Road to residency in the United States

We’ll use this post to describe the steps you need to take en route to a medical residency spot in the US. We’ll list these steps first and then expand with relevant information. Hopefully we can make the process more clear for you and help you get that residency position.

The most important steps are:

1. Taking the USMLE Step 1, Step 2 CK, and Step 2 CS exams.

2. Getting ECFMG certified.

3. Applying to residency programs using ERAS.

4. Applying for the NRMP MATCH (unless you were offered a pre-match position).

5. Attend residency interviews.

6. Get your MATCH results. Usually in March of every year.

There are other important things that need to be done during or in between these steps. For example, it is important to get United States clinical experience (USCE) in the form of externships while you are still in medical school as well as getting letters of recommendation (LORs) preferably from practicing physicians in the United States. We’ll be discussing these topics in the future.

MORE INFORMATION ON EACH STEP:

1. USMLE Exams:

The United States Medical Licensing Examinations (USMLE) consist of 4 exams; 3 of which are mandatory for applying to a residency program. The 4th exam (USMLE Step 3) is only needed if you’re applying for an H1B visa rather than a J1 visa. More information about the types of visas you can use for residency will be explained in a later article.

– Step 1: This is a MCQ computer-based exam that can be taken almost anywhere in the world as long as your country has a Prometric testing centre. It is divided into seven 60-minute blocks and 1 hour of break time, for a total of 8 hours.

Topics covered include medical basic sciences from anatomy and biochemistry to pharmacology, pathology, and physiology, etc. In the past, your numerical score on this exam was the most instrumental factor in helping you land that residency position you’re after.

Starting Jan 1st, 2022, however, exam results will only be reported as pass/fail without a numerical score. On the plus side, this means you might not have to study for this exam as much as you had to in the past since it doesn’t matter how well you do as long as you pass. This was the most challenging of the Steps to score high on and the one that needed the most study time, especially for IMGs who were sitting for the exam after graduation or after being years away from studying basic sciences. This meant that in the past, IMG prep time for Step 1 averaged anywhere from a few months to many years. So from this stand point, as a future applicant, this is an advantage.

However, on the flip side, this means that you can no longer use this exam and an opportunity to showcase your big brains to programs. Further, with Step 2 CK now becoming the only standardized exam with a numerical score, more importance will be placed on how you score on Step 2 CK and thus, you might have to spend more time studying for that exam. We talk more about this new change here.

– Step 2 CK (Clinical Knowledge): This is also a MCQ computer-based exam that can also be taken almost anywhere in the world as long as your country has a Prometric testing centre. There is 1 extra block of questions compared to Step 1, and the exam is divided into eight 60-minute blocks and 1 hour of break time, for a total of 9 hours. Unlike Step 1, this is a more clinical-based exam, in which specialties such as internal medicine, pediatrics, obstetrics & gynecology, surgery, and others are tested. With Step 1 scores moving to a pass/fail system, this exam will become more essential for IMGs to do well on. This exam usually needs much less prep time than Step 1, but with the recent changes, you want to try and get the highest possible score.

Here’s a graphic from the 2018 NRMP Program Director Survey. As you can see, Step 1 score used to be the most important factor for interview consideration. Starting 2022, Step 2 CK will likely take its place in the 2022 NRMP Program Director Survery.

– Step 2 CS (Clinical Skills): This was the only practical Step exam where you will need to take care of patients (actors) with medical complaints. It consisted of 12 patient encounters and lasted approximately 8 hours. Unlike Step 1 and Step 2 CK, This exam that could only be taken in the United States at 1 of 6 testing centres in the country. The most important areas that were evaluated are test taker communication skills (CIS), spoken English proficiency (SEP), and the integrated clinical encounter (ICE) which is related to medical knowledge.

We were using past tense verbs there because we have some good news! On Jan 26, 2021, the Step 2 CS exam was PERMANENTLY cancelled.

"We have no plans to bring back Step 2 CS, but we intend to take this opportunity to focus on working with our colleagues in medical education and at the state medical boards to determine innovative ways to assess clinical skills," the USMLE statement said.

