The IMG’s Guide to Obtaining Residency in the United States

by Alec in IMG

0 comments

Do you attend a non-US med school but want to do residency training in the US? Did you go to a Caribbean school and are worried about overcoming IMG discrimination? Are you overwhelmed by the jumble of acronyms, names, and details required in the process? Want actual data on what specialties are more “IMG Friendly”? (What? You don’t like advice from anonymous Redditors who never trained in the US?). Do you struggle to find credible information from other successful IMGs?

If you answered, “yes” to any of those questions, you’ve come to the right place.

Applications to get residency in the United States are competitive. Nearly 50% of all applicants are screened out. However, the numbers are bleaker for graduates of non-US medical schools. With the right information, however, your path can be considerably smoother and faster.

In this guide you will learn:

• What is an IMG?
• Just how hard is it to get into a US residency as an IMG?
• Average USMLE scores for successful IMGs for each specialty
• What is ECFMG certification, and how to obtain it
• When you should take your USMLEs
• How to generate a list of “IMG-friendly” programs for ANY specialty in under 5 minutes
• Visas: practical advice for non-US IMGs

NOTE: This article is jam-packed with information. There are essential dates and practical advice. Plus, you can see cold, hard data on successful past residency applicants. I recommend that you bookmark this page. You can revisit it on your journey to residency training in the US.

Legal disclaimer: we are not lawyers. This post should not be considered legal advice. You should seek appropriate counsel for your own situation, including if you are seeking a visa or other legal status. 

Definitions: What is an IMG?

Let’s start with some definitions.

IMG: International Medical Graduate

• You attended a medical school outside of the United States and Canada

IMGs consist of two sub-groups:

• US-IMGs: US Citizens or permanent residents who attended a “foreign” medical school. Example: someone born in the US, but went to a Caribbean medical school (a non-US school).
• Non-US IMGs: Non-US citizens or permanent residents who attended a “foreign” medical school. Example: someone born in South Korea, who does not have US citizenship or a green card, and who went to medical school in South Korea.

ECFMG: “Educational Commission for Foreign Medical Graduates”

• The body that will “certify” you as an IMG.
• You must be ECFMG certified to start residency. Applying for ECFMG certification is a requirement to register to take the USMLEs.

NRMP: “National Resident Matching Program®”

• The organization that administers the “Match.” In the Match, the NRMP pairs residency applicants with a residency program.

Note that “International Medical Graduate” (IMG) refers to the medical school you attended. Thus, a foreign citizen who attends a US medical school is NOT an IMG. However, a US citizen that attends a med school outside of the US would be considered an IMG. (Technically, s/he would be a US IMG).

How Hard Is It REALLY to Get Into a US Residency as an IMG?

You’ve probably heard people on Reddit bemoan how “I’m an IMG and so I need to score 50 points higher on my Step 1 – everyone knows that!” Rumors and hearsay are rampant.

It is true that IMGs (International Medical Graduates) have a lot to overcome. Fewer than 1/3 of residency program directors say they “often” offer interviews to US IMGs. That means roughly 2/3 of program directors say they “seldom” or “never” offer interviews to US IMGs. And only about 20% of program directors say they “often” offer interviews to non-US IMGs.

In 2018, 94 percent of U.S. allopathic senior medical students matched. However, only about 60 percent of IMGs matched the same year.

USMLE Scores Between Matched IMGs and US Grads Are Actually Very Similar

That said, the data aren’t all that bad. When I compiled the 2018 Match data, there weren’t the gaping differences in USMLE scores that I expected to see. See for yourself. Below are the average Step 1 scores for matched US seniors vs. US IMGs vs. non-US IMGs for the 2018 Match.

Average USMLE scores are similar between IMGs and US Grads

But Successful IMGs Have More Research Than US Grads

Next, we will look at the number of abstracts, presentations, and publications. Successful IMGs tend to have more research, as seen below. However it is not true for all specialties, and the difference isn’t as much as I expected.

My takeaway? It’s certainly more challenging to get into residency as an IMG. However, if your goal is to match at a program in your given specialty, your numbers don’t have to be world-crushing.

Advice on Finding Research Positions

Want advice on finding research positions? The best place to start is your own personal network. A referral by a common contact works best. If this isn’t possible, networking while on an away rotation/observership would be my next option. (I had a student get a paid research position after doing a 1 week observership at Harvard-MGH).

