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.

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.

The Key to a Successful Match Could be in Networking

Networking is communication among people in a similar profession or interest typically in an informal setting. It is networking that lets people become interesting because of its casual tone. If you want to avoid being passed by as “just another applicant” for a residency slot, you need to engage in networking.

It can be difficult to network as a foreign medical graduate (FMG), which is why you need to pursue every opportunity for meeting residency staff and faculty.

5 Ways to Network

  1. Conventions

One great way to get to know people in residency programs you are seeking is to go to conferences. Bring business cards and get out there and mingle. MDlinx.com is a great place to find conferences that cater to the specialties in which you are interested. After you network, follow up with the people you meet. If you are in their area, visit the hospital. Ask a faculty member if they wouldn’t mind giving you a quick tour. If you do this professionally, they will remember you, and you may have moved your way up their rank order list.

  1. Away Rotations

If you can find an away rotation at a place where you’d like to stay long-term, this is a great way to become a shoo-in for a residency program. This gives the program faculty a chance to get to know you and know whether or not they think you are a good fit. This does make away rotations a bit risky, but if you are a good fit, this should elevate your status when it comes time for a match.

  1. Connections

As a FMG, you may not have a lot of family in the area, but surely you have some friends and other connections. Make sure you scour your contact list for connections with residencies, and then talk to those people. You may be able to meet a residency program member in a casual setting prior to having your application reviewed. This may get you an interview.

  1. Current Residents

There is nothing wrong with reaching out to current residents. After all, you may be working with them in the future. Hang out with them, and find out what they think of the program. If you befriend some of the residents, they will put in a good word. Remember, everyone that works for the residency program has some influence over whether or not you are considered for the residency. Whether it’s a physician or a file clerk, use your connections to make yourself stand out.

  1. Letter of Intent

If you’ve already interviewed, and you know you’d be a good fit for the residency program, you may want to send a letter of intent. This lets the program know that you are very interested in pursuing their residency and that they’ll be on your rank order list. There are varying opinions on whether or not this will move you up on their rank order list, but the overall consensus is that it won’t do any harm. Basically, if you weren’t being considered, it probably won’t change that. But if you were being considered, it could move you up on the list.

Selling Yourself

Networking is a big part of a successful match, but it can be done in the wrong way. Don’t be pushy, unprofessional, or desperate. This is not the way to sell yourself. Instead, be genuine and show true interest. Don’t be afraid to boast about specific research or clinical experience that makes you a great candidate. Don’t be braggadocios, but be proud of your accomplishments. Highlight the things you have done, and don’t let test scores hold you back. Even if a residency “requires” a certain score, they will make an exception for a candidate who is likable and whom they could see working with in the future.

Getting Over Nerves

If networking makes you feel stressed, you are not alone, but you need to practice. Talk with your friends about your accomplishments and get over any reservations you have about selling yourself. Then, move on to people you don’t know as well. You need to be confident when you meet residency faculty whether this meeting is at a conference, at a café, or during an official interview.

Is it too late?

If you are already in the Match, there aren’t likely to be conferences with residency program directors in attendance because they are very busy looking through applications and making their own rank order lists. However, it’s not too late to engage in other networking methods. The biggest thing to remember is that you need to stand out among a pool of applicants with a similar background. The best way to stand out is to meet people outside of the work setting, so they can see you as a real person who would make a good team member, and not just another applicant.

Foreign Medical Graduates Filling Primary Care Gap

There is a primary care provider shortage in the United States that is only growing as elderly and obese populations grow and increase demands on the medical community. Much of their treatment involves a heavy concentration on family or internal medicine to help patients adhere to effective health maintenance strategies. Yet, most U.S. medical graduates seek careers in sub-specialty medical fields where the pay is higher, and the paperwork is less.

While it is understandable to want a higher paying career with less paperwork, primary care physicians are not low income workers. The average income of a primary care physician in the United States is over $200,000 per year. Primary care workers also get the advantage of knowing their patients, and they get to take part in the continuance of care where real results often take place. Their place in the medical community is essential for all populations, and primary care doctors should be proud of their role in society.

Opportunity for FMGs

The current predicament of low numbers of U.S. Medical Graduates seeking primary care positions is an opportunity for Foreign Medical Graduates (FMGs). The number of family medicine positions available, for example, has increased each year since 2008. However, the amount of U.S. Medical Graduates seeking those positions has remained stable. This means that there are more available family practice positions, but U.S. Medical Graduates are not filling them.

