Residency Training FAQs
Following frequently asked questions (FAQs) about residency training in USA were updated recently. We have broken down the FAQs in subheadings according to different situation in one's life. Please refer to subheading most relevant to your current situation. We are grateful to M. Qasim Hasan, MD, MPH for updating this information.
In addition to the following questions. We would strongly recommend that you download "Do's and Don'ts of Residency Training." You will need Adobe Reader for this document. The "Do's and Don'ts of Residency document was prepared to provide the International Medical Graduates (IMG) with guidelines to help complete their training successfully while avoiding simple mistakes that can result in potentially negative consequences. This work comes through the combined effort of the Committee for Young Physicians (YPC) of Association of Pakistani Physicians of North America (APPNA) and The King Edward Medical College Alumni Association of North America (KEMCAANA).
Planning for ECFMG Certification / USMLE exams
Graduates of foreign medical schools commit to a multistep process costing upwards of $3000 US when they decide to pursue a residence program or fellowship in the United States. Aside from investigating schools and narrowing down specialties, candidates must obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG), the body that determines whether prospective students are equipped to enter American programs. ECFMG assesses a candidate's eligibility through a battery of tests and credentials checks, including the following:
Copies of medical school diploma
United States Medical Licensing Exams (USMLE)
Step 2 Clinical Knowledge (CK)
Step 2 Clinical Skills (CS-formerly a separate step known as CSA)
English Proficiency Test
ECFMG has the above results in its database as it is the test conducting agency, but you would be required to provide them with a copy of your medical degree and transcript with your first application for a USMLE exam. If you have not yet graduated, you would have to have the dean (principal) of your medical school complete and sign a form verifying that you are a student, will be graduating in a particular time frame and are eligible for the exam. While the requirements might sound daunting, planning well before the final year of medical school provides the candidate with the best chance of getting into the right program at the right time. Studying for exams and gathering the needed applications and certifications will make the process move more smoothly. Moreover, factoring in the price of test preparation books, CD-ROMs, the time and expense involved in travel to test centers and residency application fees will help ensure a smoother, less stressful passage
It doesn’t really matter as for as your certification is concerned. The usual wisdom though is to do basic sciences first as this knowledge help in part 2 as well. If you are really into the clinical subjects and are actively involved at the time you may reverse the order.
Immediate seniors in the path can be a good source regarding latest tips. First Aid to USMLE 1 and 2 are valuable books to have. They give you most of the tips and recommended latest books in different subjects
It is definitely very important. The key is to get the better ones available. Also while some of the students put more time in preparing by MCQs most high scoring people make a sound base by going through with review books first.
One can find that a very wide selection is available. Currently the most used MCQs series is Kaplan books. Some candidates are using MCQs from http://www.usmleworld.com previously used MCQ books include Mcgrawhill series, Appleton and Lange, and the NMS series, though these are less used now.
Every now and then there is a new review course or series of basic science books available. Usually the medical bookstores know the most popular one at the time. Still some books are time tested like Lippencott’s Biochemistry and Pharmacology. High yield series in Anatomy and Embryology. BRS in Physiology and Behavioral Sciences. Javet’s Microbiology, BRS Histology, Also Pharmacology and Anatomy in a series called "Made Ridiculously Simple" are good.
There is a vast variety available. The choices of books change frequently so this information may not be up-to-date. Currently (in 2007), most candidates opt for reading Kaplan review books. Blue print series and High yield series also have all the subjects and are recommended. Some high scoring doctors have prepared their Internal Medicine from "Med Study" which is used to prepare the board exam.
CSA is now USMLE step 2 CS. You will not obtain ECFMG certification without passing step 2 CS. Bear in mind that most programs are highly competitive. If you have not passed all exams before year-end, you are asking the program director to take a chance that you will indeed pass the missing exams before the residency program commences. As an IMG, your chances of securing residency interviews decrease greatly if you have not completed ECFMG certification by the time you apply.
Go to the web site http://www.fsmb.org Unlike step 1 and 2, step 3 is a state exam. When you apply for step 3 you have to specify which state you will be applying for a license to practice. In most states, you do not have to apply for a license to apply for step 3, though there are exceptions. You application is processed according to the eligibility criteria of the state you select. Except for the following states, all states require residency experience prior to step 3: Arkansas, California, Connecticut, Delaware, Louisiana, Maryland, Nebraska, New York, Oklahoma, South Carolina, South Dakota, Texas, Utah, Virginia, West Virginia. Keep in mind that the exam content is standard, and you may appear at any center for any state exam (e.g. you may appear in New York for step 3 for Texas). The only difference is that your eligibility for appearing in step 3 will be determined according to the rules of the state board you select. Most IMGs select Connecticut as the sponsoring state for step 3, though that is more because of convention than any benefit in the exam. Step 3 exams are not conducted in Pakistan.
