Residency Program Requirements
1. Qualifying for a Residency Program
Once you receive a visa, you are eligible to apply to enter a residency program in the U.S. However, it is strongly recommended that IMGs participate in observership rotations in a clinical setting before applying to residency programs. Observerships provide IMGs with invaluable knowledge of U.S. medical clinical practice settings and with U.S. physicians who can serve as references.
The Graduate Medical Education Directory, known as the "Green Book," provides information on over 9,000 ACGME accredited residency programs in the U.S. and is available for purchase from the AMA Store. More detailed information on residency programs is available in the AMA Fellowship and Residency Electronic Interactive Database Access System (FREIDA) Online. FREIDA is an Internet database with information on all U.S. residency programs. It is available online. Both the Green Book and FREIDA are good starting points for IMGs beginning the application process to residency programs.
2. Choosing Residency Programs
There are four different tracks within an internal medicine residency program: transitional, preliminary, categorical and primary care.
- Residents in one-year transitional programs rotate through different hospital departments every couple of months. While a transitional program counts as a year of training, it may not provide enough credits to move into the second year of residency training.
- Preliminary programs are also one-year programs for those wishing to specialize who need a year of internal medicine training.
- Categorical programs are three-year programs that may allow you to train up to board eligibility if your performance is satisfactory. Categorical programs are seen as the more traditional program and are mainly hospital-based.
- Primary care programs provide increased emphasis on ambulatory care experience in the community and are becoming more prevalent. Those who are sure that they will be working as a generalist are advised to apply to a primary care program. Those who wish to fully train in internal medicine and then have the opportunity to train in a specialty should apply for a categorical position. While it is preferable to be in a categorical or primary care program, training in a transitional or preliminary program is better than being in no program at all. It is highly advisable to choose the program that best suits your needs and goals.
3. The Match - Obtaining a Residency
Applicants must register with the National Resident Matching Program (NRMP), www.nrmp.org known as the Match, which computer matches applicants and hospital residency programs according to the ranked preference lists each submits. "Beginning with the 2004 Match, all sponsoring institutions participating in the NRMP Main Match must register and attempt to fill all their positions in the Match except for those specialties or programs participating in other matching program." (source: NRMP February 2003)
Applicant registration begins in mid-August. For the 2007 Match Schedule, December 1, 2006 is the applicant registration deadline. Several primary care and medical specialty associations offer match programs or can provide more information regarding residency positions in their specific areas.
Certain residency programs require applicants to apply through the Electronic Residency Application Service (ERAS), which is administered by the ECFMG for IMGs. Each year approximately 33,000 applicants compete for about 24,000 available residency slots. The NRMP Web site has an "Applicant User Guide" which contains specific information for IMG's. Applicants can refer to the user guide at http://www.nrmp.org/. Applicants apply to the programs that interest them and must submit all application materials and register with the Match by December 1, 2006.
Generally, application materials consist of a curriculum vitae, a copy of the universal residency application form, a cover letter addressed to each residency program director, evidence of graduation from medical school and letters of recommendation from U.S. physicians along with a one-page personal statement detailing the unique qualifications of the applicant.
While U.S. medical graduates apply to 5-10 programs, IMGs should submit applications to a minimum of 25 programs to have the best chance of being matched to a residency program. The more applications you send out, the better your chances of receiving an interview and being accepted to a program. Applications should be sent in as early as possible, preferably September or mid-October at the latest. Upon review of the applications, residency program directors invite those applicants in whom they are interested to interview. Approximately 14% of applicants are granted an interview and only 8% of the entire applicant pool will be hired by any given hospital. Therefore, it is imperative that applicants make themselves stand out in their applications. Once invited to interview, an applicant needs to prepare in order to make the best possible impression. The interview is a critical part of the residency application process.
The Match Schedule - In mid-January, after completion of the interview process, both applicants and residency programs submit rank order lists (ROLs), which list their respective choices in order of preference, to the NRMP. Applicants may submit a list of up to 15 programs, with the option of adding more for an additional fee. Generally, it is not necessary to rank more than 15 programs unless you are applying to a competitive specialty. Although, the more programs you rank, the better your chances of being matched.
There are several guidelines to consider when compiling your ROL
Never rank a program that you applied to that has not offered you an interview since a program that has not interviewed you will not rank you. It is important to seriously consider the programs you put on your ROL. You will match with the highest spot on your ROL that has accepted you and this is considered a contract. By participating in the Match, both parties are bound by the outcome.
Do not put a program on your ROL that you would never attend. If you are accepted, you must go. The only exception is if an applicant does not meet the prerequisites of an institution, such as visa requirements that are not met after an applicant is matched to a program.
When compiling your ROL, make sure that you use current program information, such as codes, and that your list is received by the deadline. You may change your ROL as often as you like after originally submitting it. When doing this, it is imperative to date each list since the ROL with the most recent date will be used in the matching process.
