The Path to Practice for Foreign Medical Graduates

Foreign Medical Graduates (FMGs) have a different path to practicing medicine in the United States than those who were trained in-country. This path is different because it is an attempt at discerning quality education at foreign medical schools. It isn’t that foreign medical schools aren’t as good as American medical schools, but not all medical schools adhere to U.S. standards or higher. The different path FMGs must travel ensures that all physicians practicing in the U.S. have met or exceeded U.S. standards.


The Educational Commission for Foreign Medical Graduates (ECFMG) is the certifying organization that confirms FMGs are ready to take part in a U.S. residency that is accredited. In order to practice medicine autonomously, FMGs will have to complete a three-year (or more) residency in the U.S. no matter what type of training they received abroad.

The ECFMG makes sure that your medical school is on its World Directory of approved medical schools. It also serves in assisting FMGs with visa applications and licensing examinations. It is a FMG’s first line of support in becoming a practicing physician in the U.S.


The United States Medical Licensing Examination (USMLE) is broken into three parts. Step 1 and Step 2 (CK) cover clinical knowledge, and Step 2 (CS) covers clinical skills. Finally, step 3 is the final exam that covers knowledge and skill combined. In order to get ECFMG certification, FMGs must pass steps 1 and 2. In order to qualify to take Step 3, an FMG must have ECFMG certification.


The J-1 visa is the most common visa used by FMGs to get into residency programs. The ECFMG sponsors physicians with this visa. A FMG must have passed step 1 and 2 of the USMLE in order to apply along with having ECFMG certification. An official letter must be held from a Graduate Medical Education or training program, and the Ministry of Health at the last country of permanent residence must provide a statement of need.

Once the requirements are met for a J-1 visa, the FMG is free to complete a residency program once he or she is Matched. Then, he or she must return to the home country for 2 years before being eligible to return. This ensures that low-income countries do not suffer “brain drain” where physicians leave to obtain premium knowledge but never bring that knowledge and expertise back home.

There are exceptions to the 2 year at-home requirement if there is probably danger or persecution that the FMG will face if returning home. It can also be dropped if it would cause a hardship to a spouse or children. Lastly, there are exceptions available for those who an Interested Governmental Agency has taken interest (i.e. Department of Health and Human Services).

The Match

The National Resident Matching Program (NRMP) is how most residency candidates are matched to a residency program, and the application for the Match is called the Electronic Residency Application Service (ERAS). In order to get into the ERAS program, you must get a token from the ECFMG.

Once you have applied through ERAS, the Match process begins. This includes you evaluating all of the residency programs you are interested in and getting interviews to bolster your chances of matching into a residency program. You make a rank order list with all of your top picks (strategically chosen to increase you chance of acceptance in a program you like). The program directors also make a rank order list. Using algorithms meant to create best-fit matches with residencies and applicants, applicants are matched.

Physician Shortage

FMGs do not match as frequently as U.S.-trained medical graduates. This happens for many reasons, but it is a reality that FMGs face. Fortunately, the U.S. is realizing the severe physician shortage they are facing with people living longer and developing more chronic conditions. This has created a call for more residency slots to be available. This takes money, so it is a battle, but it is one where FMGs are seeing progress.

Networking is Key to Practicing in the U.S.

Throughout the struggle that FMGs have getting into a residency and then practicing medicine, there is one thing that helps, and that is networking. The biggest challenge for FMGs is that nobody knows them, and program directors are unfamiliar with the details of their education. That is why any U.S. experience (i.e. externships, observerships) is essential to success.

FMGs who work closely with medical facilities, especially those where the residency is, have local letters of recommendation. Medical providers have first-hand knowledge of their ability, and program directors can speak to people who know that the FMG is comfortable and good at working in the U.S. healthcare system. Without networking, there is less of a chance of being recognized during the Match, which is potentially the most important part of the path to practice for Foreign Medical Graduates.

Foreign Medical Graduates Bring Cultural Competence to Healthcare

Foreign medical graduates (FMGs) sometimes struggle to get into residency programs, and U.S.-trained graduates are often chosen over these equal but foreign individuals. The reasons for choosing U.S.-trained medical graduates vary, but there is one very good reason to include more FMGs into U.S. medical residencies and the healthcare field, and that is that they bring more cultural competence to healthcare.

          In the United States, there is a dominate culture that is Christian and Caucasian. While this culture greatly influences our government and healthcare systems, America has always been a “melting pot” consisting of natives and immigrants with religious freedom and a multitude of skin colors. In fact, the dominant culture in the U.S. came from migrant populations, but their conquering history created a long-lasting power struggle between different races.