In good old days, most people used to take this exam during or after the residency. Now with the increasing number of candidates, some programs have made it almost a criterion for interview. Still other program insists that you pass it within the first year. So now the best time is just after you take part 2. For one, your knowledge is fresh and also you are probably going for interviews and might come across the technical questions. If you get busy in interview season then the next best is after match and before you start your residency. Passing the step 3 is a requirement for obtaining an H-1 visa. If you are looking to start your residency on an H-1 visa, you have to pass step 3 before applying for a visa. It is preferable to pass the exam before your residency interview as many programs will not consider your request for an H-1 visa if you have not passed step 3 at the time of the request.
Currently the most recommended book is Crush step 3, accompanied by MCQs from http://www.usmleworld.com "A review of Family Practice" by Swanson was frequently read in the past and may still be an acceptable choice. Basically the syllabus is similar to USMLE 2, with more emphasis on management and ethics. So whichever books you used for part 2 are your best bet. Some examinees have studied Med study for Internal medicine, other have used Washington Manual. Some review and MCQs books are also available for part 3. It is extremely important that you practice the software sent to you by FSMB for the simulated cases on the computer. It is different than real life practice of medicine and small mistakes made due to unfamiliarity with the software may cost you the exam.
Applying for Residency
Yes, San Francisco Match is for Dermatology, Neurology, Neurosurgery, Ophthalmology, Otolaryngology, and Urology. All other fields come under General Match which is NRMP. SF match takes place in end January and NRMP match in mid March.
It starts as early as May, especially in case of San Francisco Match which runs 1-2 months ahead of the general match. Most residencies that IMGs apply for are conducted through the ERAS ( http://www.aamc.org/students/eras/start.htm ) and NRMP ( http://www.nrmp.org ). You have to register for both. ERAS allows you to apply for residency whereas the match is conducted through NRMP.
According to the ERAS, the deadlines for the residency starting in 2008 are:
- Mid-June 2007 ERAS 2008 Applicant Manuals will be available for PDF download by chapters or in its entirety on our Web site.
- Late June 2007 Schools may begin to generate and distribute MyERAS tokens to applicants.
- July 1, 2007 MyERAS Web site opens to applicants to begin working on their applications.
- July 15, 2007 Osteopathic applicants may begin selecting and applying to Osteopathic Internship programs ONLY.
- Osteopathic training programs can begin contacting the ERAS Post Office to download application files.
- September 1, 2007 Applicants may begin applying to ACGME accredited programs
- September 1, 2007 ACGME accredited programs may begin contacting the ERAS Post Office to download application files.
- November 1, 2007 MSPEs are released.
- December 2007 Military Match
- January 2008 Urology Match
- February 2008 Osteopathic Match
- March 2008 NRMP Match results will be available.
- May 31, 2008 ERAS Post Office will close to prepare for the 2009 season.
If you have got good scores and would like to accept a pre match position then earlier the better, which is early November. If you are a marginal candidate or would like to explore all your chances then you should schedule in such an order that interview of more lucrative positions for you, should come in the middle of your schedule, after you are done away with your nervous and novice attitude and before you have already "burnt out". If economics is the real constraint then you can schedule on a regional basis but still within a big area like New York, New Jersey and Pennsylvania you can follow the 1st advice. If you are looking for "pre-match" positions, then you should interview in the early part of the season. As the season progresses and programs fill up slots with "pre-match" offers, it gets progressively difficult to obtain an offer.
"First Aid for the Match" is a good book which takes you from application process through interview season up till the match and post match. Besides, there are few Internet sites under residency key word which are useful. Seniors from your medical school are a good resource, especially those who have just started or are still in a residency program. Contrary to what most IMGs think, people who finished residency a few years ago usually are "out" of the system and have less information than those still in residencies. Obviously, there are exceptions to this rule.
As foreign medical graduates most of us have this dilemma because most of the time we can not go into the field of our choice for one reason or another and are left confused for the left over choices. One good site for the details of specialty is the site of American academy of that respective field. http://www.aamc.org also has link to some of theses sites. Then are the seniors in that field practicing and/or doing residency who can give you first hand info regarding pros and cons. If you have time and get a chance the best way is to do Observer ship/ Externship in the field you are thinking to choose.
In Pre ERAS era, IMGs use to send paper application in hundreds to almost all programs. With the introduction of electronic applications system, however it can prove really costly. There is an old rule of third. One third of your application should go to your "dream programs" no matter what the chances are. One third to "desirable programs" and last one third to "acceptable programs". This rule may still stand true for those with scores in the upper 90s in both steps, but if your scores are in the 80s, you should concentrate on programs that are willing to accept residents with your score.