Based on the preferences of both the applicants and the programs, the NRMP matches each applicant to a program and the results are announced on the middle Wednesday of each March on the NRMP website. On March 12, 2007 matched and unmatched information on applicants will be posted to the NRMP Web site at 12:00 noon eastern time. On March 13, 2007 filled and unfilled positions for individual programs will be posted to the NRMP Web site at 11:30 a.m. eastern time. Locations of all unfilled positions are released at 12:00 noon eastern time. Unmatched applicants may begin contacting unfilled programs at 12:00 noon eastern time.
This is the process known as the Scramble, when applicants and programs scramble to find and fill positions. If a program you interviewed with has unfilled slots, it is best to contact them first and they may reconsider you. Some programs also advertise unfilled slots in newspapers, particularly if they know prior to Match Day that they will have open slots. Within 48 hours, most slots are filled and it becomes very difficult to find a position.
If you do not match and cannot find a position during the Scramble, you still have a small window of opportunity in obtaining a residency slot. Some slots open up between July 1 and August 1 during the first few weeks of residency programs. Occasionally, residents do not show up for their slots or decide to leave early in the program. Programs that have your information on file will be much more likely to call you to fill a vacated slot. Therefore, it is important that you send a complete application package to a handful of programs by June 1 if you have not been matched. After the summer, it is highly unusual for any slots to open up.
In 2006, 24,085 positions were offered through the Match. Even if you do intend to apply for a position outside of the Match, it is desirable to also register with the NRMP as it will only increase your chances of finding a residency position. There are two ways to find programs outside the Match. One, you may ask the programs directly if they offer any positions outside of the Match and if so, how you may apply. The second way is comparing listings in the Green Book and NRMP data. If programs are listed in the Green Book and not in the NRMP program book, then those program positions are offered outside of the Match. If you feel that your chances of matching are low, it is worthwhile to look at results from past years to see which positions go unfilled and then apply to those programs as they will be more likely to accept IMGs.
Most states will issue a training license to IMGs who demonstrate evidence of medical education, satisfactory results on a U.S. medical licensing examination and ECFMG certification. Details of the licensure requirements for each state for IMGs are available. Depending on the type of visa an IMG received for GME training, it may be necessary to obtain a new non-immigrant or immigrant visa to practice medicine in the U.S. after completing residency training.
4. The Application - No Room for Error
As the process of finding a residency position becomes increasingly more competitive, applicants must pay more attention to the application itself to make themselves stand out. Interviews are granted solely on the basis of the information presented in the application package.
Follow these rules without exception:
1. Application should be presented neatly, without spelling or grammar errors.
2. Make sure that the application is completely filled out with correct information, including your NRMP applicant number if you are registered for the Match.
3. All applications should be originals. Do not submit applications that are copies of those sent to other programs.
4. Do not miss application deadlines.
Your curriculum vitae (CV) is an important piece of your application package. Make sure that it highlights any unique qualifications you have to make yourself stand out from the thousands of others in the applicant pool. Include any academic experiences, such as researching or teaching, regardless of where you trained. While you should put any experiences on your CV that will be of benefit to you, always be prepared to provide further information. If granted an interview, you will most likely be asked to discuss the experiences you have included on your CV. Residency programs are putting increasing importance on community service. If you have done volunteer work, make sure it is a prominent part of your CV. Test scores too are very important. Many programs look at test scores first to initially weed out applicants. There is no substitute for extensive test preparation.
Letters of recommendation (LoR) are the final required part of the application package. You may target each LoR to specific programs; and you may have as many LoRs as you feel necessary. However, no more than 4 letters can be assigned/sent to any individual program in MyERAS. Please contact each program for their LoR requirements. While letters from overseas schools are important and may provide more insight into your background, they are not very helpful since international medical school standards vary and often are not comparable to those in the U.S.
Therefore, the best way for IMGs to get letters of recommendation is to get some experience working in a U.S. health care facility before applying for a residency slot. It is particularly important to get experience in a facility with a teaching program. Unfortunately, getting this experience can be a difficult task. Hospitals have no formal programs for IMGs to get experience. Therefore, it is largely up to individual IMGs to go out and find opportunities through their own initiative.
Often the best way to do this is to contact every hospital in your immediate area and volunteer your services as a well-trained IMG. Offer to work nights, weekends, or whenever needed in any capacity that is available. Even a short stint in this atmosphere will be able to get you both a letter of recommendation and some experience working in a U.S. facility. A letter from someone who has seen you perform in a clinical setting will set you apart from other applicants and will often get you an interview. If you are absolutely unable to find a clinical experience in a teaching hospital, try to obtain a research position in a hospital laboratory, where you will have a mentor who will be able to write a letter of recommendation. Conducting research at a hospital will often give you an entry into the hospital and may allow you to eventually observe clinical activities. No matter who your letters of recommendation come from, it is important that the authors know you and can discuss your abilities.
