“So what are you applying for this year?” one of my US medical student colleagues would ask cordially. “Dermatology”, I’d reply, and watch as they would raise their eyebrows. Some of them would make a better effort than others, “Ohh, wow! Awesome… all the best!’ While others would actually just burst out laughing and tell me “good luck with that”, assuming that I was naive, confused, and hadn’t got the memo clearly that immigrant doctors aren’t allowed into the competitive specialties.

Fast forward a few years, and here I am, about to start my final year in dermatology training as one of the Chief Residents. Now, the purpose of that intro wasn’t just so that I could say “who’s laughing now????” (although that does feel a little bit satisfying). I tell that story so that you guys, as IMGs, can be prepared and understand what you’re getting yourselves into should you decide that specialties like dermatology, plastic surgery, orthopedic surgery, ENT etc. are the ones you are solely focused on. People will raise their eyebrows. They may laugh. They may tell you in person or on online forums that you’re insane, arrogant and should give up. And that’s not only the US medical students, but your fellow IMGs too (sometimes we are our own worst enemies in this process!) But if you know that one of those is the only field in which you could practice happily for the rest of your career, it’s your job to find a way to make that happen.

Now, as I regularly say in these blogs, my job is not just to inspire you with fluffy language and tell you to ‘make your dreams come true’. I will always give it to you straight, with the facts, good, bad or ugly. In this case, even a quick glance at some of the Charting Outcomes in the Match data (last available from 2018 for IMGs) can get pretty ugly pretty quickly.

You can look up the number of IMGs who matched into the available positions in the competitive specialties I mentioned above (including in the 2019-2020 cycle), and you’ll see that, on the whole, we’re talking in the low single digits as a percentage.

The website I linked has a bunch of data visualizations showing in a little bit more detail the applicant characteristics of those IMGs who did successfully match, in terms of things like their Step 1 scores, their number of publications etc. so I do encourage you to look carefully at those breakdows for your preferred specialties.

The Obvious Stuff

I know I’m not telling you anything earth shattering here, but there are certain obvious aspects of your application that you’re going to have to ensure are strong if you want any chance of pursuing one of these hypercompetitive specialties.

Scores

First and foremost, the USMLE Step 1 score. There was an announcement in February 2020 that anyone taking their Step 1 after January 2022 will no longer receive a 3 digit numeric score, and that instead, the exam will be moved to a ‘pass/fail’ designation. This was received with a lot of relief by many medical students across the world, as this notoriously difficult exam and the pressure to do well in it drove many of us to near insanity. However, I would pause the celebrations if you’re one of the IMGs passionate about a hypercompetitive specialty. Although there is no way of saying for sure at this stage, I personally think this will be a disaster for those applicants. The Step 1 exam, for all its flaws, acted as one of the only objective, universal, easily reviewed aspects of a candidate’s academic strengths, allowing rapid comparison of even IMG and US medical students. Getting an outstanding Step 1 score was one of the only strong ways an IMG could get their foot ‘through the door’ in order to be taken seriously by Program Directors for a field like orthopedic surgery. “Yeah, he’s an IMG from the UAE, but did you see his board scores? We should interview this guy.”

When the Step 1 becomes ‘Pass/Fail’, you lose one potential part of our application that could make a reviewer stop in their tracks before filtering you out as an IMG.

For this reason, I encourage any of you who harbor hopes of chasing one of these competitive specialties to do everything in your power to take the Step 1 before it becomes Pass/Fail only.

You may ask; if it’s becoming pass/fail only, do these programs still even care about Step 1 scores now? Yes, yes they do. The chairmen/ program directors in these programs are often very senior clinicians who have been in these positions for decades. They are creatures of habit, and for them, the resident recruitment process is a fairly standardised process year on year. If their reflex is to ask about Step 1 scores for the last 10 years, they will continue to ask about them until such a point as they are no longer available.