In modern medicine, lawmakers and medical educators strive to make the healthcare culture more diverse and inclusive. People realize that there are disparities in healthcare outcomes caused by a lack of cultural competence, and they work diligently to equalize the results. No person should receive better care based on their race or religion, nor should they be forced to take part in care that goes against their personal values. This is where foreign medical graduates are able to bring more cultural competence to healthcare.

            If it doesn’t make sense how simply being from a different country could bring cultural confidence, consider the United States law enforcement or government system. In these systems, the minority races they serve feel underrepresented and therefore feel as though they have no voice. As these societal systems become more diverse, you see a decrease in disparities and more comfort with the impositions that result from these systems. It is not that a police officer should not have white skin. It is simply that having a diverse force implies that there is no bias. It is not that government should include every race, but making sure it includes multiple races without discrimination is essential to show equality among all races.

In U.S. medicine, there are surprising cultural healthcare disparities. According to one study, over 10 percent of African American, Asian Americans, and Latinos feel they would receive better care if they were a different race. That’s compared to 1% of Caucasians. This does not take into account actual results, but the simple feeling of disparity is enough to affect health outcomes. If disparities are real or imagined, they have a negative impact.

One of the most obvious places in medicine where shortfalls occur because of lack of cultural competence is in language. There are so many different languages that it is nearly impossible to include each in the primary care setting. Including more FMGs in the healthcare system provides more opportunity for bilingualism (or multilingualism), and patients who do not speak English are willing to travel or participate in remote care in order to speak their native tongue. The inability to reach people who share cultures and languages is a shortfall that is difficult to overcome without more diversity. Not only that, but the more people are exposed to different languages, the more they are able to communicate authentically despite language barriers. It is a sort of immersion therapy where people become more aware of non-verbal communication in order to improve environments. It also helps to remove biases associated with not knowing English, which has no impact on intelligence or worth.

Another advantage of including more FMGs in the healthcare provider mix is that they have awareness of other cultures. It is difficult to understand some cultures even when cultural competence is included in medical training. The values of one culture may directly contradict the values inherent in U.S. medicine. In these situations, physicians may feel they are violating their own moral code in order to satisfy a patient’s cultural needs. Having other physicians who are familiar with different cultural attitudes and goals for healthcare results in better outcomes. Patient-centered care is not possible without cultural competence.

One last reason more FMGs brings more cultural competence is that it reinforces the ideas already presented in cultural competence training many doctors receive today. It is easy to say you understand cultural competence and are ready to practice it every day in the healthcare setting.  It is much more difficult to put those words into action. Having more FMGs in the healthcare field gives all medical providers the ability to practice cultural competence among their colleagues. This makes cultural competence with patients more natural and maybe even instantaneous.

The world is diverse, but the U.S. healthcare system is lacking somewhat in its diversity. This impacts healthcare outcomes whether it is because of bias and discrimination or perceived bias and discrimination. Having more FMGs in the healthcare field will improve healthcare outcomes and make patients feel like they are equal to all others in the eyes of their providers.

Irregular Behavior According to the ECFMG

When looking at the rules of the Educational Commission for Foreign Medical Graduates (ECFMG), it can get pretty confusing. The commission sets educational and technical standards for the medical education of foreign-trained medical graduates, but it also attempts to set ethical standards in order to avoid the acceptance of fraudulent applicants. Actions that undermine this process are called “irregular behavior,” and they can result in the permanent loss of certification or potential certification.

The specific definition of irregular behavior as defined by the ECFMG is:

Irregular behavior includes all actions or attempted actions on the part of applicants, examinees, potential applicants, others when solicited by an applicant and/or examinee, or any other person that would or could subvert the examination, certification or other processes, programs, or services of ECFMG, including, but not limited to, the ECFMG Exchange Visitor Sponsorship Program, ECFMG International Credentials Services (EICS), the Electronic Portfolio of International Credentials (EPIC), and Electronic Residency Application Service (ERAS) Support Services at ECFMG. Such actions or attempted actions are considered irregular behavior, regardless of when the irregular behavior occurs, and regardless of whether the individual is certified by ECFMG.”

Basically, if it has anything to do with an FMG being allowed to practice medicine in the United States, and it is subversive, it is “irregular behavior.”

What are examples of irregular behavior?

Examples of fraudulent behavior typically involve fraudulent documents such as falsified diplomas, transcripts, or information on the ECFMG application. It can also be providing information about exams or bringing notes to an exam when they are prohibited. The USMLE has more information about irregular behavior here.

What are the consequences of irregular behavior?

The consequences for irregular behavior are severe and permanent. You can be removed from the certification process permanently or even have your certification revoked. There will be a “permanent annotation” in your ECFMG file, and you are basically removed from the U.S. medical community. In some cases, the consequences are shorter, but they still cause a delay in ECFMG certification.