One can only make a broad generalization, keeping in mind that quite a few exceptions happen every now and then. Most programs have criteria for interview calls so they will gladly tell you over the phone or through e-mail or on their website. This may save a lot of time, money and energy for candidates as well as for programs. When you contact a program, ask for the residency coordinator. Sometimes they say that they do not have criteria or will give you a general idea but you should specifically ask them about their criteria about scores, number of attempts, years since graduation, visa requirement and US clinical experience.
The most important criterion for IMGs is the USMLE scores. As residencies have become more and more competitive, most programs have made 80% and above on both USMLE steps a cut off point. Others have gone up to 85%. Most Internal Medicine programs in New York are now asking for 80 and above in "1st attempt". Still others are asking that candidate should not be out of medical school for more than 5 or mostly 10 years. Having green card, US clinical experience, some research back ground and good US recommendation letters, all can lower or elevate your Resume only 1-2 points (on USMLE score scale).
Generally rating is according to trend of US graduates seeking these disciplines and thus making these ones easier or harder to get for IMGs. Top 4 most difficult to get are Dermatology, Ophthalmology, Orthopedic Surgery and Neurosurgery. Next are OBGYN, ENT, Radiology and General Surgery (though with good scores, IMGs still have a good chance of landing a surgery position). The bottom and mostly open for IMGs are Internal Medicine, Neurology, Family Practice, Psychiatry, and Pediatrics. Anesthesiology and Pathology used to be fairly open but with increased interest shown by US graduates, they are now increasingly competitive. For Psychiatry and Pathology Programs Directors, the real criterion is the interest of the candidate in the field which should be evident from his Resume and in the interview.
It depends on your priorities. Is geography your priority for one reason or another? If you are interested in Internal Medicine and want to pursue a competitive subspecialty then a University program or programs with fellowships in those subspecialty will certainly help. On the other hand if you want to become a primary care physician then even a community hospital can provide you an adequate training. Also if you are interested in academics and research then go for university programs. Within a certain program things to look for are, stability of the program, conference/ rounds, faculty teaching, work environment including call schedules and ancillary support. Last and least, you might want to look at the salary, health benefit and vacations. These factors are important for considering rankings. If you are considering pre-match offers, your available options are the most important consideration. Do you have excellent scores (upper 90s) and would do well in the match if you refuse this offer? Do you have lower scores with only one offer, in which case you should consider accepting it or do you have multiple offers, in which case you can pick the best of the offers?
Most programs prefer US clinical references but if it has to be from out side it better be from professors or head of departments of Medical Schools. The best US reference are also from faculty especially chairman or senior professor. A Strong and lengthy letter is better. The letter must contain details about your clinical skills, knowledge, interaction with your colleagues and other staff, and your interaction with your patients.
These are actually your personality plus career profile and allow you to say things you left out in your application and Resume. It basically pertains to who you are, where you were, why you are coming into medical profession and this specialty, where you are now, what you want to become and what you can contribute to the program. The personal statement usually consists of 4-6 small paragraphs which should fit in a page. Also you can mention your other interest to highlight the versatility of your personality. If you have gaps in your resume this is a good opportunity to explain them. If you are changing specialty you better support it with a logical explanation. Some helpful hints are that revise and proofread it carefully, show it to some one else with good English, a professional editor can be a good investment. Don'ts in the statement are emotional stories and clichés, self congratulatory and self-centered statements, inconsistencies, long statements, misspelling and poor grammar and digressions.
You can travel in the US by the following methods:
Greyhound: This is a bus service that connects almost all places you would need to go. Purchasing a "Discovery Pass" allows you unlimited travel for the duration of the pass with a few conditions. These passes may be purchased with international credit cards (e.g. those credit cards issued in Pakistan).
Air Travel: Better rates are available for purchases made 14 days or greater in advance of the flight. You usually get even better rates by bidding on http://www.priceline.com, though you cannot select flights or the exact time if you bid (you specify the day and may specify approximate time e.g. morning, evening). Other websites like http://www.hotwire.com, http://www.sidestep.com etc. also offer discounted tickets. Keep looking on bargain websites for special deals. Discount carriers like Southwest Airlines (http://www.southwest.com), Jetblue (http://www.jetblue.com) and Spirit Airlines (http://www.spiritair.com) besides others do not participate in discount websites. It is a good idea to frequently check their websites for special offers/deals.
Amtrak: Traveling by train may be interesting, but usually is no better than other modes. It is usually more expensive than Greyhound (though usually faster) and may have connections. If you find look for deals for air tickets, you may find one for around the same price as an Amtrak ticket. Though not common, there are occasions where Amtrak may be the most suitable mode of communication.