Foreign Medical Graduates frequently struggle to get into residency programs during the Match. This is hopefully becoming less common, as the nation (and program directors) realizes the advantage of adding physicians who have been trained abroad to the mix of U.S. health care providers. However, it is still a struggle.

A lot of this struggle has to do with the unknown, and different areas of the world have different requirements and different demands for excellence. The Educational Commission for Foreign Medical Graduates (ECFMG) tries to alleviate the number of unknowns by using its own set of credentials including requiring that medical schools belong to a list of accepted schools. However, there is still a bit of uncertainty about exactly how one country’s approach to medical education compares to the United States’ approach.

There is also a want to give opportunities to medical students who received their education within the United States in an effort to better the country’s resources. If U.S. Medical Graduates aren’t seeking primary care professions, this ability to give opportunity will have to be shifted to FMGs.

Rural and Underserved Regions

One of the biggest challenges to providing primary care to all individuals within the U.S. is getting care to those who are in rural or otherwise underserved areas. Physicians who specialize are often in or near the city. There are also a lot of primary care providers who live or work in the city. This leaves little care for those who live in rural and underserved areas.

What does this mean for FMGs? It means the ability to start your own rural healthcare practice with little competition. It means being on a first-name basis with most of your patients. It also means having time to care for your patients and not having to run them through your exams like they are cogs on a wheel. Rural healthcare has lost its appeal for many entering the healthcare field who want the chaotic urban healthcare environment, but there are many benefits to rural healthcare that are taken for granted.

Choosing Primary Care During the Match

If you are a FMG with dreams of a particular sub-specialty, you should follow your heart and your brain. However, if you think providing care in a rural area, or providing general care to the public, is within your realm of happiness, opt for primary care. Not only do you have a better chance of getting into a residency because of the larger number of slots available for FMGs, but you would be filling a gap in the U.S. Healthcare System that is badly needed to be filled.

What about pay and paperwork?

The average pay for a physician in a rural area is enough to support a very comfortable lifestyle, pay off student loans, and save for retirement. Rural areas of the U.S. generally have lesser living expenses, so average physician salaries amount to higher amounts when all things are considered.

As far as paperwork, EHRs have made data entry a requirement for the job, and primary care providers seem to have to highest amount of information to enter because all body systems are involved in the primary care wheelhouse. There isn’t much that can be done about this chore, but hopefully the act of caring for a patient in his or her entirety makes up for the paperwork somewhat.

In many cases, the occupation of a primary care giver is what made medical graduates choose their profession in the first place. You will know your patients, and they will depend on you in order to take care of their medical needs.

Choosing a Specialty

If you have not chosen a specialty yet, you may have noticed that it is not as easy as it sounds. You may be drawn to one specialty, but more likely you are torn between a few or even many choices. Medicine is stimulating, relevant and fulfilling in broad specialties such as family medicine but also in narrower specialties such as radiation oncology. What draws you to one may be a lifestyle choice, or it may be a deeper calling. In either case, you want it to be a choice you can stick with for a long while.

What are my specialty options?

The American Medical Association (AMA) provides a database of 11,000 accredited residency programs, and that database is FREIDA. Common specialty choices are:

  • Allergy and Immunology
  • Anesthesiology
  • Cardiovascular Disease
  • Child and Adolescent Psychiatry
  • Colon and Rectal Surgery
  • Critical Care Medicine
  • Cytopathology
  • Dermatology
  • Emergency Medicine
  • Endocrinology, Diabetes and Metabolism
  • Family Medicine
  • Gastroenterology
  • General Preventive Medicine and Public Health
  • Geriatric Medicine
  • Hematology
  • Hospice and Palliative Medicine
  • Infectious Diseases
  • Internal Medicine
  • Interventional Cardiology
  • Medical Genetics and Genomics
  • Medical Oncology
  • Nephrology
  • Neurological Surgery
  • Neurology
  • Nuclear Medicine
  • Obstetrics and Gynecology
  • Occupational Medicine
  • Ophthalmology
  • Orthopedic Sports Medicine
  • Otolaryngology
  • Pain Medicine
  • Pathology
  • Pediatric Surgery
  • Pediatrics
  • Physical Medicine and Rehabilitation
  • Plastic Surgery
  • Preventive Medicine
  • Psychiatry
  • Pulmonary Disease and Critical Care Medicine
  • Radiation Oncology
  • Radiology – Diagnostic
  • Radiology – Interventional and Diagnostic
  • Rheumatology
  • Sleep Medicine
  • Surgery – General
  • Thoracic Surgery
  • Urology
  • Vascular Surgery

This list can be found on the AMA’s website with links providing more training information.

