In order for a foreign medical graduate (FMG) to apply for residency, they must be certified by the Educational Commission for Foreign Medical Graduates (ECFMG). This certification assures residency programs that a candidate is qualified to enter a program based on United States medical education requirements. This is an essential part of the residency application process, and it is important because medical education requirements vary around the world.

The quality and relevance of medical education around the world has been called into question by U.S. residency programs, as program directors are unable to compare standardized U.S. medical school education with that of education in other countries. While medical knowledge is easy to determine based on standardized testing, clinical experience is not as easy to compare. That is why FMGs must attend a U.S. residency program, but programs want assurance that their educational background is sufficient to begin practicing medicine.

U.S. medical graduates are labelled ready for residency by their Dean’s Office, but those offices are not available for international students. As a result, the ECFMG has aimed to create a Dean’s –like office that standardizes the process for FMGs through certification.

In order to get certified by the ECFMG, an applicant must apply through an interactive web application (IWA). This application allows the ECFMG to confirm an applicant’s identity, contact information, and education background. This act alone is indicative of how difficult it is to confirm FMGs’ education, as the simple identification process is extensive. Simply providing current identification is not enough.

The medical school attended by the FMG must be listed in the World Directory as meeting requirements for the ECFMG examination, which is the United States Medical Licensing Examination (USMLE). Applicants who do not have a resident status in the United States must also apply for a Visa. This is only part of the process leading up to the Match, but each step must be taken in order to meet the requirements for a residency application.

USMLE

The USMLE is separated into parts, and applicants must pass Step 1 and Step 2 of the USMLE in order to be certified. The third step can be passed during residency.  Parts 1 and 2 of the exam test medical science knowledge and clinical skills. 2006 statistics show that US medical graduates scored higher on these tests than international medical graduates, but non-US international medical students scored higher than US international medical graduates except in clinical skills. Preparation is key to passing these tests, and English proficiency has been blamed for poor performance among FMGs. These tests are administered throughout the year, but you must be certified by the ECFMG before the start of your residency program.

Visa

FMGs are typically not residents of the US, but they may have established some form of legal resident status prior to applying to be certified by the ECFMG. If not, the ECFMG is able to sponsor applicants for a J-1 Visa.

ECFMG services

While the ECFMG is responsible for certifying that candidates are qualified for American residency programs, they also provide many services to FMGs. For example, they will help an FMG apply for residency programs through the Electronic Residency Application Service. They will also help applicants create verified career portfolios. They are basically the go-to organization for FMGs who need to get ready for the Match.

The ECFMG was established in 1956, and its goal was to improve the U.S. education system by standardizing the evaluation process of FMGs. In other words, it recognized the need for diversity in the medical community and welcomed the opportunity to help FMGs advance their career in the U.S. healthcare system. It is important to remember that the differences in education received abroad versus in the U.S. are not labelled as inadequate. Instead, it is simply different, and it cannot be accurately compared without some sort of a mediating process. The ECFMG provides that mediation.

That is not to say that there is not extensive preparation involved in getting certified by the ECFMG. Applicants are advised to pay attention to the timeline of deadlines and opportunities for FMGs to get certified and further their journey on the path to the Match. It is a complicated process that can quickly fail if an FMG does not complete certain tasks at certain times. Test scores are also important, and study plans should be set up and carried out months prior to the testing.

Navigating the pathway to the Match can be very confusing, and although the ECMG helps applicants get to the Match through certification, it can be helpful to employ other agencies to navigate the system and make sure steps are taken at the right time. The key to success is preparation and the utilization of resources such as FMGPortal. Obtaining a U.S. residency is an attainable goal as long as an FMG is motivated and obtains the help needed to get from the beginning of the process with the ECFMG to the end of the process with the Match.

Some may argue that the journey to residency for Foreign Medical Students is equally challenging to that of American medical students, but this opinion lacks acknowledgement of the challenges Foreign Medical Students face when transitioning to a residency along with a new country.

While certain struggles, such as communication and culture are similar throughout time, foreign medical students also face hurdles such as constant political change. For instance, executive orders introducing travel bans can complicate visa processes. Many hurdles are well-beyond the control of the student, which is why it is important to develop coping strategies to maintain focus while navigating a medical system that can hold biases against foreign students.