Rental Car: Usually not an option for IMGs who have not lived in Europe or North America. Issues with license, insurance and getting lost on the way may make it a risky choice. If you have the time and are willing to drive the distance, this may be the most convenient mode of travel. Keeping a rental car for an extended duration (a month or more) is usually an expensive option. This ranks down besides Amtrak as one of the less desirable modes of travel for IMGs while interviewing for a residency.
Arrival at destination: Plan to arrive latest by afternoon of the day prior to your interview. It is advisable to visit the hospital that evening to give you an idea of commuting time needed. In most places, add 50% of the commute time (or 30 minutes, whichever is greater) to account for rush hour in the morning. It is better to arrive early and wait than to be late for an interview. Besides, even if you make it on time, the stress of the risk of being late may unnerve you and worsen your performance in the interview. If it is unavoidable and you are going to be late, it is best to call ahead and let the residency coordinator know. If he/she is not contactable, leave a message on their answering machine.
Accommodation: Budget hotel chains like Motel 6, Days Inn, Budget Inn, Super 8, Howard Johnson Express, Quality Inn and Ramada Inn besides others are more affordable. Best rates are usually obtained by booking in advance on the internet. Use sites like Yahoo! (http://travel.yahoo.com), Expedia (http://www.expedia.com), Hotels.com (http://www.hotels.com) or similar websites. Arriving at the hotel counter with no reservation is usually the most expensive option. When you book in advance online, you are usually charged the hotel stay. In case you cancel, it is common to charge one nights stay as cancellation fee.
Dress smartly and conservatively. For men a dark colored suit with a good tie is the safe bet. These days’ ties are worn in different shades of the color of the shirt or suit. Avoid wearing a pure white shirt-a trademark of IMGs. Ladies can choose between long skirt or trousers with shirt and jacket. Shades of blue and grey are more appropriate. You will look fresh, comfortable and confident if you are prepared. So get a good night sleep before the interview and be well fed and well rested.
There are two types of program and two types of preparations. One type of programs is community hospitals where IMGs have most chance. There you should expect straight forward clinical questions which can be either in the form of case scenario and/or simple plain viva voce. These types of questions are more common in community programs in the northeast, though you may also face them in other regions. Your preparation is your clinical knowledge and a review of the Washington Manual. The other type is the university programs which will hardly ask you a question from your professional specialty. You will get the most courteous and hospitable response and it’s more of a, "getting to know you better" exercise. The interview session usually start with, "tell me about your self" and go on to questions like, describe your strengths and weaknesses, and why are you interested in this specialty and in this particular program. It ends with a chance for you to ask questions about the program. Your preparation is a good rehearsal of your personal statement and as much knowledge as you can gather about the specialty and that program. Your resources are program’s website, brochures and NRMP web site for residency programs. The key is your communication skill, pleasant attitude and confidence.
Definitely. It is very important that you write a letter to each program, thanking them for invitation, their hospitality and time. Although it will be mostly generic but include some personal line which could distinguish you from other candidates, usually in the form of mentioning something from your interview conversation with them. In the end show your interest in the program and give all your contacts again offering your availability for any further queries. All these letters will be placed in your personal file so if you are writing to two or three different interviewers make sure the letters are sufficiently unique and give an impression to the program that you considered them worthy of the time and effort to write individual letters. If you receive a letter showing interest in you, promptly respond by a reply letter, again thanking them and showing your keen interest in the program. Not writing a thank you letter is one way of ensuring that the program does not offer you a position or rank you highly in the match!
For most desperate IMGs, the whole exercise of interview day program tours and introductions seem futile exercise as they are anxious to get into any program ASAP. But if you have got more than 10 interviews it become mandatory to keep notes of pertinent and relevant things as you go from program to program because you are likely to forget and mix them. These include location, reputation of the program, your "feel" about the program, scut work, the condition and general mood and moral of the present residents, benefit, salary, program director and subspecialties in your disciplines, to name the few. You should keep record of all these minor/ major points and tabulate them to make a comparison. If you need an answer to a question afterward, do not hesitate to contact a resident or program director in that program. Generally, you should rank programs in the order that you want to join them. Don’t worry about how programs will rank you. It is difficult to guess how a program ranked you. If you worry about program rankings, you may miss a chance to match with a program better than what you thought you would get.
Unfortunately it can happen to any one. The preparation should start before the match. Buy or have a fax machine at home. You can also call a friend for help in those couple of crucial days. As soon as you know the unfilled position, download them and start phoning. Start with the programs you already interviewed, and then phone other programs of your specialty and the city and region of your location. There is no point now days to go in person. Most programs will tell you to fax you application. You can also use ERAS application service if program agrees. If you get a disappointing response in your own specialty, expand your search to include the other acceptable specialties and preliminary positions.