Residency programs are looking for letters that provide some insight into an applicant. Letters from those who do not know you well provide little information. Almost all applicants are asked to provide medical school dean's letters, which are basically used to see that there were no major overall problems with your performance in medical school. Residency programs realize that these letters generally come from a source who does not know the applicant well and do not put a great deal of weight on them. They really look for letters from professors, residents, etc. who can attest to your abilities and future as a physician in the U.S.
Personal Statement - Some programs require a personal statement as part of the application package. This is another opportunity for you to make yourself rise to the top of the applicant pool. Even if a personal statement is not required, it is often a good idea to send one anyway. As long as it is short (not more than two typed pages) and addresses your uniqueness as an applicant, it will not be regarded negatively. A personal statement can often provide a more personal look at an applicant than does the standard application form. Include relevant information about your background, including why you have chosen medicine as a career and why you wish to train in the U.S.
It is a good idea to send in a stamped, self-addressed postcard or envelope with your application so that you can be notified when your application has been received. Throughout the process of compiling your application, always keep in mind that it is this application package that will determine whether or not you are invited to interview. Do everything you can to make yourself stand out from the crowd in your application.
5. The Interview
Once all applications are received, the program director or a selection committee reviews them and decides who to interview based upon the information presented in the application package. Most applicants go on eight to twelve interviews. However, those looking to enter highly competitive specialties or who are not strong candidates may want to go on more interviews to increase their chances of being selected.
It is important to prepare yourself for an interview, as this is your only opportunity to make a personal impression on the residency program director.
Be punctual and be prepared. Find out beforehand the name(s) and position(s) of the person(s) who will be interviewing you, something about the hospital, and something about the program in which you are interested. Programs generally send interviewees an informational brochure about the program. Read the brochure and spend some time familiarizing yourself with the program and the facility. This will allow you to spend a minimum of time during the interview on basic questions and spend more time discussing what the program is really like. It can also be helpful to talk to someone familiar with the program as preparation, as long as this person can provide reliable information. Applicants who can ask informed questions make much more favorable impressions than those applicants who do not ask questions and show little interest in the program.
Observing patient interaction "On Rounds" - Most interviews begin with a short overview of the program, after which applicants sit in on rounds. Then, there is usually a series of short interviews with the program directors, attending physicians and chief residents. This is the time when each party has an opportunity to learn about the other and see how they match up. While each program evaluates applicants differently, there are some general qualities that interviewers look for. These include honesty, enthusiasm about the program and about the particular field of medicine, a relaxed attitude and the ability to deal well with stress. Many programs do not ask a lot of questions, preferring to have applicants ask the questions. However, there are a few standard questions you should be prepared to answer, including: why you have chosen your particular specialty and that residency program; your goals; your strengths and weaknesses; and what you can bring to the program.
If there is anything unusual in your background, be prepared to discuss that. If you have been out of medical school for a long time, have not done any research or have received low grades, you may be asked about that.
Non-U.S. Citizens - Be prepared to answer questions pertaining to your immigration status. If you are not a U.S. citizen or permanent resident, your visa status will likely be questioned. Indications of a problem receiving the necessary visa may hurt your chances of acceptance. It is your responsibility to obtain a visa and to keep it current.
After the interview - Generally, after the interview this is an opportunity for applicants to meet with residents and discuss the everyday experiences of being a resident in the program. This is the time to ask how a program treats its residents, what the call schedule is like, and what the environment is like. Residents who are generally happy and satisfied are a good sign. Be wary of programs that do not let you spend much time with residents. This either means that residents are too busy or that the administration does not want them to meet applicants because they are unhappy in the program.
Expect the Unexpected - While this is a standard format, you should always be ready for the unexpected. Some programs give tests on the interview day. Others videotape applicants. Many programs will ask an applicant to discuss a recent medical case he or she has seen. This is generally the only chance a program has to evaluate the clinical abilities of an applicant. Even if you have not seen any cases recently, have a couple prepared that you feel comfortable discussing.
All in a Day - Interviews generally last an entire day. Use this time to its fullest. Make sure any questions you have are answered to your satisfaction. By the end of the day, you should feel that you have given an accurate representation of yourself to the program and that you have received an accurate representation of the program.
Interview Follow-Up - The only necessary follow-up to an interview is a short note to everyone you met with, thanking each person for the opportunity to interview. If you are still interested in the program after the interview, mention that in your note. Letters of thanks are always looked upon favorably. In this competitive application process, anything you can do to make yourself stand out will be of benefit. However, do not call the program to find out your chances of acceptance. Doing so will be looked upon negatively. If, after the interview, you are no longer interested in being considered for the program, write to the program director to inform him or her of your decision. Occasionally, programs will begin calling applicants closer to Match Day to gauge interest. You are not required to divulge your ranking of the program. Interviews are generally completed by the end of January and most applicants do not hear from any programs until Match Day in mid-March.