This means that although the Step 2 CS has been cancelled, there will likely be an alternative method for assessing your clinical skills. So I wouldn’t get all too excited right away. In the mean time, there are 5 alternatives to Step 2 CS that an applicant can use to apply for residency with the most common being the Occupational English Test (OET). More information on these alternatives can be found here. https://www.ecfmg.org/certification-requirements-2021-match/

– Step 3: Although this is also a computer-based exam, it can only be taken in the US over 2 days. It is not mandatory for the application to residency unless you are pursuing an H1B visa. Some IMG’s choose to take this exam before starting residency, but it is usually done during the first year or two of residency.

2. ECFMG Certification:

The Educational Commission for Foreign Medical Graduates (ECFMG) is the organization that takes care of certifying IMGs applying to a medical residency program.

There are 2 major requirements for the certification: examinations (USMLE) and medical education verification. This certificate is neither a medical degree nor does it allow IMGs to practice in the United States. Rather, this certificate from the ECFMG is provided to IMGs when they’ve taken the required USMLE exams and their medical degrees and credentials are verified by their medical school. It usually takes 2-4 weeks to get certified after you have taken and passed all your USMLE exams. It’s best to have your ECFMG certificate before applying to residency programs. You can start applying to residency programs in September usually, so make sure you have taken all your USMLE exams and have their grades by early August to allow some time for processing of your certificate.

The main points to know are the 2 fundamental requirements for getting certified:

1. Passing the USMLE Step 1, Step 2 CK, and Step 2 CS (or alternative) exams.

2. Medical education credentials verification. This is done by your medical school administrators. You might have to nag them a bit, but the role you play in this process is taking and passing those USMLE exams mentioned above.

We talk more extensively about getting ECFMG certified here.

3. Applying to residency programs using the Electronic Residency Application System – ERAS:

The Electronic Residency Application System (ERAS) is an electronic system that allows candidates to apply to the different residencies (internal medicine, surgery, radiology, OBGYN, etc.) provided by the American Medical Association (AMA). It offers a centralized but flexible solution for building and delivering your application and supporting materials to programs without the hassle of applying to each hospital individually. The ERAS application portal opens usually opens in September and like we mentioned earlier, it’s best to be ECFMG certified before this date. This means taking and having your score reports available by August at the most to allow for time to process your certificate which usually takes 2-4 weeks.

If you can’t do so, you are allowed to apply without it initially, but this means you will have to then individually contact programs when it is ready because programs usually download your application at the beginning of the season and you will have to update them on new changes.

4. Applying for the NRMP MATCH

Remember, registration with ERAS does not mean you are registered with the National Resident Matching Program (NRMP). ERAS is used to handle applications and interviews, while the NRMP handles the process of matching candidates to programs. You should register with NRMP before November 30th to avoid late fees. You will use the NRMP website to rank programs you interviewed with from your favourite to least favourite in what’s referred to as a Rank Order List (ROL). Programs also send their Rank Order Lists for applicants they interviewed.

In March of every year, an algorithm works on matching candidates and programs based on their ROL.

5. Residency interviews:

After applying to programs, they will then select candidates for interviews. This can be a stressful waiting period, especially for IMGs whose applications are usually reviewed after American candidates. Interview season usually means travelling across the US and attending these interviews in person. However, with COVID rampant around the world, interviews for the 2021 match were held exclusively online. We will have to wait and see how they will be conducted in the future.

Something to keep in mind is that the more invitations you get, the higher your chances of matching are.

6. Get your MATCH results:

Finally, the Match week is usually in March. You will receive an email from the NRMP letting you know if you have matched. You will not know where you have matched right away, but on Match day, you’ll be informed of where you’ll be training for the next few years. All your hard work has lead to those 3 sweet words “you have matched”. We talk about the match more extensively here.

We hope this summary of the process has helped you get more familiar with the road to medical residency in the States. It may seem overwhelming especially when starting out, but it’s important to remember that these steps are done by thousands of IMGs just like you every year. Keep in mind that these steps are done one at a time with enough time to do each if you start early and know what you’re doing. In the beginning, this pathway may be stressful and overwhelming, but it is totally doable. One Step at a time!