Writing an Excellent CV as a Foreign Medical Graduate

When you are looking for a residency program as a Foreign Medical Graduate, there are many items that must be covered. Visas, letters of recommendation and ECFMG certification are only a view of the requirements to get started on the path to residency. Possibly one of the most important items residency program directors will look at is your CV.

What is a CV?

CV stands for curriculum vitae, which is Latin for “course of life.” That is an important thing to remember because it is what makes a CV different from a resume. It is not just a list of skills and experiences, and it is a much more detailed account of your accomplishments. It is comprehensive, and it can include all or any aspects of your professional life.

It does not need to include pre-college information, and in many cases, the oldest information you will find on a CV is from graduate or undergraduate education. If there are any time gaps once beginning undergraduate school, they should be accounted for.

Because of the detail required for an effective CV, it is recommended that students begin compiling the information for their CV during the first year of medical school. This document will follow you for the rest of your professional career, and it will be used time and time again for credentialing once the FMG is practicing medicine.

How long is a CV?

While a resume should only be one or two pages, a CV can extend to a much longer length. This is because every relevant accomplishment is included, and every time gap explained.

With that said, a CV should not be too long. CVs should be organized an only include relevant information. Time gaps should not be over-explained, and everything should be succinct. A CV should be jam-packed with information, but wordiness or unnecessary items will fill it with too much fluff, and residency directors will not be impressed.

What should be in my CV?

A CV is not a place for examination scores, as directors will have that from your application. Instead, a CV is a place for educational, leadership, and research experience.

You don’t’ have to use complete sentences in a CV, as it is not a narrative account of your professional life. Instead, short comments with no “fluff” help to keep it organized and remove some of the length from the document.

Employment experience, awards or recognitions, and publications should be included in your CV. What you have to ask yourself is, would my program director want to know this about me? If the answer is yes, then find a way to include it.

There is no set way to write a CV, which makes research necessary to make sure you are covering everything in a manner that is standard but at the same time stands out. There is a TON of information online, and talking to other medical providers or mentors is also a good place to start getting information about what to include.

Lastly, what to include is not standardized but rather dependent on the position you are applying for. For instance, if you are applying for a pediatric residency, volunteer work at an elementary school may be more relevant than that same volunteer work used in a surgical residency.

What are the sections of a CV?

As previously stated, every CV is different, but there are a few things you should expect to include:

Personal Data: contact information
Education: current first with expected graduation date, then reverse chronological order
Honors/Awards: anything that will gain the attention of directors including community awards
Professional Memberships: include years and any positions held
Employment: only since medical school, include position and dates
Extracurricular Events/Activities: volunteer work, second languages, special talents
Publications: title, place and date…include things currently being published as “forthcoming”
Professional Interests: (Personal Interests too!): this section is to make sure your character is represented on your CV, and sometimes things don’t fit in any other category. Don’t be afraid to add personal interests if it is relevant.
References: For FMGs, local letters or recommendation are essential to proving you know how the local healthcare system works. Don’t disregard quality letters from your home country or other places abroad, but make sure to include letters from the residency’s country as well.

How do I use my CV in the Match?

ERAS will create a CV for you during the Match application process, but this information should come from your own, personal CV. A “master copy” of your CV should include all information that may be relevant for any professional application, and information can be removed for specific purposes where some information becomes irrelevant.

A well-written CV is essential for residencies and for a professional medical career. If you have not started one or are unsure about yours, get help ASAP. There are many resources available to help you write a stellar CV that will make you a shoo-in for a residency program.

Health Security and the Foreign Medical Graduate:

Foreign Medical Graduates (FMGs) face skepticism from Americans and healthcare professionals, but that is changing quickly. While many FMGs come to the United States to obtain a quality residency and return to their home country, many stay in the U.S. to continue practicing medicine as a career. This has many switching from skepticism to thankfulness as FMGs fill gaps in the accessibility of healthcare.

By the year 2050, 20 percent of the U.S. population will be made up of adults 65 year’s old and older. That is an increase from 12 percent in the year 2000. Currently, there is a physician shortage of over 30,000. This number will increase to over 100,000 in the next 30 years.

Elderly patients cost the healthcare more than younger populations because of chronic metabolic and geriatric disorders such as type II diabetes, heart disease, and dementia. They need physicians for continued care in order to manage their health. Telemedicine does a lot toward improving healthcare accessibility, but there is still a growing need for physicians in order to meet face-to-face and tele medical needs.

The physician shortage will not be eliminated by nurses or advanced-practice nurses. It will only be somewhat lessened. With the growing shortage of physicians will come an equally burdensome shortage of nursing and ancillary staff. This leaves the mystery of why FMGs are met with skepticism instead of appreciation.