In the short term, the main immediate difference this intervention is likely to make, is that also now give a larger amount of importance to the USMLE Step 2 CK exam, which will continue to have a 3 digit score even after January 2022. If you’re not sure what the differences are between the Step 1 and Step 2 CK exam, we cover this in excruciating detail in our online course, so refer to that along with this article.

So yeah, bottom line, do really, really well in these exams (don’t worry, we’ll teach you how in our videos).

Publications

Throughout my years in medical school, I grew to hate the word ‘publications’ so much. It felt like something that was always at the back of my mind, gnawing away at me with guilt. I knew it was something I should be doing, but I didn’t really understand what it was or how I should go about ‘getting publications’.

Unfortunately, irrespective of what we might think of this often frivolous pursuit of case reports, just for the sake of getting a number on our CVs, it’s a game you will need to play if you’re applying for a hyper competitive specialty as an IMG. Fields such as orthopedic surgery are especially notorious for favoring IMGs who are ‘well published’, with successful previous IMG applicants sometimes averaging 17 publications.

That sounds insane (because it is). But don’t despair just yet! Hardly any programs have a high ‘cut off’ when it comes to number of publications, because it’s not something that can be easily filtered for on the application system without losing potentially brilliant candidates. What this means is that it’s more about what your application tells them about you as a person - can you get a healthy combination of publications in peer-reviewed journals, ideally one or two as first author, and some posters etc. to give the reviewer the impression that you are someone who is serious about academia and self-motivated? Most initial application reviewers will not go into all the details about how interesting or detailed your case report was, or how many citations your review article actually had. So in a lot of ways, quantity does trump quality (even if ideally you want both).

I’ll be writing another blog in future giving you guys some tips on how to get publications, but for now, let’s just acknowledge that having more of these will give you a better chance as an IMG of matching into a competitive specialty.

Electives/ LORs

I say this over and over again to almost any IMG I ever give advice to.

“You need to become a real life person in their eyes, not just a foreign sounding name on paper”.

This is human nature. How many times have you read about something tragic happening to someone where you see their name, but it basically makes you feel nothing. Not because you’re a sociopath (I hope… although some of you may be), but because it just doesn’t feel real to you! Now, substitute in that same tragic story, and have a video clip accompanying it where you see the person walking around and talking into the camera, and all of a sudden, it really hits home to you.

Interview selection committees are made up of human beings (although I’m convinced some of them are part gargoyle). If they have had a chance to meet you in person, interact with you, see that you are fluent in English and someone enjoyable to work with, then when it comes time to see your name on the application as they review you, they can suddenly generate an image of you as a real life human and they are so much more motivated to give you a call back.

This is why doing electives in your top choice department is essential. You should assume that wherever you go on your elective is the strongest possible chance you have for getting an interview in a competitive specialty. So, choose wisely! We go into greater detail explaining the different types of elective, and how to make the most of your time on elective in our videos, so don’t miss those!

Letters of Recommendation are basically the next best thing. “Hey, we know you haven’t had the chance to meet this person, but here I am, as a trusted fellow US physician, telling you that I met them before and I can vouch for the fact they are a good person.” A strong letter of recommendation has the effect of making the reader feel like they know you.

“Rohan is a breath of fresh air to work with. His dedication, humility and compassion were on clear display throughout his time with me. I remember an occasion where I was walking through the wards late one evening, after I thought the day team had all gone home. I saw Rohan sitting with one of his elderly patients at the bedside, helping them figure out how to dial the number on the hospital phone to reach their daughter. Neither he, nor any of the other residents, ever mentioned this to me, and that is indicative to me of Rohan’s self-sacrificing and genuine commitment to helping his patients.”

Let’s be honest - we all love Rohan now, don’t we? I’m calling Rohan for an interview because I can now imagine the kind of person he is. He’s no longer just another foreign name from a foreign university - he’s Rohan! The wonderful human being who helps his hapless old patient stay in touch with their daughter!