How to Choose One Specialty

There are many ways to choose a specialty, and the advantage of doing it early is that you have more time to plan. First year medical students who successfully decide on a specialty can tailor every medical school decision to that specialty. However, if you aren’t sure as a first-year medical student, it’s better to wait than to try to force a choice too early. Here are a few ways to help you along regardless of whether you are entering medical school or choosing programs for The Match.

Set Goals:

You have to know what you want before you can start looking for it, and many medical students have misplaced dreams about reputation or riches. Entering a specialty because of the pay will not ensure a successful path to residency. Instead, focus on more functional aspects of the specialty such as the population it serves, geographic limitations, and lifestyle provisions. For example, you may find that emergency medicine hours do not suit your lifestyle despite the pay, and family medicine affords you the lifestyle you want to live comfortably and have time for leisure. On the other hand, maybe you want the excitement that the emergency room can provide, and saving lives in traumatic situations is fulfilling. If you want to fight infectious disease, there may be geographic limitations. There are factors in residency programs and the subsequent medical careers that are much more important than how impressive it is or how much money you make.

Gather Information:

Once you know what you want, you should find out all you can about the residency programs available. One way to do this is by attending residency fairs such as the AAFP National Conference or the AMSA Residency Fair. Looking on program websites is another way to find out if they offer what you are looking for, and you can find out if you meet the prerequisites to enter the program.


You should be fairly methodical about your choice. That does not mean don’t choose from the heart…or the gut, but make sure you verify that with more objective means. Make lists of pros and cons. Research facts about job prospects and the future of the specialty. Get an idea of where you are going to have to live to support a career in that field of medicine. For example, some surgical specialties may not have a lot of prospects in rural areas where hospital resources are minimal. Spend a good amount of time reflecting back upon your goals and making sure your specialty reflects those goals. Then, make sure your heart…or your gut agrees. You should objectively and subjectively feel good about your choice.

Follow Your Passion

Money should not be the driving force behind your medical specialty choice, but it may be a factor. In order to live certain lifestyles and have the means to travel, you will need to make a certain amount of money. However, if you are miserable doing it, you probably won’t last. Physician burnout is a real thing, and even if you think you can hack it, long hours in a position you don’t feel passionate about will wear on you. Instead, choose a specialty in which you have passion. Stanford University has a comprehensive questionnaire to help guide you in your specialty selection. It offers a roadmap for the selection process, but there is no one way to pick a specialty. That is why this choice is worth so much of your time.

Foreign Medical Graduates’ Barrier is Red Tape

According to the Association of American Medical Colleges, the United States will suffer a shortage of 122,000 doctors by 2032, which is similar to past predictions by other organizations. As aging populations with multiple, co-existing morbidities continue to grow, a shortage of this magnitude should be worrisome. People are living longer, and older physicians are retiring. For many Americans, the idea of not being able to see a physician when necessary is unimaginable. However, it is quickly becoming a reality.

One solution to the shortage of physicians in the U.S. is to enable more foreign medical graduates (FMGs) to practice medicine. There are plenty of FMGs trying to advance their medical knowledge and careers by entering the U.S. for a medical residency. There’s also too much red tape for many of them to get through. Limitations on visas and residency slots hamper America’s ability to produce enough doctors to fill this deficit.

J-1 Visa

Most FMGs apply for a J-1 visa. There are multiple requirements to be eligible for this type of visa including:

  • USMLE step 1 and step 2 CK completed and passed
  • ECFMG certification
  • Position in a graduate program or medical school
  • Statement of need from Ministry of Health

After training in the graduate program or medical school is complete, the visa holder has to go back to their home country for two years. This is intended to spread the wealth of their knowledge gained in the United States to their home country. This prevents nations from losing all of their skilled workers and increases levels of global health. It can also present significant hardship for visa holders who may not get a chance to return to the U.S. Following the 2 year return to the home country, FMGs can attempt to change their visa to an H-Temporary worker, L-Intra-company transferee or U.S. permanent resident.

J-1 visa waiver

The two-year return to home country can be waived in 3 circumstances:

  • If applicant can prove he or she will suffer in home country.
  • If applicant’s absence will be a hardship to immediate family members who are U.S. citizens.
  • Sponsorship by an Interested Governmental Agency (IGA).

Once an FMG gets a waiver and a medical license, he or she can apply for a H-1B or immigrant visa.