What happens when you are accused of irregular behavior?

If a complaint is filed, the ECFMG first evaluates the complaint to see if it is worth investigating. If it is reasonable to investigate, the ECFMG refers the case to the Medical Education Credentials Committee. The alleged person will be notified in writing of the alleged irregular behavior. They will also be allowed the chance to provide a written explanation or appear in-person to explain before the committee. If found “guilty” of irregular behavior, the accused will have the opportunity to appeal.

What to do if you are accused of irregular behavior?

Irregular behavior is a serious accusation that can have career-ending consequences, at least if you plan on practicing medicine in the United States. That is why you must act quickly and thoroughly to defend yourself.

The first thing you should do is identify the event in question. Write down any details that you can remember, so you don’t forget what happened should the case be drawn out for any length of time. If you have any evidence to support your case, collect it and preserve it, so you can present it when the time comes. Ask for character references from peers and colleagues to provide evidence that you are not the type of person that would engage in the accused behavior.

Lastly, consult with an attorney that is familiar with irregular behavior cases. He or she will be able to make recommendations about further documents that you should present and how you should handle yourself during your presentation/defense. Not all irregular behavior consequences are permanent, but they can cause significant delays in your medical career and serious black marks on your record. It is worth it to spend the extra time and money to ensure you are found to be NOT engaging in irregular behavior.

The Intentions are Noble

The intentions of the ECFMG are to ensure that quality health care is delivered by all medical providers in the U.S. healthcare system. In order to do that, they must have accurate information and transparency about the entire medical education applicants have received. Without this information, the U.S. cannot guarantee quality healthcare in the country, and lives could be harmed or lost.

Typically, it’s nothing to worry about.

If you are fully transparent and honest on all of your applications, you probably don’t have anything to worry about. However, mistakes happen, and you could potentially be accused of irregular behavior while remaining completely innocent. Mistakes can be forgiven, and the ECFMG is not looking to eliminate people from the certification process. This is why it is important to ensure that you plead your case if you are accused. In many cases, people are punished for intentional acts because they were trying to cheat the system. However, if you are unjustly accused, you should fight back and make sure that you don’t suffer career delays due to a mistake or misunderstanding.

What is Brain Waste? It’s What Some FMGs Face While Waiting for Residency.

It takes time to pass the USMLE exams and get ECFMG certification. Even then, a residency candidate may not match into a program. If they can and do stay in-country, they have to find a way to subsist, and that is where brain waste sets in.

Brain waste is the term used to describe people who are overqualified for their positions. It is the foreign medical graduate who must drive for Uber or work as hotel concierge in order to make ends meet. It is earning minimum wage despite the education to make a comfortable living and save lives. It is unfortunate, but it happens.

Brain Waste Costs the Country

One of the bizarre things about brain waste is that the victim of brain waste is not just the foreigner who cannot use his or her medical training. It also cost the state and the country in tax revenues that could be obtained by higher income earners. According to one article, brain waste cost the State of California approximately 700 million dollars in taxes. Imagine how much it costs the entire country.

Brain Waste Sets the Tone for Future Employment

Brain waste has a harmful and lasting effect on the employment opportunities of FMGs. It waste precious time for FMGs who could be getting experience in the medical field and improving the odds of future residency positions. Basically, driving for Uber doesn’t do much for your curriculum vitae. In some circumstances, FMGs are also taking very low-skill medical positions such as medical aids and assistants. This is only slightly better, and FMGs have much more to offer the medical community. Their brains are wasted in low-skill positions.

Brain Waste is Crazy When There is a Physician Shortage

The most astonishing part of brain waste when it comes to the medical community is that America is suffering a severe physician shortage that is only expected to grow as baby boomers reach the age where chronic age-related diseases are more common. According to the Association of American Medical Colleges (AAMC), the year 2032 will see a physician shortage of 122,000 physicians. While this is worrisome, it doesn’t seem like the medical community is doing much to make it easier for FMGs to fill this physician shortage.

Why Make it Difficult for FMGs?

While the difficulty FMGs face getting into a residency program in the U.S. seems contraindicated to the state of the physician population, it is not completely without warrant. Whether or not you are of the opinion that the U.S. has one of the top medical systems in the world, you have to admit it does have quality standards. Some foreign medical schools have more stringent standards than the U.S., but some also fall completely short of acceptable. This is why there is a lengthy vetting process to ensure that FMGs were trained in a manner that satisfies American standards. It is also why some residency program directors may be a little leery of hiring FMGs without local experience.