My last resort would be cold-emailing people. The MGH attendings told me when I was a resident that they get lots of e-mails from people asking for research positions. They ignore most of them. It’s much better to go with people you know/have met in person.

What Are the Most “IMG-Friendly” Medical Specialties?

A common question is, “what are the most IMG-friendly medical specialties?” Instead of relying on rumors, I present the data. Here is every specialty participating in the 2018 NRMP match, and what % of spots were filled by US and non-US IMGs.

What Are Good USMLE Scores for IMGs?

Want to know what score you need to match into your desired specialty? Below are the average USMLE scores by specialty for the 2018 Match. Scores for both matched (successful) and unmatched (unsuccessful) IMG applicants are shown.

Average Step 1 Scores for Matched and Unmatched IMGs for 2018 Match:

Source: National Resident Matching Program, Charting Outcomes in the Match: International Medical Graduates, 2018. National Resident Matching Program, Washington, DC 2018.

Average Step 2 Scores for Matched and Unmatched IMGs for 2018 Match:

Source: National Resident Matching Program, Charting Outcomes in the Match: International Medical Graduates, 2018. National Resident Matching Program, Washington, DC 2018.

Next, we will discuss the steps you need to take to gain admission to residency in the United States. We’ll start by examining ECFMG certification.

Why Do I Need ECFMG Certification?

If you want to do residency or fellowship in the United States, you need ECFMG certification.

Who is Eligible to Apply for ECFMG Certification?

The ECFMG certifies students from many, but not all, international medical schools. Want to check to see if you are eligible to apply for ECFMG certification? Find your school in the “World Directory of Medical Schools.” There you can verify if your school’s graduates are eligible for ECFMG certification.

Go to the World Directory of Medical Schools to see if your school meets ECFMG eligibility requirements.

Note, that in 2023, the ECFMG will require medical schools to be accredited. Per ECFMG Website:

Important Note: Beginning in 2023, to be eligible for ECFMG Certification, ECFMG will require that applicants graduate from a medical school that has been appropriately accredited. To satisfy this requirement, medical schools must be accredited by an agency that has been recognized by the World Federation for Medical Education through its Programme for Recognition of Accrediting Agencies. ECFMG is in the process of establishing policies and procedures for implementing this requirement and will publish updates, as they become available, on the ECFMG website. International medical students and graduates interested in ECFMG Certification should monitor the ECFMG website for the latest information.

Basic Outline to Get ECFMG Certification

In general terms, there are two things you need for ECFMG certification:

1. Pass the USMLEs: Pass Step 1, Step 2 CK, and Step 2 CS
2. Have graduated from an ECFMG-approved medical school, and have it verified

Note that applying for ECFMG certification is NOT the same as being certified. For example, before you can take the USMLEs, you need to apply for ECFMG certification. However, before receiving the ECFMG certificate, I need to pass USMLE Step 1, Step 2 CK and Step 2 CS. (Confused? See table below for clarification).

Steps for ECFMG Certification

I will outline the necessary steps for ECFMG certification below. For more information, please visit the ECFMG website.

1. Apply for a USMLE/ECFMG ID.
2. Submit an application for ECFMG certification. Note: this merely begins the process of ECFMG certification (see requirements above).
3. Verify status as current student/graduate. The ECFMG must verify with your medical school that you are attending/have graduated. Verification is either electronic through the ECFMG Medical School Web Portal (EMSWP) Status Verification program or via a paper form (Certification Statement Form 183). Note: students report this can take take anywhere from 1-4+ months. It is highly recommended you begin this process early, as you cannot take the USMLEs before verifying your student status.
4. Apply to take the USMLEs. Once you have your ECFMG ID and have applied for ECFMG certification, you can sign up and apply for the USMLE exams.
5. Pass all required USMLEs (Step 1, Step 2 CK, and Step 2 CS).
6. Graduate from med school. You must confirm graduating from your medical school and receipt of your diploma.

Do I Need to Be ECFMG Certified to Apply to Residency/Participate in the Match?

This is a common point of confusion. You do NOT need to be certified by the time you apply for residency. However, you do need to have the complete ECFMG certification before you start residency.

Here is an excerpt from the ECFMG Certification Factsheet:

“You must be certified by ECFMG before your program’s start date, although you can apply to programs before becoming certified.”