IMG Friendly Hospital List ALABAMA: Anniston, Alabama (GC) CALIFORNIA: Alameda County Hospital, Highland, CA Kern Medical Center, CA St Mary's Hospital, San Francisco, CA Most University of California, San Francisco, CA Most USC, Los Angeles, CA CONNECTICUT:: Bridgeport Hospital, Bridgeport, CT (H1,J1,GC) Danbury Hospital, Danbury, CT (H1,J1,GC) Hospital of St Raphael, CT (H1,J1,GC) Norwalk Hospital, Norwalk, CT (H1,J1,GC) St Vincent's Medical Center, Bridgeport, CT (H1,J1,GC) U of Connecticut, Farmington, CT (J1,GC) DISTRICT OF COLUMBIA (Washington, DC): District of Columbia General Hospital, Washington, DC Howard University Hospital, Washington, DC (H1,J1,GC) Providence Hospital, Washington, DC (H1,J1,GC) ILLINOISE: Cook County Hospital, Chicago, IL (H1,J1,GC) FUHS/Chicago Medical School, Chicago, IL Illinois Masonic Med Ctr, Chicago, IL Jackson Park Hospital, Chicago, IL(GC) Mercy Hospital, Chicago, IL (J1,GC) Ravenswood Hospital, Chicago, IL (J1,GC) Rush Copley Medical Center, Aurora, IL (J1,GC) Rush Presbyterian Hospital, Chicago, IL (J1,GC) Rush Westlake, Melrose Park, IL (J1,GC) St Francis hospital, Evanston, IL (H1,J1,GC) Univ of Illinois at Urbana Champaign, IL (GC) Univ of Illinois at Chicago, Chicago, IL (J1,GC) Univ of Illinois/Michael Reese Hospital, Chicago, IL (J1,GC) Univ of Illinois at Peoria, IL MARYLAND: Franklin Square Hospital, Baltimore, MD Good Samaritan Hospital, Baltimore, MD Harbor Hospital,Baltimore, MD (H1,J1,GC) Maryland General Hospital, Baltimore, MD (H1,J1,GC) Prince George's Hospital, Cheverly, MD (GC) St Agnes Health Care, Baltimore, MD (J1,GC) MICHIGAN: Henry Ford Hospital, Detroit, MI (J1,GC) Hurley Med Ctr/MSU , Flint, MI (J1,GC) McLaren Regional Medical center, Flint, MI Midmichigan Medical center, Midland, MI Providence Hospital, MI (J1,GC) Saginaw Cooperative Hospitals, Saginaw, MI St Joseph's Mercy Hospital, Pontiac, MI (H1,J1,GC) St John Hospital, Detroit, MI (J1,GC) Wayne State University, Detroit, MI (J1,GC) William Beaumont Hospital, Royal Oak, MI (J1) MISSOURI: St Mary's Hospital, St. Louis, MO St Lukes Hospital, St. Louis, MO NEW JERSEY: Atlantic City Med Center, Atlantic City, NJ (J1,GC) Jersey Shore Med Ctr, Neptune, NJ (GC) Monmouth Med Ctr., Long Branch, NJ (J1,GC) Mountainside Hospital, Montclair, NJ Mount Sinai, Englewood, NJ Mount Sinai, Jersey city, NJ Muhlenberg Regional Med Ctr. , Plainfield, NJ (J1,GC) Overlook Hospital, Summit, NJ (GC) Raritan Bay Med Ctr., Perth Amboy, NJ St Barnabas Medical Center, Livingston, NJ (GC) St Joseph's Medical Center, Paterson, NJ (GC) St Francis Med Ctr, Trenton, NJ UMDNJ, Pistacaway, NJ UMDNJ, Newark, NJ (GC) UMDNJ, Camden, NJ (J1,GC) UMDNJ, New Brunswick, NJ (J1,GC) NEW YORK: Albert Einstein/ Jacobi Med Ctr., Bronx, NY (H1,J1,GC) Bronx Lebanon Hospital, Bronx, NY Brooklyn Hospital, Brooklyn, NY (GC) Brookdale University Hospital,Brooklyn, NY Catholic Med Ctr., Jamaica, NY (GC) Lincoln Medical and Mental Health Center, Bronx, NY Maimonides Hospital, Brooklyn, NY (H1,J1,GC) New York Hospital and Med Ctr of Queens/Cornell U., Flushing, NY New York Methodist Hospital/ Wyckoff Heights, Brooklyn, NY (H1,J1,GC) NYMedical college (Metropolitan) Hospital, NY (J1,GC) NYMedical College (Sound Shore) Hospital, New Rochelle, NY NYU VA Med Ctr., NY New York Flushing Hospital, Flushing, NY St Barnabas Hospital, Bronx, NY (GC, J1, H1) St Lukes Hospital, New York, NY (J1,GC) St Joseph's Hospital, NY St John's Episcopal South Shore Hospital, Fair Rockaway, NY (H1,J1,GC SUNY at Brooklyn, NY (H1,J1,GC) SUNY at Buffalo, Buffalo, NY (H1,J1,GC) SUNY at Syracuse, NY (J1,GC) Winthrop University Hospital, Mineola, NY (J1,GC) Woodhull Med Ctr., Brooklyn, NY (J1,GC) NEVADA: U of Nevada, Reno, NV Univ of Nevada, Las Vegas, NV OHIO: Fairview Hospital, Cleveland, OH (J1,GC) Good Samaritan Hospital, Cincinnati, OH Jewish Hospital of Cincinnati, Cincinnati, OH Meridia Huron Hospital, East Cleveland, OH (H1,J1,GC) Mount Sinai of Cleveland, OH PENNSYLVANIA: Abington Memorial Hospital, Abington, PA (H1,J1,GC) Allegheny