There are Programs to Ease FMGs Path to Practicing Medicine

There are visa programs that will help FMGs stay in the United States as long as they promise to practice in rural areas, but this still means that an FMG must find a residency. There are also unique bills such as the Holly Mitchell Bill in California that allows Spanish-speaking IMGs to work in underserved areas under supervision. There are many people who recognize the absurdity of the difficulty FMGs face in the U.S., and they are trying to do something about it.

What can FMGs Do About Brain Waste?

If you are an FMG struggling to get into a residency program, you may feel helpless, but there are many things you can do to increase your chances of matching in a residency program. Most of it has to do with getting involved in the U.S. healthcare system. Volunteer at hospitals that have residency programs you desire. Converse with doctors, nurses, and staff, so your residency application will have a face to go with your name. Enroll in observerships, and get letters of recommendation from local doctors. Lastly, make sure you are prepared for the USMLE exams, so you don’t end up wasting precious time retaking exams.

The Struggle is Real, but FMGs Can Improve Their Odds

In the U.S., there are many inequities, and foreign populations sometimes suffer disparities because of efforts to improve quality that have collateral damages or consequences. Obviously, this does not mean all hope is lost, or you wouldn’t be here. Just make sure that if you don’t match into a residency that you are engaging in behaviors that will improve your odds next time. Unfortunately, this may involve some brain waste in order to survive financially, but make sure it also includes further efforts to get involved in the medical community in which you desire in your future.

Creating Global Health Standards with the WFME

The World Federation for Medical Education (WFME) is a program that creates the World Directory from which International Medical Graduate’s (IMG’s) schools must be listed in order for them to get certified from the Educational Commission for Foreign Medical Graduates (ECFMG). It is basically the accreditation organization for medical education, and the WFME is one place where global health standards are created by standardizing medical curricula (sort of).

One of the reasons IMGs have struggled to get into American medical residencies is uncertainty about the quality of medical school education received. Residency program directors do not know if the education received abroad is comparable to accredited education received in the United States. The ECFMG resolves this issue by only certifying residency applicants who attended a school on the World Directory by the WFME. Its world directory is the key to practicing medicine in the U.S.

What Standards Does the WFME Set?

There are nine standards for basic medical education that the WFME uses to get a medical school on the World Directory. They are as follows:

  • Mission and objectives
  • Educational program
  • Assessment of students
  • Academic staff/ faculty
  • Educational resources
  • Program evaluation
  • Governance and administration
  • Continuous renewal

A medical school does not necessarily have to meet every standard in order to be included on the World Directory, but the WFME uses these standards as a guide to evaluating the program. The WFME admits that these standards must be applied differently in different locations according to a “local context.” It also recognizes the overall aim of standardization in a world that is increasingly globalized or international.

Country Statistics

It turns out that India has the most recognized medical schools (392). This is followed by Brazil (242) and then the United States (184).

If the ECFMG uses the World Directory, why do IMGs still struggle?

A lot of the reason that IMGs still struggle to get into residency programs is confirmation bias. It is difficult to change longstanding beliefs that international medical education is subpar. Any time that a person hears a negative story that involves an IMG, they have those beliefs confirmed despite plenty of evidence that IMGs are as capable as American medical students, program directors simply cannot confirm that the education received abroad was similar to U.S. standards, and they may not be willing to risk accepting a foreigner who they feel may have difficulty rising to the occasion in the American healthcare field.

If you ask program directors, they will likely tell you this is not the case. In fact, program directors are fully aware of the crucial role IMGs play in filling the growing physician gap that strains the U.S. healthcare system. Still, the statistics show that IMGs still struggle to get into residency slots.

Other possible reasons IMGs may not be considered for residency slots is the potential for visa issues, language barriers and other biases. There are standards for ECFMG certification that should resolve most of these issues, but the difficulty for IMGs remains despite ECFMG certification.

How Can IMGs Break Free of Foreign Status Limitations?

The world is becoming a melting pot, and foreign status is much more common than ever, but there are still limitations to being an IMG when applying for a U.S. medical residency. This begs the question, how does an IMG get into a medical residency?

The answer may not surprise you. International Medical Graduates must integrate into U.S. society. This means working with American doctors to get local letters of recommendation. It means volunteering or attending mentorships at the hospital in which you’d like to work. It also means rocking that interview. You want your program director to view you as a candidate without the label of IMG, and they can only do that if you present yourself to them authentically and professionally. They need to see YOU, not where you went to medical school.

The Numbers Look Good, But Not That Good

In 2019, the number of non-U.S. citizen IMGs matching to first-year position residency slots was higher than it has been since 1990. 4,028 candidates matched. This is great news, but it is a far cry from the 93.9% of allopathic medical school seniors and 84.6% of osteopathic medical school students who matched first-year positions. Clearly, there is some prejudice against IMGs.

