of scans - really impress these people. They will be doing the interviews, can pass the word up the ladder, and the more senior resident will be the chief residents.
In addition, there are rare opportunities to jump into available spots mid-year - so we would be looking for any available spot that opens mid-year - funding is attached to resident slots, so if people leave secondary to illness or family crisis, or disciplinary action,etc. , there are opportunities to move laterally into programs.
Not foolproof, and no guarantees, but a solid plan to set you up to be that approximately 30% of the entering PGY 2 class that comes from outside of US allopathic seniors.
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