Potential Struggles for FMGs

1. 1. Communication: The most obvious struggle for Foreign Medical Graduates is communication barriers. While FMGs are required to pass a language proficiency test such as the TOEFL (Test of English as a Foreign Language) in order to obtain ECFMG Certification, passing this test does not eliminate all language struggles. In fact, an acceptable score on the TOEFL means a student is fluent and capable of conversation professionally in their profession, but they still may struggle with the language nuances developed among native speakers. This can be frustrating for students, professionals and patients. If the student is not careful to clarify any misunderstandings, this can lead to medical errors and unacceptable mistakes. As a result, communication can be a big struggle for FMGs.
2. 2. Culture: A foreign country may have very different cultural norms than the cultural norms of America, which is not bad but can present challenges during interviews and professional processes. For instance, one country may find assertiveness to be a rude attribute, while it may be considered a strength in an American interview. Handshakes may be perceived differently in other areas of the world. The details of these differences are not as important as the fact that they cause added stress for FMGs in uncertainty and newness.
3. 3. Team Work: Team work is essential in the healthcare field, and it can be difficult to insert oneself into a team when presented with communication and cultural differences. Additionally, once in a team setting, it is easy to fade into the background and not be a quality participant in the team. Not only must Foreign Medical Students have the courage to join teams, but they must conquer their fears of making communication and cultural mistakes in order to become a valued team member.
4. 4. Logistics: On top of communication and culture, which can greatly impact one’s ability to engage in team work, FMGs must ensure that they are handling all the details of their transition to another country. As mentioned previously, things like visas can become complicated by political agendas. In addition, it can be difficult to develop a strategy for applying to residencies because it often involves a careful balance of applying to residencies that are known to accept FMGs without neglecting the residencies a FMG is truly passionate about. Organization, strategy, and perseverance is integral during this time, but it adds stress that the traditional medical student from America does not face.

Coping Strategies

There are many other struggles FMGs face, and many of them are unique to the student and their home country, but inherent in all of these struggles is increased stress that can negatively impact the outcomes of residency placement. That is why FMGs must develop coping strategies to handle stress and keep their minds focused on the goal.

1. 1. Personal Resources: One of the most important strengths that a FMG can develop is personal resources. These are skills and actions that one takes in order to avoid fatigue and burnout, which can create an abrupt end to residency pursuits. For example, a FMG may practice breathing techniques, yoga or meditation in order to center himself or herself on his goals. FMGs may need to take personal time to reconnect with their own lives, which may seem displaced in a different country. Music can be a valuable reminder of home. There are endless possibilities when it comes to personal resources, and it is important that FMGs identify these resources prior to the time when they are needed. In this way, they will be emotionally prepared for stressful transitions.
2. 2. Social Support: Alternatively, social support can be as essential as personal resources. It is very easy to hide from social interactions when faced with communication and cultural differences, but this actually increases stress for the inevitable social interactions that will need to take place for successful residency placement. Orientation and acculturation programs are available to assist FMGs in mixing American culture with that of their own, so they can achieve residency placement success without discarding their own traditions completely.

It is essential to FMGs that they remember their own cultural identities while blending that with American culture in order to provide effective care that is in line with American Medical School standards. It is a stressful challenge to maintain both the past identity of a home country while integrating that with American culture. This is why FMGs must focus on coping strategies, which will become easy to implement when needed if they are developed in preparation to stressors instead of on an as-needed basis.

Foreign medical graduates make up 25 percent of the working physicians in the United States, yet the U.S. does not have standardized accreditations for these medical schools. As a result, the quality of the education received abroad has been questioned by policymakers and voters. That is not to say that foreign medical schools are not of high quality, but foreign medical students seeking U.S. residencies have difficulties with successful placements if they cannot prove U.S. clinical experience. This is why U.S. clinical electives/clerkships are integral to the education process.

The outlook for foreign medical graduate’s placement in U.S. residency programs is good. In 2010, 2,881 non-U.S. citizen foreign medical graduates were placed into residency programs, but that number increased to 3,641 in 2015. That is 760 more filled positions by non-U.S. citizens. This is not what was originally predicted, and the outlook was predicted to be negative for non-U.S. citizens. However, the National Residents Matching Program (NRMP) has determined the cause of the increase in non-citizen medical graduate placements to be the shortage of U.S. medical graduates to fill the positions. There are simply not enough graduates to fill the available positions. This is good for foreign medical students, but they still have to be able to prove quality education.

Residency directors have acknowledged difficulty placing non-U.S. graduates do to non-standardized education measures, but there may also be biases present among some who simply don’t know if foreign medical schools are producing the quality of residents desired. This is why clinical electives/clerkships work so well: they give non-U.S trained medical students clinical experience under well-reputed Attending Physicians. This results in multiple benefits when it comes to applying for residency programs and interviewing during the Match process.