H-1 B Visa

To get an H-1 B visa, an FMG must have passed all USMLE exams and have an unrestricted license to practice medicine. There is no 2-year home requirement, and the FMG can be employed in the U.S. for up to 6 years. This is the best visa option for FMGs looking to enter the U.S. for a medical residency.

H1-B visa requirements

  • Position in residency or fellowship
  • Medical school graduate
  • ECFMG certification
  • USMLE steps I, II, III passed
  • State medical license if required

The story behind H1-B visas

The purpose behind H1-B visas is to get employers the skilled workers they need for their businesses. Employers petition for a pool of visa numbers, and there is a cap on the amount of visas offered at 65,000 new hires per year with 20,000 extra slots for those who have graduated with a U.S. master’s or doctorate degree. This cap is always met quickly, and the majority of H1-B visas are not in healthcare positions.

Residency Positions

Although medical schools are trying to produce more medical graduates, residencies are not able to create more slots because of a cap set by congress on the number of Medicare-funded residencies. Congress has control of how much money is allocated to teaching hospitals for residencies. The 1997 Balanced Budget Act of 1997 and 1999 capped funding, and at that time, America was looking at a surplus of physicians in the future. Things have definitely changed, but the cap has not been adjusted to make up for the shortage, mostly based on budgetary concerns. Some hospitals privately fund extra residency positions, but the majority are funded by Medicare.

Protecting the U.S.

Much of the red tape surrounding FMG visas has been an attempt to maintain the opportunities for American citizens. However, H1-B visas bring in skilled workers, and studies show that they improve the economy. One study of an increase in H1-B visas predicted that it would create 1.3 million jobs by 2045. Foreign skilled workers and FMGs are not a threat to U.S. citizen opportunity. In fact, Americans need more FMGs training to become U.S. physicians to address the shortage of physicians.

It is clear that the consideration of FMGs has not been paramount to the decision-making of the U.S. government, or else there would be more residency programs and better visa options for FMGs. However, change is coming. The looming physician shortage is scary to all Americans, and it is stimulating people to come up with solutions. One of those solutions will surely be the promotion of more FMGs into U.S. residencies. There are not many suitable alternatives.

Clinical Rotations and Foreign Medical Graduates

What are Clinical Rotations?

In the U.S., the first two years of medical school are typically classroom lectures and book-inspired learning with very little hands-on experience. But applying these skills to real life medical situations is difficult without actual experience. That is why the third and fourth years of medical school include clinical rotations.

Clinical rotations are time spent shadowing physicians and residents in order to see what it’s like to truly experience practicing medicine. Students get to participate in the medical decision-making process, and they gain the invaluable experience about uncertainty and solution-making inherent in medical practice. This may be the first time medical students have dealt first-hand with patients, so it is really an opportunity to understand the physician-patient relationship.

Core Rotations:

Core rotations are not elective, but they may vary depending on the medical school. These rotations cover the breadth of general medicine. They may include family medicine, internal medicine, pediatrics, OB/GYN, psychiatry, emergency medicine, and surgery. The learning opportunities expand as the student progresses through the rotations, and they leave with a greater understanding of their future responsibilities and skill requirements.

Elective Rotations

Elective rotations are specified and more applicable to your future hopes and dreams in the medical field. These rotations may cover subjects such as ophthalmology or plastic surgery. Elective rotations typically occur during the fourth year of medical school. Because of this, it is easy to get distracted and focused on residency rather than rotations. This can make it difficult to select rotations, and the help of an adviser or mentor is suggested to keep you on the right path.

Clinical Rotations are a Job

One thing about clinical rotations is that it can be very much like a job, and it should be treated like a job. Even though there is no pay, and you may work long hours, this is very similar to what you will do as a resident and then a practicing physician. The hours and the work environment will be similar, and rotations are a first opportunity to experience “the real world” of a physician.

It would be a mistake to underestimate the importance of rotations, and a medical student should take it seriously. This means dedication, attentiveness, eagerness, and self-care to make sure you are getting everything you can from every moment observing others in the medical field. It is also a chance for networking, and some of the professional connections you make during this time will be life/career-long.

Clinical Rotations and Foreign Medical Graduates

As a foreign medical graduate, U.S.-based experience is a must. It may be helpful to get assistance from an outside source such as FMG Portal to help you get started. Any U.S. experience obtained prior to the Match will help a student get into to more residency programs, as it will look better on applications and during interviews.