General Hospital, Pittsburgh, PA (J1,GC) Easton Hospital, Easton, PA Frankford Hospital,Philadelphia PA (H1,J1,GC) Guthrie Healthcare, Sayre, PA Lehigh Valley Hospital, Allentown, PA Mercy Hospital, Pittsburgh, PA MCP Hahnemann University Hospital, Philadelphia, PA Pinnacle Health/ Polyclinic Hospital, Harrisburg, PA UPMC Health System/ Shadyside Hospital, PA RHODE ISLAND: Miriam Hospital of Brown University, Providence, RI (J1,GC) Roger Williams Hospital, Providence, RI TEXAS: Texas Tech University, Amarillo,TX Texas Tech University, Odessa, TX Texas Tech University, El Paso, TX (J1,GC) VIRGINIA: U of Virginia, Roanoke Salem, VA (J1,GC) WEST VIRGINIA: West Virginia University Hospital, WV (J1,GC) WISCONSIN: Sinai Samaritan Medical Center, Milwaukee, WI
After Obtaining Residency
If you passed step 3 and pre-matched or matched with a program that is offering you an H-1 visa, congratulations!! The pathway for H-1 sponsorship should have been agreed upon between you and the program prior to your accepting the pre-match or matching (i.e. who will pay for the attorney etc.). Most universities have a separate department of international affairs that will do all the paperwork for your visa. If you are going to such a program, find out who your advisor is (the employee at international affairs who will process and coordinate your visa) and immediately contact them to initiate your paperwork. Most community programs do not have such departments. If that is the case, either you or the program will have to pay for an immigration attorney to process your visa. Hopefully, you had discussed this with the program previously and already know who will bear the financial burden. In most cases, programs agree to pay for the expenses because they want to work with an attorney they have previously worked and are comfortable working with. Be sure to get in touch with the immigration attorney and your program as soon as you find out which program you are going to as the visa process may take a few months.
If you accepted a pre-match position or matched with a program that is offering you a J-1 visa, it is important that you contact the program ASAP (as soon as possible) after identifying the program. You will need a copy of your signed contract to apply for and obtain an NOC (No objection Certificate) from the Ministry of Health (a pre-requisite for applying for J-1 visa). Some programs initially issue offer/confirmation letters (offering a pre-match or informing you of the match and requiring the letter to be signed and returned to confirm your intent to join the program). Copies of such letters are usually accepted by the Ministry of Health for the purpose of issuing the NOC. After obtaining the NOC, you will have to complete the J-1 sponsorship form available from the ECFMG website (http://www.ecfmg.org/evsp/index.html) and mail it to your program. The program will need to complete their section on the form and send it to ECFMG for processing. If you want to shorten the time frame, you may establish a Federal Express courier account (www.fedex.com) and request the program and ECFMG to use that account. This will reduce delays in mail. An even better way to decrease the processing time is to pay the fee online in your ECFMG OASIS account. If you elect to do this, the program may fax the application. Both the electronic payment and faxing the application reduce processing time. For candidates wishing to have the DS 2019 (sponsorship document) sent by courier, ECFMG requires a pre-paid air bill. Discuss this option with your program if you wish to do so.
OASIS is the On-line Applicant Status and Information System run by ECFMG ( https://secure2.ecfmg.org/emain.asp?app=oasis ). Once you register on the website, you can check the status of your USMLE step 1, 2 (CK and CS) and your ECFMG certificate as well as the status of your DS 2019 (J-1 sponsorship). You can also make credit card or electronic check payments to ECFMG via the website, which shortens processing time for your application.