In order to be placed into a residency of choice, a foreign medical graduate must prove that their educational experience was exceptional and that they are ready to work hands-on as a medical provider. Without clear clinical experience during medical school, a challenging process becomes nearly impossible. Especially for the foreign medical student who is dealing with the cultural changes of an American society, the lack of U.S. clinical experience can cripple an interview for a residency. In contrast, clinical experience within the U.S. assures directors that a foreign medical student has had the chance to apply his or her knowledge and skills in the U.S. medical system, and it makes abilities confirmable. Not only are interviewers assured of a candidate’s ability, but the candidate is able to communicate in a more confident manner. Clinical electives/clerkships pave the way for residency placement.

Not only is U.S. clinical experience a way to influence residency program directors to choosing foreign medical students, but so is the word of U.S. physicians. In an effective clinical elective/clerkship setting, a medical student should be able to gain multiple letters of recommendation (LORs). Letters of recommendation can be the tipping point for directors who need a bit more assurance that medical training has been sufficient. Glowing letters of recommendation from Attending Physicians at teaching hospitals are like a giant stamp of approval for interviewers who need sound confirmation of a candidate’s experience.

Finding a clinical elective/clerkship can be done through FMG Portal. Through FMG Portal, a foreign medical student seeking clinical electives in the U.S. has access to many tools to aid him or her through the process. These services include USMLE preparation assistance, experience with Attending Physicians who are ACGME-affiliated, Visa Embassy Interview Assistance, help with accommodations and a simple, monthly payment program. Students are able to experience outpatient and inpatient situations, and core specialties along with sub-specialties are offered. Most-importantly, the Attending Physicians that students will work with are seasoned professionals, and their recommendations will be influential.

The benefits of clinical electives/clerkships are undeniable, and they give confidence to foreign medical students who need experience in the U.S. to prepare themselves for the Match and residency interviews. They also serve the needed purpose of confirming the quality of education received abroad. Again, there is no denying the fact that there is quality education abroad, but residency directors must be able to confirm that education has been fulfilled in a way that meets or exceeds the quality of U.S. medical schools. That is why getting some clinical experience in the U.S. prior to graduation is a good way to guarantee success.

While it is worth noting the potential biases and discrimination that foreign medical graduates may receive when applying to residencies, it is also worth noting their advantages. Foreign medical graduates have a different perspective when it comes to applying medical knowledge, which may include more education along the lines of infectious disease or among cultures that exist in the U.S. but are not specifically targeted in the U.S. medical school system. There are definite advantages to foreign medical schools, but it must be coupled with U.S. experience in order to make a U.S. residency match a probability.

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Registering for The Match through the NRMP begins September 15, 2018. International Medical Graduates (IMGs) should have ECFMG certification in progress, as it is due by the rank order list deadline of February 20, 2019. The ECFMG provides the NRMP with confirmation that USMLE exams have been passed and that applicants are eligible for The Match. It serves as a Dean’s office for all foreign students to ensure that they meet the standards to qualify for a residency program.

The Match

The NRMP facilitates the ranking and placement of medical students into residency programs, but they are not in charge of program requirements or supported visa types. Applicants to each program must pay careful attention to whether or not the program accepts IMGs and the deadlines for sponsoring visas if applicable. The majority of residencies participate in the NRMP, but it is not a requirement.

Do IMGs have less opportunity for a match?

Foreign medical graduates have a history of obtaining less first-year residency matches than U.S. medical graduates, but the numbers are improving. First-year residency matches went from a 53.3% match rate in 2017 to a 56.5% match rate in 2018. This rate has been steadily increasing over the past decade.

The reasons for the lower number of first-year residency matches may not be warranted, but they still exist. Some program directors may have unfounded judgements about the quality of training abroad, but this is a stigma based on archaic thinking rather than facts. A more reasonable explanation may be that international programs differ from U.S. programs, so they are difficult to compare. Transcripts and academic achievements from different countries with different curricula are challenging to fully understand because they differ from the standard U.S. curriculum. While this creates a challenge to obtaining a match, it also opens a window of opportunity to market oneself during the application and interview process.

Market your Abilities and Stand Out Above the Rest

Applications are a starting point to combat any biases that may emerge during the application process. Program directors need to know that an applicant has proper training, skill and experience. A high score on the USMLE may be the first thing evaluated on an application from an IMG, but there are additional ways to stand out. Another way to stand out is by submitting letters of recommendation by U.S. doctors with whom an applicant has worked closely. Letters that clearly explain clinical abilities and provide examples of it will have a big impact on program directors. Supporting documents such as letters of recommendation and transcripts will be transmitted to ERAS applications through ECFMG.