Advantages of Clinical Rotations for Foreign Medical Graduates

  • Hands-on Experience: For all medical graduates, foreign or not, clinical rotations add valuable hands-on experience that cannot be replaced by classroom lectures. Students will learn from actual doctors and in the professional setting.
  • Letters of Recommendation: When applying for residencies through the Match, foreign medical graduates will need letters of recommendation from colleagues within the United States. This sends a message to residency directors that your educational background includes cultural acclimatization and that you have experience practicing medicine in the U.S. Healthcare System.
  • Performance Evaluations: Most clinical rotations offer performance evaluations where you will be informed of you strengths and weaknesses in certain areas of medicine. This is very valuable for future studying and in order to know where to get more experience.
  • Pathway to Residency: As a foreign medical graduate, you need local training to be considered for many residency programs, and clinical rotations provide a pathway for that to occur before graduation, so you don’t have to spend time after graduation getting experience before the Match.

The outlook for foreign medical graduates is constantly getting better despite political issues causing problems with visas, etc. There is a physician shortage that must be filled, and the American people and residency directors are consistently looking at foreign medical graduates as hope for a system that is lacking.

One of the ways that you can help foreign medical graduates (yourself) along is by making sure you have the background to show that you will be a formidable physician in the U.S. Clinical rotations are one way to do that. Not only do they give you added knowledge, experience and skills to help you practice better medicine, but they also make you look good to residency directors who may be concerned about your medical school experience. This shows them that not only is your educational background strong, but you have already had success applying it to patients in the U.S.

Residency Match Program Types

When you are considering residency programs, one of the things to consider is the type of program in which you will be seeking. This includes evaluating how you will personally fit into a program, if you got along well with current residents in the program and whether or not you can see yourself their long-term. It is less about how programs rank and the reputation of the program. If it doesn’t feel right during your interview and other interactions with people in the program, then it shouldn’t appear on your rank order list.

Beginning the Match process can seem overwhelming, especially after recently finishing the USMLE-2 exam. It seems like life is one whirlwind after another, and for the foreign medical graduate (FMG), there can be added stress in communication and logistics. With this may also come difficulty over Visa processing or difficulty getting ECFMG certification. It is not easy to maneuver life throughout your transition to PGY-1 (Post-graduate year 1), and one thing that can help is understanding how residency programs are set up. If nothing else, it clarifies a bit of the “mud” when you are trying to navigate the NRMP process.

One thing you may not completely understand is the program types offered through the Match. There are 5 program types available, and they each specifically coded for your rank order list.

How are programs coded?

Each program has a 9-character code that is recognized by the rank order list computer algorithm when you create your list. The first four characters are the institution code. The next five to seven characters are the ACGME specialty code, and then comes the program type or letter. Last is the track number, which is typically zero unless there is more than one track in the program. If there are more tracks, they are listed sequentially.

For example, anesthesiology programs at George Washington University – DC have the codes 1802040A0, 180204C0 and 1802040R0. Emergency medicine programs at the same university have the codes 1802110C0 and 1802110C1. The first four characters remain the same for the university. 1802 is the code for George Washington University – DC. The number 040 is the code for anesthesiology, while the number 110 is the code for emergency medicine. Anesthesiology offers three program types, advanced (A), categorical (C) and physician reserved (R).  Emergency medicine only offers categorical (C). The anesthesiology programs only offer one track, while emergency medicine offers two tracks. The second track is an international track.

You may not think it is important to understand how the programs are coded, but understanding the codes can help you to avoid errors when choosing programs for your rank order list. It also helps to understand that there are different categories of programs for planning purposes. For example preliminary and advanced programs are meant to be ranked together but separately, as the advanced program will be on your primary rank order list, while the preliminary will be on your supplementary rank order list.

What are the categories?

There are five categories of programs, and they tell you what post-graduate year they will start in along with the level of training offered.

  1. Categorical (C).

    If the program code has a C as its second to last character, it is categorical. This means it starts in PGY-1 (year one following medical school), and it offers full residency training. At the end of the program, a resident should be prepared for specialty board certification. Common categorical specialties are internal medicine, family medicine and neurological surgery. The length of categorical programs is 3 to 5 years.

  2. Primary (M).

    Primary programs are very similar to categorical programs in that they begin in PGY-1 and prepare the resident for boards. What makes M programs different is that they focus on primary care in that specialty. For example, they may focus on primary care in internal medicine or pediatrics. These programs may only take 3 years.