Similarly to residency program directors, the general public does not know if the education FMGs receive abroad is equal to what would have been received within the United States. Of course, FMGs know that they are thoroughly checked out via the ECFMG certification process, but that is hardly common knowledge.

It is important therefore for the American public to understand how FMGs are vetted. It is also important for FMGs to be able to communicate the vetting process, so patients can have faith that they are getting quality care. Americans need to rely on FMGs in order to get access to quality care, so confirmation of quality education will go a long way to building trusting relationships between FMGs and their patients.

How are Foreign Medical Graduates vetted?

Educational Commission for Foreign Medical Graduates (ECFMG):

We already mentioned ECFMG certification, but it is integral to the vetting process of FMGS. It is essentially a Dean’s Office for international medical graduates. It is the ECFMG’s job to make sure that education received abroad meets the standards of the American Healthcare System. It also ensures that a resident has the communication skills necessary to treat English-speaking patients.

ECFMG certification requirements

Medical Schools must be listed on World Directory of Medical Schools
United States Medical Licensing Examination (USMLE)
- Step 1 and 2: clinical knowledge
- Step 2: clinical skills
  - English proficiency requirement
- Diploma and credential verification

By the time FMGs have been certified by the ECFMG, it is established that they have had sufficient education and can perform well in a clinical setting.

Visa:

It can be very difficult to get a visa to enter and stay in the United States, and travel bans increase the challenges faced by FMGs. However, U.S. Citizens should rest assured that FMGs are not only trained adequately, but they are not criminals and are welcomed by the U.S. government. The hurdles to getting FMGs in the U.S. are controversial, but they can be a positive item too.

USMLE Step 3:

This last stage in USMLE testing is a final assessment of a physician’s ability to practice medicine alone in the United States. It determines their ability to be independently responsible for patients and is a final step in medical licensure.

Residency:

Every state requires at least one year in an accredited residency program. This means that before the FMG is released to practice medicine, he must practice it under the supervision of other physicians. The FMG has to do basically everything every other doctor does, but they also have to prove it.

Health Security and the Foreign Medical Graduate

In order for the United States citizens to have security in their healthcare system, they are going to have to embrace international medical students rather than question their abilities. That does not mean eliminating the vetting process, but it does mean streamlining it.

Americans need to remember that FMGs bring diversity and unique medical knowledge to the healthcare system. They also represent one solution to alleviate some of the physician shortage present and growing in the U.S.

With that said, FMGs must remember that they have been thoroughly vetted, and they are fully equipped to practice in the U.S. They also must be able to communicate that to patients.

Hopefully, as the world continues with globalization efforts and communities become more diverse, FMGs will be looked at similarly to any other trained physician. FMGs are not a questionable entity with a questionable background. They have been scrutinized in many ways more than the American Medical Graduate.

January Agenda: Rank Order List

As 2019 approaches, it is time to consider which residency programs you’d like to attend, and this decision is integral to successful placement in the Match. On the one hand, candidates need to consider residency programs where they feel they’d be a good fit and be able to pursue their medical career successfully. On the other hand, candidates also need to pick programs where they will be successfully matched.

A word of caution: don’t pick residency programs simply because you think you’ll be matched. There are worse things than not getting matched, and you’ll get another chance to be matched through the Supplemental Offer and Acceptance Program (SOAP) where unmatched candidates fill unmatched residency program positions. The Rank Order List should reflect your best picks, not your safest.

Janurary 15th marks the opening day of the Rank Order List entry, which is located on the website of the National Resident Matching Program (NRMP). You should list programs in your order of preference, with those you most want to attend listed first.

Things to consider when ranking programs:

Which program did you simply like the most? This questions does not necessarily mean the program seemed the most challenging or that you would fill a provider gap in your future area of practice. It is more about where you would be a good fit. Did you get along with the people running the program? Did it seem to progress at a desired pace? Is there a good support system? Whatever you are specifically seeking in a residency program should be considered when ranking.

How was the interview? Was it amazing? Did you make connections? Did the interviewers seem receptive, or did you feel unaccepted. Especially for Foreign Medical Graduates (FMGs), this can mean the difference between a successful and an unsuccessful Match. Those who are FMGs should also be considering how the program handles the inclusion of all residents, so an FMG is not set aside as a viewer more than a doer because of cultural or language barriers.

Is the program competitive? Can you succeed at this level of competition? This would include considerations such as your USMLE scores and any education gaps you may have experienced. Especially for FMGs who may have had a different medical school curriculum, this can really impact success.