A second way to improve the odds of a match is aggressive marketing. Applying to many schools is one tactic to increase odds, but 5 to 10 top picks deserve extra attention. Contact program directors and coordinators of these programs for introductions and tips prior to the interview. Those who wrote letters of recommendations may also contact program directors and give verbal recommendations. Ultimately, when applicants make themselves present in the lives of the people in the program, their applications become more meaningful, which increases the odds of a match.

Ranking Strategies

There are many strategies for ranking residencies for The Match. The ECFMG instructs applicants to rank them in the order in which they most want to attend them, which exercises the full purpose of the Match but may not yield a match. A quick internet search will provide lists of IMG-friendly specialties. Applying based on this may not be the best option for long-term career choices. There is not one clear-cut method that will guarantee a match, but some recommend a mix of high-competition residencies and low-competition residencies to improve the odds. Others recommend applying to as many residencies as possible. While one ranking strategy may work for some and not others, the application process combined with smart ranking choices will yield more positive results for Foreign Medical Graduates.

Rank Order Lists

Twenty programs are allowed to be listed on the rank order list (ROL), and 20 more can be listed on the supplemental ROL. Extra fees can be applied to place more programs on the ROL, but there can be no more than 700 listed for one applicant. The deadline for certification is 9 p.m. February 20, 2019. No changes can be made after this time, and matches are binding.

The Foreign Medical Graduate Prospective

As mentioned previously, the matches among foreign medical graduates are growing in number. Physician shortages and increased knowledge sharing from organizations such as the ECFMG are facilitating matches by matching the need for more providers with the surety that applicants are trained and skilled in their profession. It is a difficult process for all medical students and graduates, but it is a process that can be a success if a person provides proper evidence of their education and skill through documents and interviews.

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For foreign medical graduates, there’s no denying the complexity of the process of landing a position in a US medical residency program. From the day you start brainstorming your personal statement to the final hours of Match Week, it is essential to make sure that you stay on top of all the requirements and check all of the necessary boxes so that you can end up in the program of your dreams. One of the things that can initially be confusing is the fact that there are two separate organizations that are heavily involved in the overall process of landing a US medical residency: the ERAS and the NRMP. Read on to learn about the role that each of these organizations plays in the process as you go from a foreign medical graduate to a US medical resident.

The Key Distinction between the ERAS and the NRMP: A Question of Purpose

As you try to land a US medical residency, you will work with both the Electronic Residency Application Service (ERAS) and the National Resident Matching Program (NRMP). Perhaps the most significant distinction between these two organizations is that they differ in their fundamental purpose. Specifically, the ERAS is the system through which you will submit all of your residency application materials, while the NRMP is the organization that facilitates the actual matching process, once all of your documents have been submitted to your programs of interest.

From a practical perspective, this means that you’ll be focusing primarily on ERAS requirements during the first part of the process, while the NRMP takes over during the second half. With the ERAS, your goal is to make sure you get all of your application materials into the system so that they are sent out to the programs of choice–complete and on time. Once the programs have evaluated these materials and you have had the chance to interview with interested programs, the NRMP facilitates the creation and submission of ROLs, and it generates the results that you end up receiving at the start of Match Week, and it coordinates the SOAP process until the final results are announced on Match Day.

Comparing the 2018-2019 ERAS and NRMP Timelines

Because the ERAS and the NRMP are two different organizations, they operate on two separate  timelines. They have different registration start and end deadlines, and they separately set other key dates as well. If you are looking to participate in the 2018-2019 application and matching process–that is, if you want to start your US medical residency program in July 2019–it is important to be familiar with the schedules of both the ERAS and the NRMP for the 2018-2019 season.

The ERAS 2018-2018 timeline is already underway. It started on June 7, 2018, when it first became possible for applicants to register on MyERAS and start preparing their US medical residency applications. If you haven’t started the registration process, now is the time. In less than a month–on September 5, 2018–applicants can start sending their applications to ACGME-accredited residency programs through the ERAS system. These programs start receiving the application materials ten days later, on September 15, 2018

Conveniently, that date coincides with the start of the 2018-2019 NRMP timeline. At 12:00 p.m. Eastern time on September 15, 2018, applicants for 2019 US medical residency programs can register with the NRMP. Registration remains open for the next two and a half months, until 11:59 p.m. Eastern time on November 30, 2018. After that date, candidates are required to pay a late fee alongside their main registration fee.

The last important date for the ERAS is October 1, 2018–the day that Medical Student Performance Evaluations (MSPEs) are released to residency programs. That means you have to be absolutely sure that your medical school has submitted your MSPE by that date. Alternatively, as a foreign medical graduate, you may need to submit the MSPE yourself, so you should make sure that you are ready to meet that deadline.