You also do NOT need to be certified to participate in the Match. (Although you DO need passing scores for Step 1, Step 2 CK, and Step 2 CS).

To learn more about ECFMG certification, see the ECFMG website.

What is Required to…?

Are you thoroughly confused? Does this feel like a meaningless jumble of letters/words? Here is a table with various relevant requirements.

What is the Big-Picture Timeline of the Residency Application Process?

This is a list of the most important dates to remember for residency applications, for Match 2019. Note that applications begin the year prior for a given Match year. Thus, to participate in the 2020 Match, I would submit my application during September of 2019. I would then begin residency summer of 2020 (typically June or July).

• September 15 (date usually fixed): Can begin submitting residency applications. (Most interview offers are on a rolling basis. It is highly recommended to submit your applications on the first day possible).
• October 1: MSPE (formerly Dean’s Letter) released to residency programs. Typically programs begin sending out interview requests starting Oct 1.
• October – January: applicants interview at residency programs
• January 15: can begin submitting a rank list
• February ~20 (date variable, but within several days of Feb 20): Rank order list certification deadline
• Mid-March (date variable, but usually around March 15): Match Day!

When Should an IMG Plan to Complete Their USMLEs?

When should an IMG plan to take the USMLEs, so their residency application doesn’t get delayed?

The short answer: take all your USMLE exams as early as you can while still achieving good scores. A conservative recommendation? Have all USMLE scores (Step 1, Step 2 CK, Step 2 CS) available before submitting your application.

For ECFMG certification, you need passing scores on USMLE Step 1, Step 2 CK and Step 2 CS. You also need passing Step 1, Step 2 CK and Step 2 CS scores before you certify your rank order list. (Due date: usually around February 20 – check the NRMP calendar, as this date varies slightly year to year. This allows you to participate in the NRMP Match). (The typical rank order list certification deadline is late February of the year of the match. For example, to be in the 2019 Match, the deadline for rank order list certification is February 20, 2019).

However, most residency programs look closely at your USMLE scores. As we saw above, attaining a US residency spot as an IMG is highly competitive. As such I recommend having Step 1 and Step 2 CK scores available before submitting your residency application.

When Should You Take Step 1 or Step 2 CK to Have Your Scores in Time?

The NBME typically reports USMLE Step 1 and Step 2 CK scores within 4 weeks of taking the exam. As such, the latest you should take Step 1 and Step 2 CK would be 1 month before applying to residency. (Remember, you should submit your application on September 15.) However, delays in score reporting can occur when the NBME modifies the test format. As such, you should check usmle.org for announcements.

When Should You Take Step 2 CS?

It takes roughly 2-3 months for your CS score to be reported. Ideally, you would have a passing Step 2 CS score before September 15 (the first day you can submit residency applications). However, the latest you should take Step 2 CS would be December 31 of the year before your desired Match. In other words, if I wanted to participate in the 2020 Match, I should take Step 2 CS before December 31, 2019.

For more specific information on Step 2 CS reporting deadlines, see the USMLE.org site.

Summary of USMLE Recommendations/Deadlines

The ideal time to take:

• USMLE Step 1: before August of the year before desired Match Year
• Step 2 CK: before August of the year before desired Match Year
• Step 2 CS: before mid-July of the year before desired Match Year

Required time to take exams to participate in Match:

• USMLE Step 1: before August of the year before desired Match Year. (Your application will almost certainly be ignored without a Step 1 score).
• Step 2 CK: technically, you’d have to take it before January of your desired Match year. However, it’s recommended you have your Step 2 CK score available by the time you apply for residency.
• Step 2 CS: before December 31 of the year before desired Match Year

Clerkships vs. Observerships: The Basics

Typical advice is for IMGs to have at least 1-3 months of clinical experience in the US before applying to residency. Why? Program directors want to see that you are familiar with the system. It is rare to see IMGs admitted to a US residency without experience in an American hospital. However, this experience varies dramatically.

What is the best way to get US clinical experience?

The largest difference is the kind of experience. A “clerkship” is what 3rd and 4th year US medical students do. You are a part of the team, and can participate in direct clinical care of patients. You typically would write notes, give presentations on rounds, and otherwise be a part of a care team.

An “observership” is strictly shadowing. You would observe an attending/care team. The general rule is that you would not participate in clinical care of patients (e.g. patient notes, presentations, etc.).