This is a good time to catch up on refreshing your knowledge. Most candidates will be entering Internal Medicine or Family Practice. Revise preventive and disease guidelines. Revise important topics in your specialty (Internal Medicine: Congestive Heart Failure, Diabetes Mellitus, Chest Pain / Acute Coronary Syndrome / Pulmonary Embolism, Deep Venous Thrombosis, Gastro-esophageal reflux disease, Abdominal Pain, Stroke. Family Practice should concentrate more on outpatient issues). You may also practice writing admission orders and History and Physical Examination. Most importantly, if you have not already passed step 3 (Step 3 is required for H-1 visa), start studying for it. The sooner you can appear you have better chances for passing. Candidates think they will perform better after they have spent some time in the US medical system, which is not necessarily true. Yes, it may help, but Step 3 is a pass/fail exam. Scores really do not count for much. Once you start residency, you may find it difficult to get dedicated time for step 3. A number of programs require passing step 3 by the middle of your second year to be eligible for being promoted as a third year resident, which puts added stress on you. Step 3 is a requirement for obtaining a medical license in the US. If you are applying for a J-1 waiver, the waiver application (submitted in the beginning of your third year) requires a copy of your medical license application (or a copy of the medical license if you have already obtained one). If you are on an H-1 visa, you would still need to pass step 3 to apply for a license. The time line for license approval varies from state to state, but usually is between 3-12 months. So you have to apply for a license in the beginning or middle of your third year to start working when you graduate.
Get ready for the ride of your life! Things will be hectic, tiring and sometimes worrying, but always exciting. You should pack clothes according to the weather in the city/state you will be residing in. It is advisable to obtain an international drivers license, though not all states in the US accept it. Try to reach your destination city a couple of weeks prior to joining. Recently, due to visa issues, this has not always been possible. If you are delayed due to a visa, try to reach your destination as soon as possible and keep in contact with your program. Give yourself a couple of days to adjust from the jetlag and get things in order before you join your program. Residency is hectic, especially in the first year (internship). You will find that it is not easy to complete other tasks in the beginning of your residency, as you will be working hard to adjust to the new system of medicine, medical records and other activities. The first thing you should do once you reach your destination is to contact the Social Security Administration (www.ssa.gov) and complete the form for obtaining a social security number. You will not be able to get paid unless you have a social security number. If you have friends or relatives in the city, contact them before arriving to make sure that you have someone to receive you at the airport and a place to live until you can find your own apartment. If not, search the web for different rental websites (www.rent.com; www.apartments.com; www.apartmentguide.com; www.rentals.com besides others) and contact them with your requirements. This way, they will have a list of apartments for you to see when you arrive in the US. There is no fixed rule as to what to look for in an apartment. Every person has their own preference and requirement. In general, living close to the hospital will cut down on commute time, giving you more time to relax and sleep when you are post-call, though a number of residents are able to manage with the commute. If you have a family, security is something to consider and you may have to compromise on the distance from the hospital to get a better/safer neighborhood. If you have children who will be going to school (children start elementary school at the age of 5 yrs), it may be wise to also consider the rating of the school district for the area where you are renting the apartment. Once you find the apartment, do not attempt to furnish it immediately. Take your time to settle down and understand the flow of money (how much you get paid, what your expenses are, etc.). It may take a few months, but it is better than spending too much and ending up in debt at the beginning. Begin by purchasing a bed (which is expensive) or mattress and a couple of chairs). Computers are almost a necessity so you may have to purchase one sooner rather than later. It is inconvenient to rely solely on computers at work. Most workplaces also limit the websites you can visit from the network. If you shop around, you should be able to find a good deal for a decent desktop, monitor and printer for around $400-$500. A car is an expensive but necessary purchase. Except for a handful of cities (e.g. Los Angeles, Manhattan-New York) it is very difficult to survive without a car. If you did not have a social security number before, you do not have an established credit history. This means that the lender financing your car will charge higher interest. Generally, it is better to buy a used car in the beginning as they are more affordable.
Be proactive. Show the program that not only are you willing you learn, but also seek out knowledge. Chances are the hospital system will be new for you. Learn the ins and outs of the system. How do you access old records of the patient? What about previous labs, radiology images? Always find out the patient’s baseline (labs, radiology images) so you can better interpret the results. You may have worked in Pakistan and may have more hands-on experience than other interns (first year residents) working with you. Do not brag about your exploits. It is best to learn how things are done here. Medical practice is significantly different in the US and what you have learnt in Pakistan may not be considered good practice here. Social skills are extremely important. In some cases, they may actually be more important than your performance. Work on them. The social set up here is very different as compared to Pakistan. Students/Residents are not spoon-fed. You are supposed to access resources to study/read yourself. When you admit a patient, you are expected to read up on the topic and manage accordingly. You are expected to pick up responsibility of the patient (own the patient) which increases incrementally. By your third year, most programs would like to see you fairly independent in patient management. If they keep finding your patient management lacking, that reflects poorly on you. If you have been delayed in joining your program due to visa issues, you will have to work twice as heard. You are at a disadvantage because you did not receive orientation and are being judged against other interns who got a head start on you. Use your co-interns, senior residents and faculty members as resources to catch up.