Is the program good from a logistics standpoint? Is it located in an area that will be acceptable for you to live for a while geographically? Does it pave the path to the medical career you are seeking?

Are the current residents happy? Physician burnout is real, possibly more than ever. Make sure the current residents are satisfied with their residency program. You don’t want burnout to begin early, and a good residency can provide a resident with the tools necessary to avoid it in the future.

It is recommended that you rank around 10 residency programs, but you won’t have to pay additional fees until you reach 20. It is also recommended that you have a qualified person look at your list and discuss any opinions about questionable choices. A mentor or a current physician may be a good choice.

Once you have your Rank Order List Complete, you must certify it in the R3 system. This must be completed by 9 p.m. Eastern Time February 20th 2019.

There are two other things that should be mentioned about Rank Order Lists:

1. If you did not interview with any residency programs, you won’t be able to generate a Rank Order List because no residency programs will be considering you as a candidate. It is not the ideal situation, but don’t forget that this does not mean the end of your residency hopes for this year. There is still SOAP in March.

2. If you are having a lot of difficulty deciding whether or not you should rank a program because you aren’t sure if you’ll be Matched, you can communicate with the programs, and they can reach out to you. Letters of intent may or may not have a positive influence on the Matching process, but they are allowed. Additionally, programs may reach out to you, but it is not recommended that you let this influence your Rank Order List. There is a Communication Code of Conduct that should be followed during this time, which highlights confidentiality and eliminates unnecessary communication.

Remember, your interview days were the time to fully vet each residency program, and your choices should be made based on the positive and negative qualities of the program, not whether or not you think there is a good chance you’ll be selected.

There are differing opinions on how Rank Order Lists should be created, and each person has a different experience based on personalities and professional backgrounds. For FMGs, there may be programs that are friendlier toward foreign education, but again, this should play a minimal role in your selection.

Match week is in March with Match Day falling on March 15th, so if you are in the Match as a Foreign Medical Graduate, your journey is almost complete!

Journeys in Medicine makes FMGs feel connected.

It is easy a foreign medical graduate (FMG) to feel isolated and even discriminated against, especially during the Match. The Educational Commission for Foreign Medical Graduates (ECFMG) is an organization committed to alleviating some of these feelings, but the world’s university systems are simply not set up in a way that completely remedies the added dilemmas FMGs face.

Thankfully, the ECFMG is constantly working on making conditions favorable for FMGs, and one of the ways they have recently accomplished part of this goal is by creating a blog. Journeys in Medicine is a blog that focuses on the true stories of foreign physicians and their experiences in the United States and in home countries through the Exchange Visitor Program.

The stories in the blogs are not terrible stories of failure or complaints about the stress of being an FMG. They are instead inspirational stories that confirm the importance of FMGs in the U.S. and abroad. They are also incredible tales about the amazing resources available for FMGs, and how to keep a positive attitude and perspective about training and education.

Sometimes, all it takes to remain motivated during studies as an FMG is to feel connected and like you are part of a community. Journeys in Medicine helps one to accomplish this goal by giving authentic accounts of experiences rather than analogies or fictitious tales of what should be. The stories are the real deal, and they are a reminder of the reasons FMGs should keep striving to do their best.

5 Reasons to Read Journeys in Medicine as an FMG

Anecdotal Evidence: The purpose of the stories in this blog are to encourage participation in the U.S. healthcare system. Sure, it is a difficult road, but the road is filled with heartfelt success stories. Often, the anecdotal evidence FMGs receive is negative and focused on discrimination and failures due to things out of one’s control such as Visa issues. This blog gives a person hope through real life success stories, which can encourage the FMG to keep trying no matter what obstacles get in the way.

Sense of Community: Reading Journeys in Medicine is a reminder that FMGs are part of the medical community. The stories remind FMGs of this by noting the accomplishments and importance of FMG contributions. It is not only the FMG that reaps rewards from their education while in the U.S. The patients in the healthcare system also benefit from the unique knowledge FMGs may possess. Sometimes, FMGs can forget that they are an asset to a nation that struggles with a physician shortage and lack of diversity.

Connections: In many cases, Journeys in Medicine gives FMGs connection to doctors who have shared similar experiences. One they have read a blog post, an FMG is free to try contacting that physician for more information or help with their own struggles. Admittedly, the blog does not have a discussion forum or contact information. However, the names of the physicians are included in the stories, so an FMG could look up the doctors in a physician’s directory.

Resources: Many of the blog posts in Journeys in Medicine give clear information about resources that aided the visiting physician and allowed them to have a positive learning experience. Being able to follow the trail of resources used to get to a certain endpoint can be instrumental in another FMGs successful finding of their own resources. It also confirms for an FMG who is feeling lost that there are resources available to put them on the path to success.