However, some of this makes sense. There are only so many residency slots, and it makes sense to want to provide citizens of your own country with as much opportunity as possible. If 90% of IMGs were given positions, the percentage of American graduates who matched into residency programs would lessen.

More Slots is the Answer

The WFME, ECFMG, WHO, and other organizations have made many efforts to ensure that applicants to American residency programs have received quality medical school education no matter where they obtained it. However, there still remains a large disparity between U.S. and IMG residency applicants. While some of this may be caused by bias toward foreign education, the more likely problem is that there simply aren’t enough slots to give to everyone. With the overwhelming physician shortage looming, the focus should be on opening more residency slots.

Certify Your Perfect Rank Order List by Feb. 26

If you are currently in the Match, you’re probably finished or about finished with your interviews with potential residency program directors, and it’s time to finish your rank order list (ROL).

What is a Rank Order List?

A ROL is a list created in the National Resident Matching Program (NRMP)’s registration system. The list is intended to allow you to rank the programs in which you’d like to attend. It also gives residency program directors a chance to rank their applicants in the order of preference of whom they’d like to train. The idea is that residency programs and applicants are matched based on who will be a best fit.

Tips on Ranking

There are varying opinions on whether or not you should flood your ROL with as many residency choices as possible. You can rank 100 programs without any additional fees and up to 300 with additional fees (up to $30 per program). As an International Medical Graduate (IMG), it is true that you are at a disadvantage statistically speaking, so it may be worth it to include more choices on your list. However, you also want to be thoughtful in your choices. Your residency is a huge step in your career path, and you want it to be the right step. Here are some tips:

  • First, make a list of all residency programs you are willing to attend. Don’t exclude programs you aren’t sure about. Put them all on there. You’ll prioritize later.
  • Don’t choose programs simply because you feel the program director will choose you based on interactions or letters received. In addition, if you are pretty sure you will place in the residency of your dreams, DON’T SHORTEN YOUR RANK LIST. You don’t want to miss out on an opportunity if your “promised” residency doesn’t pan out.
  • Consider competitiveness. It is great to get into a highly competitive program, but consider your chances, and make sure you rank a combination of competitive and less-competitive programs to increase your chances of a Match.
  • Don’t wait until the last minute, as you risk servers shutting down due to too many users. Instead, add your rankings early, and know that you won’t run into technical difficulty.
  • Other things to consider when ranking:
    • Program quality: Who are the attendings? How successful are the graduates? How does the hospital rank? What is the philosophy of the residency/program director? Make sure you understand the program for which you are applying.
    • Research opportunities: The availability of research opportunities is very important if you are expecting to enter a medical profession where you engage in your own research projects. Entering a residency with research opportunities gives you a head start.
    • Success of residents: Find out if graduates from this residency program are successful in their futures. Whether the measurement of success is fellowship placement or overall happiness, finding out about graduates can be a huge indicator of your future should you Match with that program.
    • Relocation: You may have to move to enter a residency program, but are you okay with the location? Could you see yourself moving there for an extended period of time beyond residency? This is something worth considering.

Considering multiple factors regarding residency programs will help you to appropriately rank them. You should rank them in order of preference based on these factors but also rank them based on a good mix of competitive and less-competitive programs along with programs that tend to be IMG-friendly.

Certification of Your ROL by Feb. 26

By February 26th, you must have your Rank Order List certified in NRMP’s system. Once it is certified, you can still make changes until 9 p.m. EST on that date.

What if You Didn’t Match?

If you didn’t get any interviews, then you didn’t have a chance to submit a ROL. If you didn’t Match, then you may also be wondering what to do. There is a Supplemental Offer and Acceptance Program (SOAP) that allows candidates to apply for programs that have unfilled positions.

Overall Message in Regard to Rank Order Lists

Ultimately, you should not rank a residency that you do not want to be a part of. At a certain point, it defeats the purpose of your entire medical journey. Instead, be open to opportunities, and rank according to your preference. There are some tactics that may help to get you placed (i.e. IMG-friendly, competitive mix), but you don’t want to simply take an option because you can or limit your options because you think one program is a sure thing. Instead, a well-thought approach to ranking programs should be used.

Have your advisor look at your list if you have any concerns, and make sure you aren’t forgetting about any opportunities. Your rank order list is confidential (except for NRMP staff), and residency program directors will not see it, but it doesn’t hurt to get a little extra input.

Practicing Confidence in Preparation for an Interview

When you are interviewing for a residency slot, confidence is the key to success. This can be a huge challenge when stress and a perceived need to please get in the way of holding on to any self-confidence. Forcing confidence can turn the tables from positive to negative, and it is important to make confidence authentic. This puts candidates in a conundrum when trying to exhibit confidence. It can’t be forced, it may not be natural, but it has to be authentic. No wonder interviews are stressful! It is not impossible to learn how to be confident during an interview. In fact, practicing confidence in preparation for an interview can ensure that it is genuine and effective.