Generally, Only Med Students Can Do Clerkships

Rules vary from institution to institution. The most important thing to note is that most hospitals only allow current medical students to participate in clerkships. In other words, if you graduated from medical school, you likely will only be able to do an observership.

Why? Supposedly it is due to concern for malpractice.

The upshot? If you are a current medical student, see if your school supports clerkships abroad to the US. This is by far the best way to gain clinical experience. Not only will you have hands-on experience in the US system. But you will also have a better chance to impress attendings. (Remember, most programs require at least 3 letters of recommendation, which are very important to program directors).

Note: you may have read about “externships,” for IMGs who have graduated already. From what I can gather, these are like clerkships. You do work for the hospital. However, you don’t get paid or receive credit with your medical school. While they sound great, I have never actually heard of someone doing an externship. (If you have experience with externships, please let us know in the comments!).

US IMG vs. Non-US IMG

It is critical to understand the difference between US IMGs vs. Non-US IMGs. Non-US IMGs need visa sponsorship for any US graduate medical education (e.g., residency). US IMGs do not (they already have the legal right to stay in the United States).

Visa sponsorship presents a challenge to residency programs. It may be an extra administrative burden, with additional cost, for the residency program.

Take Family Medicine (FM) for example. Only a subset of FM programs will consider giving an interview to a candidate who requires visa sponsorship. Others will not. In a 2018 survey of program directors, 40% said they considered “visa status” when offering interviews.

For non-US IMGs, that means fewer residency programs available to you. Also, some residencies may discriminate against particular regions like the Caribbean. So while they might say they are open to “IMGs,” there is a chance that you are not the “right IMG” for their program. Example: A residency is open to offering a spot to a candidate from Oxford or Cambridge. However, they will not consider any candidates that are coming from the Caribbean.

How to Create a List of “IMG-Friendly” Programs in ≤ 5 minutes

My advice? Compile your own list of acceptable programs.

Begin with a directory that has all the available residency programs. You can use the ACGME directory. Personally, I find FRIEDA most useful.

(To read FREIDA: The “Residency/Fellowship Search Engine” You’ve Been Looking For, click here.)

On FREIDA, you can further refine your search by state and specialty. Even better, you can sort for programs which offer J1 or H1-B visas (see below). You can also find programs that have had IMGs in the past.

Search FREIDA for visa sponsorships, % of class that is IMG, and much more

As you can see above, I can search for internal medicine programs that sponsor J-1 visas. Additionally, I can even find programs that have above a certain % of IMGs. (In the above example, there are 267 IM programs that support J-1 visas, and have ≥5% of residents as IMGs).

Compare Programs for Key Statistics

This is an effective way to generate a quick list. Next, you can start to see these programs in the context of how competitive your application is (Scores, letters, publications, etc.). You can use the “Compare Programs” tool to see quick stats, like USMLE Step 1 cutoffs, # interviews, etc.

Use the FREIDA Comparison tool to look at stats like minimum Step 1 score, # of interviews, and # of spots available

Then you can see each individual program, for more details on competitiveness, like average Step 1 scores. They even list when the survey was last filled out, to see how up-to-date the info is.

You can look at each program individually for even more detailed info. Note that not all programs report all info.

Once you have a preliminary list, you can go to the program’s actual website. There you can see further information, including IMGs among their current residency class.

I know what you’re thinking: “FREIDA sounds perfect. What’s the catch?” Honestly, it is by far the best tool I’ve found to find up-to-date information on programs. However, nothing is perfect. FREIDA is based on surveys from the programs themselves. While I doubt many programs would misrepresent themselves, not all programs share all information.

For example, the Harvard-MGH Anesthesia program only lists basic information. They don’t include cut-off Step 1 scores, % of residents who are IMGs, or what visas they sponsor. I completed residency there, so I know that they have IMGs and sponsor visas, but programs like MGH Anesthesia won’t show up in your searches.

Thus, if you have a program you are particularly interested in, don’t cross it off just because it doesn’t show up in a FREIDA search.

Non-US IMGs and the Visa

For this section on Visas, I enlisted a former student, “Grateful Student.” He attends a Caribbean med school, and is a non-US IMG.

Legal disclaimer: we are not lawyers. This post should not be considered legal advice. You should seek appropriate counsel for your own situation, including if you are seeking a visa or other legal status. 