Authenticity: Lastly, Journeys in Medicine is an authentic account of real life experiences, so the reader is not getting a story about how things are SUPPOSED to be but how it actually is. Too often, FMGs are presented with promotional material that paints a false picture of reality. That does not mean that reality is not as good, but it does mean that the information in the promotional material may be inaccurate. Reading actual stories from people who have been visiting from abroad gives credence to the account.

The news is filled with stories about the challenges FMGs face, and the news is also filled with stories that question the abilities of FMGs. Much of this has to do with politics, but there is another story that is starting to emerge, and that is the story of how important FMGs are to an overburdened healthcare system. Not only do FMGs fill the gap in healthcare accessibility by creating more providers in the U.S. healthcare system, but FMGs gain a valuable education about state-of-the-art medical practice that they may not be able to receive in the U.S.

Journeys in Medicine highlights the positive aspects of visiting physicians from those physicians’ perspectives, and it is a must-read for FMGs who need a little connection and pick-me-up during residency matching and training.

American International Integrated Observership Programs

It is a difficult road for any international medical graduate (IMG) trying to practice medicine in a country different from the one where they graduated from medical school. Each country’s requirements for medical school are different, and pre-requisites for those medical schools vary greatly. As a result, other countries do not know what they are getting when they take on a foreign medical graduate. Although their education may be superior, there is no way of telling whether it was superior or greatly inferior.

Whether inferior or superior, education abroad combines many strengths and challenges. Being multi-lingual and multi-cultural is a definite advantage when it comes to bedside manner and diversity in care. However, language barriers, standards of care, and the overall practice of medicine may differ greatly from one country to another. There are also different exposure rates to the treatment of various regional illnesses. For example, experience in the care of dengue fever patients varies across different countries. While one country may have a large incidence of the illness, another country may have little to none. It is difficult to determine what medical graduates have had adequate training in all illnesses.

There are no “apples-to-apples” comparisons of international medical school programs, but this does not mean foreign medical graduates are inferior. Instead, it means that they have to prove their academic and clinical know-how in an effort to provide a comparison to those who need it. The EFMG does a good job of serving as a Dean’s Office for foreign medical graduates, but residency applicants still need to have experience in the United States in order to confirm that their clinical skills and training fit the practice of medicine in this country.

The American Medical Association (AMA) registers American International Integrated Observership Programs (MedicalObs) to help foreign medical graduates become accustomed to medical practice in the United States. These observerships last for one to three months, and they allow FMGs to get a taste of American medicine and do a little networking along the way.

Program Elements

Observation: The first thing the program does for FMGs is gives them the opportunity to observe doctors in a hospital setting. This gives FMGs a greater understanding about the workflows of American hospitals, the types of patients they may encounter, and the relationships between physicians and other staff. Nurses are critical to the care of patients, and the doctor-nurse relationship is a huge facilitator of care. FMGs must understand this in order to perform successfully during residency training.

Evaluation: FMGs who are enrolled in observerships will also get reviews from the program director. This is critical feedback by professionals in the medical field, and it can be instrumental in helping guide an FMG into a successful residency Match.

Letter of Recommendation: The evaluating director will also provide a letter of recommendation. Letters from American medical leaders are critical for residency applications, as they prove that you have worked successfully in American healthcare settings.

Certification: The certification from an observership is a great credential because it shows that you are focused on integrating your culture with the American culture of healthcare rather than letting it be a barrier.

Mock Interviews: The interview process can be very intense for FMGs who have all the same struggles of American residency applicants and the added difficulty of language and cultural differences. Mock interviews are the best way to hone answers to interview questions, and they help to build confidence.

Review of Application: Acting alone in the residency application process is a mistake for FMGs, and personal statements made with the review from a qualified and experienced healthcare professional can ensure that personal statements contain the elements needed for program directors to see the candidate as a success.

Speech: For FMGs with strong accents, it can be difficult to practice medicine. Not only will staff and patients have difficulty understanding thick accents, but some patients may not be able to trust a physician whom they cannot understand. Accent reduction courses are available through observerships to combat this problem.

There are many other benefits to American International Integrated Observership Programs. Membership to the alumni network can be a good tool to help find connections with other physicians. Local community groups and events where FMGs participate in events helps to integrate future residents with community members.

In many cases, the challenges FMGs have in finding a good residency Match are unfair, as there are many good and in some cases better medical schools outside of the United States than within. However, residency program directors have no way of knowing what an FMG’s specific circumstance was, and they must be presented with evidence not only that training was sufficient but also that the applicant is ready to transition into the culture of the American healthcare industry. Observerships make it easier for residency program directors to see the quality of FMG applicants.

