by Lori Ramos

There is a tremendous amount of mythology and legend bouncing around the internet “echo chambers” about how to prepare for the U.S. residency match, mostly because the vocabulary involved, the cultural nuances, and the complexities at every stage of the process. It can be confusing and overwhelming. In this article we will lead you through a no-nonsense, jargon-free introduction to planning for the U.S. residency match and building a competitive application. We will cover preparation components and key issues, how to prepare a timeline flow chart for yourself, and some information on each component. Subsequent articles will exam each component in more detail.

As you begin thinking about seeking a position in a US residency program, first and foremost you must remember that this process is essentially a job search. It is critical to incorporate key job search strategies with the strategies you will use for applying to a training program. You should also understand that there is considerable risk involved in this process. These risks include large expenditures of money, time and energy, and there is no guarantee that you will be successful. Also the differences in the US economy vs. developing countries can make it even more expensive.

Planning is key to reducing your expenditures and increasing the probability of getting an interview.  The earlier you begin the planning process, the better you are able to fit in all the components in an efficient manner.  Also, you will be more in control of the timing of each component.  Timing is crucial because many programs will not look at you if you have been out of medical school more than 5 years, and your letters of recommendation should be dated within a year of submitting your application.  Finally, in order to avoid banging your head against a rock searching for the elusive “perfect” clinical experience scenario, you should attempt to gain at least a basic understanding of how the US medical system works and how opportunities for clinical experience vary for students vs. graduates as well as the terminology involved.

The best way to inform yourself by going directly to the source. You should read the www.ecfmg.org and www.nrmp.org websites from start to finish, and then you should be checking it periodically for updates. Also, you will see references to two studies cited in this article. These studies will help inform you as you plan, and will answer many of the speculative questions about your chances in different specialties given your USMLE Step scores and accumulated experience.

There are three main components of the application package that you will submit:

---Clinical Electives/Externship and Observership as demonstrated by your CV and Letters of Recommendation

In this article, we will not address the USMLE Step Exams or the ECFMG certification in detail, except in terms of planning your timeline.

“Ideal’ Timeline Flow Chart

As you begin your planning process, or even if you are already in the thick of preparing your application, we suggest you make a flow chart.  To do this, you will start with the MATCH date and work backward in time. We will call the year before the MATCH date your “MATCH Year.”  We will call the year before the “MATCH Year” your “PREP Year.”  Before that is MEDICAL SCHOOL.  

Starting from the MATCH date (on top), work down and backward in time:

For example, if you are preparing for the 2015 match, your flowchart might look like this (remember we are working backwards in time and there may be some seasonal overlap):

Application upload is historically in September. By this time you ideally should have ALL of your components (LORs, fully developed CV and personal statement, Step 1, Step 2cs and Step2ck, and ECFMG certification, and if possible Step 3).

No matter where you are in your process, but especially if you have already finished medical school, you will need to adjust this flowchart to fit your own reality. The point is that in order to make your application as competitive as possible, it is helpful to start planning early.

Now that I’ve shown you how to design a flow chart based on your own reality and with the important components, we are going to unpack each one of these steps.  Here is a little bit of the rationale behind the design of the flow chart.  At this point we are starting from the beginning of your planning and preparation and moving forward.

Medical School Period

If you start planning in your last or penultimate year of medical school, you will save time, money and reduce your anxiety.

While you are still in medical school it is possible to apply for clinical rotations at some of the U.S. hospitals that offer this opportunity to foreign students. If you have the time and the money, this is an excellent way to build your CV with hospital-based US clinical experience. The letters of recommendation you would get at this time will most likely be too old when you submit your application, but you are doing it to build your CV at this point, to show hospital experience, and if you are lucky you will do some networking and get to know people who run the residency program. At this point in your process there is no need to use a 3^rd party placement service because you can and should apply directly to the hospitals if you are still enrolled in medical school

PREP Year

Have a look at this article on page 3. http://www.nrmp.org/data/programresultsbyspecialty2012.pdf

There is a lot of speculation about one’s chances for getting an interview, but as you can see from this survey of residency program directors, 82% cited the Step 1 score as a factor in deciding to interview.  The Step 1 is the single most important thing you do to make your application competitive.  Seventy percent of program directors cited the Step 2 as a factor. This is why I recommend that you dedicate an entire year to preparing for and taking the Step exams, without distraction.

The exams are SO CRITICAL that we recommend you dedicate an entire year to this. However, when you make your own flow chart, you will need to consider your own reality, when the exams are given and where, and other competing factors.

MATCH Year

Choosing your focus

During the MATCH Year, you are going to choose your specialty and do some research into programs.  It is important to begin to focus at this time.  Consider this report on the NMRP Results and Data document, specifically the table on page 3.  http://www.nrmp.org/data/resultsanddata2012.pdf

You can get a sense of the number of slots won by international medical graduates by looking at the “No. of Matches” column and subtracting the number of US seniors from the total.  For contrast, look internal medicine:

                  Total matches:  5226     US seniors took 2941 of those slots. 

                  This means that 2285 went to non-US graduates, a full 44%. 

Now for a stark contrast, look at dermatology in PGY1. 

Total matches:  23     US seniors took 22 of those slots. 
Only 95% were filled, so likely that last slot was not filled by a non-US graduates.  The picture doesn’t get much better for dermatology PGY2.

So when you are deciding which specialty to choose, do the math, consider the odds, and then try to match that with your passion. It is important to follow your passion, but it is also important to be realistic as this is a job search, and it is important to go where the jobs are.

After you make your decision, start to research the programs and you will get a better idea of the odds and which programs are IMG friendly. Choose one specialty and stick with it.

