The Guide

After you have done a lot of thinking, if you are considering training in the US, then start making plans early. It’s much harder to get into a residency program as an international medical graduate (IMG) compared to a US graduate (and even harder if you choose an already competitive specialty), so preparation is key. Here are the main requirements to apply for residency:

1.USMLE Step 1

This is the most important exam you will take if you want to train in the US as an IMG. Most people pass, but what really matters is your actual score. Have a look on the USMLE website for score distributions and means, and you’ll see that for the most competitive specialties (e.g. plastics, orthopaedics, dermatology), successful applicants tend to score within the top 10-15% of all test takers. If you want to train in the US, the best time to take Step 1 is your penultimate year, or a bit later. It’s heavy on preclinical topics such as anatomy, biochemistry, physiology, pathology and embryology, but each question is framed as a clinical vignette, so some clinical knowledge is required.

2.USMLE Step 2 Clinical Knowledge

This tests clinical knowledge, judgement and reasoning. It’s also an important test, though usually not as much as Step 1. Nevertheless, a great Step 2 CK score can help mitigate a less good score on Step 1. The best time to sit Step 2 CK is in the final year of medical school or later.

3.USMLE Step 2 Clinical Skills

This is an OSCE-style exam in which you interview patients and then type up your ‘patient notes’, including history, examination and diagnosis. You will need to go to the US to sit this exam as it is not offered internationally. The best time to sit Step 2 CS is in the final year of medical school or later.

4.Letters of recommendation (LoRs) 

To apply for residency, you need to have LoRs from at least 3 US doctors who have seen you work in a clinical setting in the US. The best time to get these letters as a student is by going to the US for your elective. Importantly, when applying for electives, you should look for ‘clerkships’, ‘clinical electives’, or ‘subinternships’ (where you will essentially be treated as an FY1-equivalent) to get hands-on clinical experience. ‘Observerships’ are shadowing electives where you won’t be allowed to perform any clinical activities, so whilst the doctor you shadow can write a LoR, they won’t be able to comment on your clinical ability. Some residency programs will not accept observerships as US clinical experience. Note the ‘status’ of the doctor/institution you do your elective with, because as controversial as it may be, a LoR from a well-known doctor/institution may hold more weight. 

5.CV and Personal Statement

Check out our Guidance and Lessons on CV development and writing.

6.Visas

There are 2 main types, H1-b and J1. I won’t go into detail about them here, but it’s vital you do your homework on which one is best for you; your visa is the bedrock of your application, and will play the biggest role in shaping your plan if you want to move to the US. For example, the J1 visa has a duration of 3 years, which can have implications for a residency program that is longer than 3 years (there are a few solutions to this problem, best to look them up for yourself).

7.Medical degree & transcripts

As an IMG, can only apply to US residency programs after you have your medical degree, which means applying during FY1 year at the earliest.