  3. Preliminary (P).

    Preliminary programs are to be coupled with Advanced programs (A). Common examples of preliminary programs are internal medicine and surgery. In P programs, the skill set learned is broader and covers a variety of disciplines in preparation for Advanced programs. They may take 1 or 2 years and begin in PGY-1.

  4. Advanced (A).

    Advanced programs follow preliminary and complete the full course of training began during preliminary training. Examples of Advanced programs are anesthesiology or dermatology.

  5. Physician Reserved (R).

    Physician reserved programs are advanced programs for physicians with graduate medical education. There are not many positions available in these programs, and they are for physicians that already have prerequisite resident training. These programs begin in PGY-1.

If you are beginning your journey to the Match, you may feel like it is a little premature to start figuring out the details of programs and how they are handled by NRMP to make sure your Match meets your needs and the needs of the program. However, there is a wealth of information and small details that can confuse the process if you aren’t adequately prepared. Casually studying these details will reduce the stress of the Match once it comes time for interviews and ranking.

Strategy, Stamina and Truth: The Path to a Residency

There are many motivating factors that influence one to enter medical school, and some of them are better than others. Your passion for medicine is a good one, and it may be coupled with family pressure or monetary expectations. These are not bad motivations, but becoming a doctor is more difficult than motivation, and if you are preparing for the Match, your path to a Match is far from over. That is why there are a few tools you can use to mentally prep yourself into a successful medical career.

Three Tools for a Successful Match


Strategy is basically the planning process. You don’t just go to medical school, get a couple good recommendations, and Match in a residency program. Of course, there are the tests necessary to apply for residency, such as USMLE step 1 and USMLE step 2. However, more importantly is knowing what you need to get into the program you want.

When you entered medical school, you probably had an idea of the direction you would go. Maybe you were interested in pathology or plastic surgery. By your third year in medical school, you should have it narrowed down to one or two specialties.

After you know where to focus your efforts, you need to look at the requirements. What test scores are required to be considered for that residency program? How are you going to study for the boards? Are there sub-internships available? Find an overseas rotation in the U.S. and make sure you are doing it.

Your efforts should be targeted, and the target should be clear. This will make all of your efforts efficient, so you won’t waste time where it doesn’t need to be spent. You don’t need to study 12 hours a day to get into the residency of your dreams. In fact, over studying can diminish retention. So, focus and plan your efforts to a Match.


You must already have a can-do attitude, or you wouldn’t have made it this far. From now on, any procrastinating tendencies you have must be disregarded for committed action. This means committed action in all walks of life.

It is natural to find excuses why you cannot or should not do something. When faced with adversity, our natural inclination is to preserve and protect instead of fight until the end. Some physicians will reflect on residency as “not that bad” or “most people could do it if they tried.” This is not true! They are either remembering incorrectly in a fit of nostalgia, or they are one of a handful of geniuses on the planet gifted with unreasonable talent.

Don’t expect anything to be easy, and don’t plan on waiting for anything. If you want to do something to prep for the Match, get started now and keep going.


There is some hard honesty that must be had during this journey. One of those truths involves self-reflection. If you are holding on to dreams of a surgical residency, but you just don’t fit in with that group of people or are having second thoughts for other reasons, go with your gut! This is going to be your life. Good physicians don’t clock out at 5 p.m. on the dot, and neither do happy physicians. Recognize the places where you fit, and you’ll shine.

It can cost some money to prepare for your tests, but you need those scores to get into your program of choice. Accept the reality that prep courses work, and you’ll maximize every second spent studying. Some courses to consider are Kaplan, UWorld, and Doctors in Training. You may spend thousands on prep, but think about the time and money you’ll save in the long run. A couple thousand is worth it to capitalize on the hundreds of thousands you may have spent on education.

Lastly, be honest about the integrity of the advice you receive. Listen to the person who bombed their step tests, but take any advice with a grain of salt. They don’t know how to get to where you want to be, as they weren’t able to do it themselves. Unfortunately, these people are typically forthcoming with their advice.

Learn from the mistakes of others, but seek out advice from people who have been successful. They know how to get over the hurdles of residency. Hopefully, they are willing to share. You don’t need to know how not to pass the USMLE or how not to succeed in an interview. The accounts of people who have failed may contain a few useful do-nots, but they contain no how-tos. The tips from successful applicants will be much more valuable.

You are getting so close to becoming a physician, but you still have a long and tough road to travel. With strategy, stamina, and truth, you will be able to reach the end of that road with a career that was meant to be, and one which you will be able to enjoy. Success is not just about money and prestige…but you can have it all in your medical career if you listen to yourself and plan accordingly.