US Clinical Experience

At this point you have aced your Step exams and have decided on your specialty.  While you are researching programs, you need to get US clinical experience. If you started the planning process early, you may have already done some hospital-based US clinical rotations while you were in med school. If that is the case, that’s great!  Those were CV-builders.

Now you are continuing to build your CV and on top of that, you are collecting your letters of recommendation.  As an international medical graduate, you will need to participate in an  externship in order to secure a letter of recommendation.  Your letters should:

• Be written and signed by a physician who is board certified in the specialty area.
• Reflect varied and content-rich experience.
• State the activities you were involved in during your clinical rotation. For this reason it is critical that your letter be based on a hands-on externship, NOT an observership.
• Express an opinion regarding your clinical skills and professionalism.
• Reflect a variety of inpatient and outpatient work if possible.

Here is where there is a lot of confusion around the mythical “teaching hospital LOR” that everyone seeks and only a very few find. Assuming that at this point that you have graduated from medical school and are now what we call an “IMG” (international medical graduate), getting a clinical rotation in a teaching hospital is going to be nearly impossible.  The teaching hospitals don’t want you!  The university teaching hospitals really don’t want you!  Unless your brother-in-law is a resident or your aunt is a faculty member (and probably not even then), there are very few opportunities nationwide for IMGs in teaching hospitals, and these are usually observerships which won't help you much in terms of your LORs. Don’t waste your money or your energy banging your head against the wall trying to find the IMG golden unicorn: LOR from hands-on clinical rotation in university teaching hospital.  

The best you can do is to work with a physician who is affiliated with a teaching hospital, and even then, in primary care and many subspecialties your rounding experience will likely be minimal as the U.S. health system move more and more towards ambulatory care.

This is one of the reasons why we encourage you to start planning early and do the hospital-based clinical rotation while you are still in medical school. Even though your LORs will not be usable (because they are likely to be too old), it looks good on your CV.

Program Research

While you are doing your externships and collecting your LORs, you can begin your research in to the programs. We suggest that you make an Excel database, and try to prioritize them by the likelihood of matching there and other geographical or personal criteria. If you are five or more years post medical school graduation, you will have to use that criterion as well and filter out the programs that have this limitation.

Again, look at this article on page 3. http://www.nrmp.org/data/programresultsbyspecialty2012.pdf.  You will see that after the Step 1 scores, most program directors are looking at your letters of recommendation in the specialty (note that it does not mention “teaching hospital” or inpatient!) and your personal statement in order to decide whether to interview you or not.  This tells you that they want to see that you are focused and passionate about the specialty to which you are applying.

Application Upload

Now we are in the summer before the application upload. You should have thoroughly researched everything you need to know about the application process. 

Here are some tips about preparing your CV and personal statement:

CV:  Download a hard copy of the application and model your CV on it. Many companies offer CV review services. Absolutely take advantage of this. Remember these two key points:  your CV should be content-rich and minimally formatted. Go to the internet and get a list of active verbs and use them (performed, conducted, supervised, coordinated, etc.). 

Personal Statement:  Your personal statement should be professionally oriented.  In subsequent articles we will discuss ways to prepare this, but the same advice applies to the personal statement—content rich, no fluff, focused, and readable.  We suggest using the standard essay format, and again, use a reviewing service.

The first paragraph should introduce the reader to you and state clearly why you are the best person for the position.

The body paragraphs develop supporting evidence that ties back to your main argument. Introduce each idea with a transitional sentence, and stick to each point.   

Start by describing how your academic preparation makes you the most qualified candidate for the residency position, and let the reader know how your academic preparation helped you arrive at your choice of the specialty.   Dedicate a paragraph to explaining why you think this choice is right for you, and how you have prepared yourself experientially. This should include your clinical experience, as well as research, extracurricular or work experiences that are pertinent.  Essentially you discuss how your experiences (internship year, US clinical experience, etc.) make you the most qualified candidate for the residency position.  Your final body paragraph should inform the reader what you see as your long-term goals, or how you see yourself in this specialty. And how do your career goals make you the most qualified candidate for the residency position?

Finally, end with a concluding paragraph.  Here is where you restate why you are the best candidate for the residency position, add personal comments or anecdotes, and then close by thanking the committee.

Networking Observerships

After you have uploaded your application, it is time to go back to your list of programs. Pick the top 5 or 10 and start calling to request an observership. As we have stated before, it is unlikely that you will get clinical experience at a teaching hospital, but they may be amenable to having you observe.  You are not doing this to get LORs, you are not doing this for your CV. You are doing it to know people and to be known.  With your presence and the people you meet, you will put a face to your application. It is like a month-long interview.  The timing of this is critical. Any earlier than August/September/October and they may not remember you. Any later and they may have already filled the spots.  Start your calling in August.

With all confidence and a little humility, call the program and tell them that you are applying and very interested in observing for a short time. Call each program every two weeks. Try to get the name of the person (secretary or administrator) each time so that when you call back you can address them properly. Be polite, but keep at it. If any program allows you to do this, drop everything and go. 

The next piece are all the interviews you will get. This is an entire workshop in itself that discusses the topics to the right of the box. Next fall keep a look out for our workshop on this.

Interviews

If you are lucky to get invited to an interview, make sure you prepare for it.  Do your research, know what questions to expect, and practice in front of a mirror or with a friend.

SOAP

Finally, we come to the end of the process, and that is the SOAP.  The SOAP is a messy, high-anxiety way of filling the final unfilled spots and it generally takes place by phone and internet over the course of one week in the spring.  If you did not get invited to an interview, there is always the SOAP!

Remember, planning is key to getting started and staying on track. Before you start, make sure you have enough time and resources to take you through to the end. Best of luck to all of you!

Lori Ramos, MA, MPH
President and CEO
Chicago Clerkships