Difficult Residency Interview Questions

The purpose of residency interviews during the Match is to pair a medical graduate with an environment that will enhance learning and develop the skills of the physician. However, interviewers are not equipped with the time to get to know every medical student, so they must use challenging interview questions to really get to know what type of candidate a medical graduate is. For the foreign medical graduate, difficult interview questions can be particularly challenging.

The Easy Questions

Don’t worry. There will be easy questions, and medical graduates will have plenty of general questions in which they can rehearse answers. Typical “easy” questions are:

Why do you want to be a physician?
Why are you interested in this residency?
What are your strengths when it comes to practicing medicine?
What is your biggest weakness when it comes to practicing medicine?
What are your goals for the future?
Why did you choose your specialty?
Describe your medical school training.
Who has been your greatest mentor?
What will you do if you are not selected for this program?

These questions are easy because they can be predicted and rehearsed. Especially for foreign medical graduates who may struggle with cultural or language barriers, the easy questions are a stress reducer because they can be practiced.

These questions are also very important because they confirm your education experience and the quality of education received abroad. They also give the candidate a chance to insert some personal details that will allow him or her to stand out amongst other candidates.

Although rehearsing the easy questions is advisable, answers should not be memorized. This can make replies come out robotically and make answers seem disingenuous. When practicing the easy interview questions, it is better to use bullet points to rehearse rather than full replies in complete sentences. This will give the candidate a chance to practice delivering natural and semi-spontaneous responses. The interviewer is not seeking a prepared speech but rather a natural conversation.

The Difficult Questions

While the content and delivery of the easy questions is important to assessing your ability to communicate your skills, difficult questions are designed to see how a residency candidate handles stress. They may be bizarre questions that have nothing to do with the residency program, and how you react to them tells interviewers a lot about your ability to handle stress.

For the foreign medical graduate, the difficult questions can be extra stressful because the interviewee must understand first that it is an intentionally difficult question. This can be difficult if the contextual elements of the question are misunderstood. This may force the interviewer to ask the question in a different manner to try to get the FMG to understand the question, and if this does not work, the interview may take an awkward negative turn. Examples of difficult questions are:

What is your favorite color and why?
Have you heard any negative comments about our residency program?
If you were stranded on a desert island and could bring one item from home, what would it be?
Tell me a joke.

It is obvious that these questions have nothing to do with your skills or qualifications, but they can show a lot about what a person is able to handle.

Preparing for the Difficult Questions

It is impossible to predict what the difficult questions will be, but your response to them should be candid. Some questions are meant to evoke hard emotional responses, and how you handle your emotions matters. Remain calm, and answer the questions with as many facts as possible. Leave any feelings or emotions out of your replies whenever possible. This is a test of emotional fortitude, which is a requirement in medicine, and the only way your interviewers can judge your strength is by throwing out some unexpected lines of questioning.

When you are practicing with mock interviews, throw in some crazy lines of questioning, and practice responding in an intelligent and calm manner. If it is a funny question, don’t be afraid to give a clever or witty response. The difficult questions are a chance to show personality and uniqueness. Everyone has practiced, canned responses for the easy questions, and the difficult questions are an extra way to stand out.

Lastly, start thinking about the difficult questions as an advantage. They are really an opportunity more than an obstacle, as long as the candidate is prepared. They are an opportunity because they give the interviewee a stab at capturing the interviewers’ attention and showing how the candidate can think on his or her feet. If a candidate feels like this is where their weaknesses are, then they should practice more because the difficult questions are going to happen.

The Match is a lengthy process, and after all the exams, certifications, and residency hurdles, there is still one part of the residency application process that must be conquered to be matched, and that is the interview. Like everything else, it requires preparation, and practicing the easy and the hard questions will give the foreign medical graduate a big advantage in the interview.

The difficult questions during an interview are not necessarily graded by the quality of your answer but rather how you react to being asked such a question and then if you are able to shift your thoughts in order to answer thoughtfully. The interviewers are not expecting your answer to be as amazing as they expect from the easy questions, but they want to see that you are not easily thrown off by a little uneasiness in a situation.

ECFMG: The Starting Point for Residency Applications

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.

Coping Strategies for Foreign Medical Students

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. 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. 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. 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. 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. 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. 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.

U.S. Clinical Electives/Clerkships Increase Confidence and Confirm Education

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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Ranking and Marketing: Getting a Residency Match as a Foreign Medical Graduate

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.