Here is “Grateful Student”:

There are two types of visa one can pursue graduate medical education in the US. There is the “J1” (“Exchange Visitor”) and the “H1-B” (“Temporary Work”).

The J1 is known as the exchange visitor visa. Basically, it means that you will be allowed to come to the US for the duration of your training (ex: 3 years for FM). You must then return to your home country for a minimum period of 2 years. After these 2 years, you can apply to immigrate back to the US as a physician.

The H1-B is the temporary work visa. It will allow you to stay in the US for the duration of your training. It does not have the requirement of going back home for two years. As long as you get a job after your residency, you can stay in the US and work your way towards a green card or even citizenship.

The H1-B sounds like a great deal, and it is! However, most residency programs will sponsor J1s only. A fraction sponsor H1-Bs. (For example, of the 538 programs on FREIDA in 2019, 376 IM programs stated they sponsored J1 visas. However, only 122 sponsored H1-B visas, roughly 32% as many that sponsor J1.)

Why? One reason is that the ECFMG sponsors the J1 visa. As such, it does not place an onus on the residency programs except for filling out and certifying forms.

Why H1-Bs are Harder to Find

The H1-B is more difficult for residency programs. It requires a lawyer to fill out forms. Additionally, the residency must reportedly prove they were unable to get a qualified US citizen to fill that job. The programs also need to pay more money to sponsor the H1-B visa. Because of this difference, most residency programs only sponsor the J1.

Another caveat to keep in mind is that to get the H1-B, you will need to be fully certified and have passed Step 3. Being eligible to take Step 3 requires you to have the complete ECMFG certification. (Read: you have to have graduated and completed Step 1, CK, and CS). This extra Step 3 requirement can be a big challenge. This is especially true if you are graduating in the spring of the year you will start residency!

A final note: the J1 visa lasts up to 7 years. The H1-B lasts only 6 years. Depending on the length of your planned training, including fellowship, you may need to apply for an extension. Also note H1-Bs are assigned via “lottery” – not everyone that applies will receive one.

J1 Waivers Allow You to Stay in the US

There is a process one can use to get a waiver of the two-year return to your country requirement. It typically entails working in an “underserved area” in the US for three years. After which, you can then start the process of becoming a US citizen.

Please note, these waivers are not guaranteed. There are many restrictions on them, and they are limited in quantity. For example, they are usually in primary care and may require you to move to a different part of the country. So if you finished a residency that doesn’t qualify as “primary care” then there is a good chance you won’t be eligible for the J1 waiver. In that case, you would have to return to your home country for at least two years.

Inspiration: Other Successful IMGs

I’ve worked with a large number of IMGs, many of whom successfully went on to residency in the US. The issues they face are often different from those of US Seniors. You can read more of their experiences below:

• How this Caribbean IMG Got Her Top Choice “ROAD” Residency
• USMLE Step 1 207 to 241 in 4 weeks
• From 136 to Step 1 247: Conquer Memorization for Impressive Boards Scores

Further Resources

FREIDA: search self-reported surveys from US residencies/fellowships. Many detailed searches, including visa sponsorship, % of IMGs in residency classes.

ECFMG Website: information from the body that will “certify” you and allow you to attend residency in the US.

Charting Outcomes in the Match: actual data from the NRMP on successful residency applicants, including IMGs.

USCIS Website: US Citizens and Immigration Services website, with information on visas, J-1 waivers, and much more.

ECFMG Echo: further useful resources for IMGs.

Concluding Thoughts

The process of obtaining residency in the US can be overwhelming. The rumors, misinformation, and hysteria are deafening.

The decision of whether to train in the US – and your medical specialty – have lifelong consequences. My goal with this guide is to provide data, advice, and perspective so you can make the best decisions.

If you this guide has helped you, please share it with others!

What do you think? Does being an IMG seem as hard as before? Let us know in the comments!

Sources: National Resident Matching Program, Charting Outcomes in the Match: International Medical Graduates, 2018. National Resident Matching Program, Washington, DC 2018.

National Resident Matching Program, Charting Outcomes in the Match: U.S. Allopathic Seniors, 2018. National Resident Matching Program, Washington, DC 2018.

National Resident Matching Program, Data Release and Research Committee: Results of the 2018 NRMP Program Director Survey. National Resident Matching Program, Washington, DC. 2018.