Eye Contact

One of the biggest ways to appear confident is to maintain eye contact during conversation. Depending on your home country’s culture, this may be difficult. That is why practicing making eye contact during conversation is essential to the success of an interview. You don’t want your eye contact to appear awkward or forced. Most residency program interviews will have multiple people involved in the interview. It is okay to favor eye contact with the program director over other participants, but make sure you give everyone some of your attention. Shifting your gaze will also prevent you from staring, which can look odd and uncomfortable. Practice interviewing with friends and family, but make sure they are native to the U.S. and willing to give you any tips on correctly using eye contact to exhibit confidence.


Standing and sitting with good posture also reflects confidence. Cowering in the face of judgement in front of interviewers shows that you are not confident in your skills, and you must exude confidence in your posture both in front of your interviewers in your patients. Practice holding your head up high, and make it a habit to hold your shoulders back. It will become natural, and you won’t feel odd doing it during your interview.


A smile is essential to greeting new people, but a smile can be done incorrectly. This can be especially difficult if your own culture does not commonly use “toothy grins.” The key to a good smile is to do what you can. Not everybody looks genuine with a wide-mouthed tooth-revealing smile. It is okay to make it small, but make sure it makes you relatable.


In America, everyone appreciates a firm handshake. This doesn’t mean it is a power struggle between you and the recipient. Rather, a limp handshake feels wrong and weird. Too strong of a handshake feels like you are insecure. Firmness should be warm and indicative of your earnestness.

Slow Down

It is very common to speed up your speech patterns when you are nervous. It is okay to show some nervousness during your interview, but ramping up the speed of your speech can make it difficult for interviewers to understand you and will leave more room for errors in your speech. Take a breath. Slow it down. Make sure you are saying what you meant to say and not rambling.


One of the biggest mistakes you can make in an interview is not listening. This may sound obvious, but it is very typical for an interviewee to talk too much and even interrupt because of nervousness. Don’t let this be you. Take the time to think about your interactions with your interviewers. Are you listening? Are you responding when appropriate? You must stay engaged during an interview in order to show confidence, and this can be lost if you let your nervousness take over.

Ask Questions

Don’t just respond to questions. Make sure you have some questions to ask. This shows that you are truly interested in finding a good fit in your residency choice. It shows interviews that you’ve thought about what you want out of your residency, and you are confident enough to ensure you get it. This works almost like reverse psychology. If you ask questions, it makes interviewers feel like they are being interviewed, which makes them feel like they want you. This may not always work, but it definitely shows that you are looking for the right spot, and that shows confidence and self-worth.

Practice Makes Perfect

All of the tips to appear confident in an interview might seem elementary, but they work. The trick is to perfect these methods to make them seem authentic and effortless. That means practice, practice practice. Make sure to practice your interviewing techniques and include these tips. It’s not all about having the right answer. It is also about having the right demeanor and personality to make program directors know that you have the confidence to make crucial medical decisions. Confidence is necessary in any medical profession, so you have to show confidence to rank highly with your prospective residency programs.

Thank You Notes Following Interview? Why Not?

If you make a stellar impression during your residency interview, a thank you not is probably not the thing that is going to get a residency program director to rank you highly. You’ve already made it to the top of their list. However, there are only one or two people that will perform this well, and other interviewees may be less memorable. A thank you card is not going to single-handedly get you into a residency program, but it doesn’t hurt. When residents ask whether or not to send thank you notes following an interview, the simple answer is, why not?

When NOT to Send a Note

Some residency programs specifically state that they do not want thank you notes sent following interviews. Abide by their wishes. Even if you are absolutely smitten with the program, an overzealous thank you note will not impress. It may even eliminate your chances at a residency slot because it shows you don’t like to follow instructions.

When to Send a Note

In cases where it is not stipulated, it is best to send a thank you note immediately following the interview and not more than one week afterward. You may want to wait one day to digest the information, but get it sent out early, especially if you know the program will be making a decision soon. If you wait too long, the people who interviewed you won’t remember your interview well enough to link it to your note.

Handwritten or Email

The jury is out on whether a handwritten or email thank you is preferable. Handwritten notes show that you went the extra mile, but they take time to get through the postal service and may never reach the program director’s desk. When they do get there, they are memorable because of their rarity. Email is generally accepted but requires less effort. Do what you feel is right, and stick to email when you know that directors are making their decisions soon.

Who to Send a Note

Send a thank you note to everyone who was at the interview. Each notes should be individually addressed with a unique note to that person, as they may be compared among the interviewers. Check with the program’s administrative assistant to make sure you have all the names correct, and ask the best way to make sure you reach them.