Research Fellowships

The idea of having to commit to a research fellowship at a department before applying to residency there is one that a lot of IMGs are uncomfortable with. “They should be willing to take me without that if they really like me!”

That may be true for some specialties like Internal Medicine, Pathology, Psychiatry or Pediatrics, where the match rates for IMG applicants are fairly high. But if you’re an IMG aiming for the hypercompetitive specialties, you need to get rid of this idea immediately.

Increasingly, US medical graduates understand clearly that if they want a strong chance of matching into a field like dermatology, they likely will have to commit some time to a department as a research fellow. Whether they take a break between their 3rd and 4th years of medical school, or an enforced break after an unsuccessful match attempt, US medical graduates often will have committed one or two, often unpaid years of research to a department if they’re applying for a very competitive residency. If that’s the case for US students, just imagine how much more true this is for IMGs.

Building on from the last section about becoming a ‘real person’ in their eyes, working in a department as a research fellow gives you often a year or two to not only become a real person, but become a cherished colleague in one of these departments. The goodwill you can build towards yourself can catapult you into a residency spot you may not have had a chance at before. It also shows a tremendous amount of loyalty and commitment to a program, something they often will repay.

Don’t get me wrong; even getting a research fellowship in one of these departments can be immensely competitive, as they are increasingly being appreciated as runways to residency. Also, there are countless examples of IMGs choosing the ‘wrong’ fellowships, getting abused as low cost labor for a few years, and then not being taken as a resident after this period of time, so it’s not all rosy!

I’ll be writing a blog in the future explaining how to find a good research fellowship, what are the key aspects to research before accepting a job, and how to make the most of it once you get one.

My Own Story (Conclusion)

So, I’ve explained these different aspects in the abstract. Let me just talk you through my journey briefly and it’ll tie together the above points as a recap.

• I studied hard, and effectively, for my Step exams. I got a 262 in my Step 1, and a 264 in my Step 2 CK.
• My total number of publications and posters combined were 18.
• I did electives at the Cleveland Clinic Dermatology department, and also at the Hospital for Special Surgery (orthopedics - I’ll explain in the videos!) and got strong LORs.
• I also met with the Mount Sinai Dermatology Program Director, and once I had informed him of my Step scores and we’d had a chance to meet (become a real life person…) I was offered a Post-doctoral Research Fellowship with the department.
• I worked at Mount Sinai’s Dermatology department from October to March during the year I was applying for the Match. I received interviews from a number of programs, including Mount Sinai, Cleveland Clinic and Harvard, and ultimately stayed at Mount Sinai.
• I’m about to enter my 3rd year as a resident at Mount Sinai.
  
  

So yes, you can see how the various aspects I discussed above in theory were put into practical use here. And this isn’t just a one off. A colleague of mine from medical school was committed to pursuing orthopedic surgery as an IMG. We discussed it, I offered the above advice and mentoring, and her journey concluded just this year with her matching into the Cleveland Clinic Orthopedic surgery residency program in the 2019-2020 cycle.

I’m going to persuade her to film a video for us in the not too distant future sharing her experiences, so watch this space!

It’s not going to be easy, but if you are truly committed to pursuing one of these hypercompetitive specialties as an IMG, you have clear proof in front of you that it is possible. We can help you make that a reality.

How can I find out more about moving my career to the U.S.?

If, based on this article or just generally based on interest you've had from before, you want to find out more about how a doctor/medical student from India, the UK,  Pakistan, South America etc. can actually go about moving their career to the U.S., we can help. We've produced the most thorough, A-Z, step-by-step guide on the process of international medical doctors moving to the U.S. that we've seen anywhere. Check out our 'How To Make It In America' course for more details, including an in-depth discussion of all of the other most common 'pros and cons' of moving your career to the U.S. We also provide insider tips and advice on how to ace the USMLE exams (all 4 of them), to secure electives and make the most of those, how to get incredibe letters of recommendation, the entire 'Match' application process, as well as visas and immigration advice!

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