For the importance and timing of Step 3, please refer to the question "I am waiting for my visa. Anything I should do in the meantime?"
If you are on a J-1 visa, you need to start applying for jobs in the second half of your second year (March/April). This will give you time to get your CV out, schedule interviews between different rotations and consider the job offers you receive. Most J-1 waiver applications are based on the Conrad program which has been updated and allows each state to sponsor 30 J-1 waivers annually (previously state 20 program). The government/immigration year starts October 1st, so to start working in the July after your graduation, you should apply for a waiver in the preceding October (first half of your third year). Wait too long and the state may use all 30 seats, leaving you unable to join the job you wanted in that state. For residents on J-1 and H-1 visa, once you have accepted a job offer, contact the state’s medical board and find out the requirements for licensing in that state. Make sure you are eligible. If not, complete the deficiencies to prevent any delays in your license.
A lot of IMGs are looking for research positions these days. Following is very useful advice from a Pakistani physician research scientist. This is a very popular misconception in Pakistan that with some research experience you can definitely find a place in a good residency program, especially a surgical program. This might be true in some cases but I have following problems first with this particular application and then with this approach in general:
1) First of all, no program will offer a "paid" research position to a fresh foreign medical graduate without any research experience. Most of the programs with some contacts may offer a voluntary (without pay) J1 position. If you get a J1 research and get a spot in a residency program, ECFMG will not allow the conversion of J1 research to J1 for residency. You will have to first get a waiver of 2 yr home country rule and then find a residency position. Even if you manage to convert from research to clinical J1, you will be subject to two 2 year home rule requirements.
2) Applicants who have not taken USMLE yet and want to prepare for it while doing research don’t understand that research is a full time job and sometimes requires more than typical 8 hrs in the lab. It is extremely difficult to concentrate on two things and achieve a score good enough to get into a residency program.
3) This applicant wants to commit for two years which is a positive but it is my experience and also of my colleagues in academic research that these kind of applicants are most unreliable and would not honor their commitment to the program. As soon as they find a position in "any" residency program they will run away, which I believe is in best interest for the candidate but leaves the research program in jeopardy.
4) Not all mentors of research programs have enough leverage to help their fellow find a spot in any residency program. Therefore, it is absolutely mandatory for the person who wishes to take this route to find a position in a well reputed lab and with a well recognized Principal Investigator (PI).
5) It is also very important to find a clinical research position because the time you spend in basic research is the time you are away from clinics and this will serve as a red flag on the residency application.
So, for any applicant in this situation, I have a few suggestions: Please don’t come to US without passing your USMLE exams. Even if you are having difficulty passing your exams at home don’t be discouraged, you will find it much easier to pass this exam and score high with a family support system around you. Unless you have substantial funding, please don’t take a voluntary research position. Don’t think that you will be able to do odd jobs to support yourself. You will be miserable. Try to get some research experience in Pakistan, especially try to learn some basic techniques like PCR, Cell culture, Flow cytometry, if you are interested in basic research. Get yourself familiar with data acquisition and statistical analyses software, if you want to pursue clinical research. Identify academic researchers who are either program directors or chairman/chief of their departments/sections. Learn about their research and find similarities/ interests with your research experience and highlight these points in your cover letter to them. Last but not the least; please be truthful about your ambitions. Your mentor will only be able to help you if he/she trusts you. Almost every one you ask for a recommendation letter will write one for you but trust me; the addressee will recognize a difference between a true supporting letter and a generic one.
Visitor Exchange Visa (J visa) is one of the few visas where the dependant visa holder is allowed to work. Dependants of a J visa holder have a J2 visa status. They are allowed by law to apply to the immigration service (USCIS) for work authorization. Once approved, they are issued an EAD (Employment Authorization Document) which is unconditional. This EAD allows the J2 holder to undertake any kind of work and is valid until the expiration of the primary (J1) visa holder’s DS 2019 expiry date (DS 2019 is the sponsorship document on which the J visa is based). Thus, the EAD has to be renewed annually, or whatever duration the primary visa holder needs their DS 2019 renewed (this expiry date is listed on the EAD itself). The J2 is NOT allowed to work without the EAD. The application for employment authorization is known as I-765 and can be found at http://www.uscis.gov/files/form/I-765.pdf Under NO circumstances should a J2 visa holder work without obtaining an EAD.