Reflection and Notes

One of the first things you should do when returning home from an interview is jot down some notes about things that went well with the interview or things that really stood out. It is the details that matter in the notes, and you don’t want to forget anything substantial. This will also help you reflect over the evening and have a well-constructed thought process to write about the program the next morning.


Generally speaking, you want your note to be pretty simple. If it is too long-winded, busy program directors won’t have time to read all of it. Keep it to a three-part letter. The first part should be a thank you for the interview. The second should be some key reflections, and the third part should be your continued interest in the residency program.

Don’t Include These Thoughts

What should not be in your thank you note is anything negative under any circumstance. Even if it is gnawing at your consciousness, leave it out of the letter. Keep it positive, and don’t talk about the monetary benefits of the residency. This isn’t about anything other than your thanks and enthusiasm for the residency, so keep it short and sweet.

Worst-Case Scenario

In the worst-case scenario, your letter won’t reach its destination. This would most likely be because it was filtered by administration, or it was forgotten somewhere by the recipient. There is no guarantee that a thank you note will do anything, but even then, it does no harm. This is why it is good to write or email thank you notes. It can only help and is guaranteed not to do any harm.

Best-Case Scenario

In a best-case scenario, a thank you card opens an extended line of communication between you and the program director or other interviewers. In some cases, this has led to further discussion and near-guarantees of ranked positions. In other cases, it has made candidates memorable. A remembered face with an application generally outperforms a forgotten one. The best-case scenario is the whole point of sending a thank you note, and it is virtually risk-free.

A well-written thank you note can only be a positive aspectto your chances of being ranked for the residency program desired. Do make sure it is well-written. If this means having a friend or colleague edit it for you, make sure you enlist in their help. You want to make a good impression during your interview, but that impression can be confirmed through the follow up thank you note.

With a J-1Visa Waiver, You Don’t Have to Return Home

Foreign Medical Graduates (FMGs) typically enter the U.S. for medical training with a J-1 visa. This visa is intended to allow people from all over the world access to U.S. medical training, but they aren’t allowed to stay. Following the end of a program, the person must leave the country within 30 days. In order to come back to the U.S. permanently, the person must live in their home country for 2 years, then apply for another visa.


The Conrad 30 Waiver Program

There are multiple ways to waive the two-year home country requirement. The government of the home country can release a no objection statement (NOS). The requirement can also be waived if it would cause exceptional hardship to a U.S. citizen or legal resident. If the person would be persecuted in his or her home country, it may be waived. The U.S. government can also waive the visa requirement if it would harm the intent of the person’s project or agency’s interest. Lastly, the Conrad 30 waiver program allows physicians to stay if they will fulfill the needs of the American healthcare system in rural or underserved areas.

Under the Conrad 30 waiver program, the department of health in each state can request waivers for 30 International Medical Graduates who would otherwise have to return home for two years before coming back. In return, the graduate must agree to practice medicine in an underserved area for three years.

The underserved area must be specifically listed as a:

  • Health Professional Shortage Area (HPSA)
  • Medically Underserved Area (MUA), or
  • Medically Underserved Population (MUP)

The person must also obtain a NOS from their home country if that country’s government funded the initial exchange. Understandably, the Conrad 30 waiver program aims to fill gaps in the number of U.S. healthcare providers while maintaining the interests of the home country.

How to Get a Conrad 30 Waiver

A physician who wishes to obtain a waiver must get the sponsorship of the state health department where they plan to practice. There is an online application, and it must be filled out before getting a recommendation. The Department of State Waiver Review Division electronically communicates the application status to the U.S. Citizenship and Immigration Services (USCIS). If there are no concerns, the USCIS will typically allow the waiver to proceed.

What About After the Waiver?

After a successful waiver, the physician must submit their waiver letter along with a Petition for a Nonimmigrant Worker, so his or her visa status can be changed to H-1B. Children or a spouse must submit an application to extend or change nonimmigrant status, so their visa can be changed to H-1B status as well. After this, the physician can begin working in an area where they are very much needed for 3 years. Following this, the physician and family may be eligible for permanent residence, an immigrant visa, or certain types of non-immigrant visas. If they don’t work for 3 years, then the physician has to go back to his or her own country for the original 2-year requirement before returning.

The U.S. Healthcare Provider Shortage

The American Academy of Medical Colleges predicts a shortage of 122,000 doctors by 2032. Demand for medical care is exceeding supply, which could result in catastrophic delays in care and negative health outcomes. Because the population is living longer, the number of patients needing care is growing. By 2032, the number of people living over age 65 is expected to increase by 48 percent. Additionally, elderly populations often have co-morbidities that require multi-disciplinary teams. On the one hand, people living longer is a great thing. However, they still need medical care. The doctors are also aging. According to the AAMC, 1/3 of doctors practicing today will be over 65 within the next 10 years. If these doctors retire early, this could drastically negate active provider numbers.