After that, no more documents will be submitted through the ERAS. However, the MyERAS 2019 season technically continues alongside the matching process facilitated by the NRMP. As a result, MyERAS will remain open until May 31, 2019, so you’ll always have easy access to your documents if you need them.

As the role of the ERAS essentially ends in the fall, the NRMP basically takes over in the winter and early spring, which means there are a series of important dates you need to be aware of in the lead-up to Match Day. First, on January 15, 2019, Rank Order List (ROL) entry opens at 12:00 p.m. Eastern time, and candidates have until 9:00 p.m. on February 20, 2019, to certify their ROLs. Match Week begins on March 11, 2019, when candidates find out if they got matched and the Supplemental Offer and Acceptance Program (SOAP) opens for those who did not. It all ends on Match Day–March 15, 2019–which marks the end of the NRMP timeline.

The Bottom Line: ERAS vs NRMP

The bottom line for foreign medical graduates is that the ERAS and the NRMP differ in both their purpose and their timelines, but understanding and working effectively with both organizations is essential for landing the residency position of your dreams. FMG Portal is here to help you with all of your needs when it comes to the residency application and matching processes. Contact us today to learn more about all of our services for foreign medical graduates!

Once you have earned your medical degree, you might not be sure if you really need another mentor in your life. After all, throughout your academic career and early professional experiences, you’ve probably already had countless mentors–from your kindergarten teacher to your high school sports coach to your favorite college professor to the dean of your medical school. However, as a foreign medical graduate looking to get matched to a US medical residency program, you can still benefit from the mentorship of an attending physician in a graduate externship experience. Here are a few of the top reasons why:

 

 

• A mentor can familiarize you with their particular specialty area.

 

When you apply for a US medical residency program, you need to be ready to show the program that you are truly committed to the specialty area that you have selected. A mentor can offer insight on specialty (and subspecialty) areas that goes far deeper than what you experienced during your rotations in medical school. As a result, when it comes time for you to apply, you’ll have a better sense of what you do (and don’t) want from your medical career. For instance, a mentor may have done a residency in internal medicine before choosing a more specific subspecialty for their fellowship, like infectious disease, and they can help you learn about both–and decide which one is right for you, or whether you want to pursue something else altogether.

 

 

• A mentor can help you with professional networking.

 

If you decide you want to pursue the same specialty or subspecialty as your mentor, they can help connect you with top clinicians and researchers in the field. Alternatively, if you want to go in a different direction, a mentor may already have a broad network that can help you access the resources you need.

 

 

• A mentor can help you get “back in the game” if you have taken time off after medical school.

 

More than ever, foreign medical graduates are choosing to take time off to work or start a family before shooting for a US medical residency. As a result, it can sometimes be challenging to jump straight back into a clinical setting. The guidance of a mentor in a graduate externship program can help smooth the transition, so you’ll be well-prepared and ready to go when you finally get matched to a US medical residency program.

 

 

• A mentor can help you understand what it means to be a true medical professional.

 

You might not realize it, but when it comes to professionalism, there are important differences between being a medical student and being a practicing physician. Once you’re a medical resident, you’ll have more responsibilities, which means you’ll be held to higher standards of conduct. Before you start your US medical residency program, you need to be ready for the change, and a mentor can help you rise to the challenge by modeling professional behavior and offering their honest perspective on what it means to be a professional physician. This guidance can help you smoothly make the professional transition from medical student to medical resident.

 

 

• A mentor can help you get a better idea of what your life outside of work would be like as a physician in their specialty area.

 

Your relationship with a mentor during your graduate externship is fundamentally a professional one, but that doesn’t mean you won’t have conversations about everyday life. In fact, a mentor can be a great source of information about what day-to-day life looks like for a professional in their specialty area. For instance, they may be able to help you understand how they make time in their schedule for family and/or recreational activities. A mentor may also be able to offer insight on lifestyle opportunities in particular regions of the United States, which can be helpful if you’re not familiar with the different parts of the country.

 

 

• A mentor can be a valuable asset in the residency application and matching process.

 

Today’s US medical residency application process is increasingly competitive, so you need to be ready to capitalize on your strengths and compensate for your weaknesses. After spending months working with you during a graduate externship, a mentor can often offer you frank advice on the strengths you should highlight in your application and the areas you should try to improve on in the future. Depending on your relationship, a mentor may also be able to advise you on program selection, help edit your personal statement, and/or write you a letter of recommendation, all of which can be invaluable as you try to land the residency of your dreams!

 

FMG Portal offers graduate externships around the country for foreign medical graduates who want to get matched to a US medical residency program. We also provide assistance throughout the application and matching process. Contact us today for more information about all of the services we offer!