Problems with Conrad 30

Conrad 30 is one solution to the physician shortage, but it isn’t enough. Only 30 physicians per state are allowed to get waivers regardless of the state’s need. Legislators are seeing the impact that the physician shortage is already starting to have, and they are responding with solutions that involve expanding the Conrad 30 program to more satisfy the needs of America’s underserved populations.

In April, legislators submitted the Conrad State 30 and Physician Access Reauthorization Act. If passed, it would create additional waivers for each state based on need, allow spouses of doctors to work, and streamline the green card process. It is unclear if this Act will pass, but in its current state, the Conrad 30 waiver program is very limited. It responds to the need for more physicians, but it does not satisfy that need. Hopefully, the future will bring an expansion of the program, so more FMGs can stay in America to practice medicine.

Learning Common English for USMLE Step 2 CS

Step 2 of the USMLE exam has two components, clinical knowledge (CK) and clinical skills (CS), and language is an important part of CS. That is because you will have 15-minute “encounters” with patients and be expected to communicate with those patients while being observed. The fluency used will have to be much more than a functional grasp of English in order to fully understand, diagnose, and establish a relationship with the patient. Encounters may be face-to-face or over the telephone, in which case pronunciation and fluency are even more critical.

The scoring of USMLE Step 2 CS is further broken up into Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP) and Integrated Clinical Encounter (ICE). This means that not only must a physician be able to speak clearly and professionally, he or she must also be emotionally supportive and speak at a level that is understandable to the patient.

True English fluency is difficult for those who haven’t spent enough time conversing with those for whom English is their native tongue. Like most languages, there are nuances to learn that can only be appreciated when immersed in the language. The most-dedicated medical student can memorize all the medical terms in the text books, but he or she won’t be able to communicate with a patient without understanding common vernacular.

There are many methods to learning English, and often, living in an English-speaking country for a while is the best one. However, there are other ways to speed up the process that are valid and make learning American lingo an easier quest.

10 Non-traditional Ways to Learn Common American English

  1. Watch television

The TV is an excellent way to listen to common English, and if your language skills are very rough, subtitles can help with comprehension and pronunciation. Stick to entertainment television, not the news, or you won’t get the lower-level diction required for fluency.

  1. Watch YouTube

If you watch television, you’ll definitely get some exposure to slang, but YouTube allows you to see real people doing ordinary things. Watch children’s videos, how-to videos, and viral videos to get a variety of voices and dialects.

  1. Read magazines

Don’t restrict yourself to books when you are reading, as magazines offer fun language opportunities and a different format that enhances the variety of your language knowledge. It’s all about variety, and the more variety you get in your language use, the more complete your language fluency will be.

  1. Listen to music

Music is a fun way to learn any language, and it is a great way to work on pronunciation. This makes any drive time more productive because you can sing to the music in the car.

  1. Go out for coffee

Many foreigners have a tendency to hang out with people from their home country or other foreigners because of the shared situation. As a result, they diminish their exposure to native speakers. Going to a coffee shop, even with fellow foreigners, will expose you to ambient native language.

  1. Sit in lobbies

Like going to a coffee shop, sitting in lobbies is an excellent way to eavesdrop and hear normal conversations. This will help with your listening skills and also teach social norms. One-on-one conversation is difficult to observe unless you are in a public place like this.

  1. Ask questions

If you don’t understand, make sure to ask. It may seem cumbersome at first, but asking questions will catapult your learning. It also helps people to understand that you are trying to speak fluently.

  1. Socialize with Americans

Foreigners sometimes socially isolate themselves from Americans because they don’t speak well enough to engage in casual discussion. This isolation only furthers the problem, so get out there!

  1. Don’t be shy

Plenty of people who speak English perfectly are shy, and changing that is nearly impossible. However, that doesn’t mean you cannot force yourself to communicate more. Chit chat with the person at the cash register, and say hello to people passing by. You may make some mistakes, but surviving those mistakes will make you more confident.

  1. Practice

Practice all of the time. Give up your own native language for a day. Immerse yourself in everything that will give you more practice. If language is your hurdle for USMLE Step 2, conquer it.

Learning proper English is difficult, but learning common English with all of its idiosyncrasies and colloquialisms can take some time. The only way you can ensure that you have enough fluency to effectively communicate with patients is to use it often. As you can see from these tips, it is all about exposure and usage, and the more you surround yourself with the English language, the more natural it will feel to hear and speak it. When you get to the clinical skills portion of your USMLE exam, language will no longer be a problem.