Yes USMLE scores are important - but not everything for a Medical Residency in USA!
To be Pre-Informed is to be In Form :-)
Sharing Wisdom learned through application experience and mistakes - especially for IMGs / FMGs!
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Friday, December 21, 2007
Improving chances for a Family Medicine Residency
Family medicine residency program directors tend to be cautious about applicants with good reason - residents switching over to other specialties after the first year and has been especially true for IMGs.
It gets tough to sift out applications of truly interested applicants in Family Medicine from those that are using the Family Medicine as a "Route" to clinical experience to help get into other specialties like Internal Medicine. Hence, program directors, in addition to decent scores, look for clues that suggest a high likelihood that the candidate in indeed interested in the field and will stay around to complete the program. Consequently phone interviews are on the rise and the actual interview too will focus at least some part to find out your interest in the specialty. Some programs may even send you an additional form with questions about specific experiences and career goals.
One funny thing my cousin perceived after he interviewed a good family medicine program, that the programs are even more skeptical of candidates with good scores - making one wonder if having good scores actually reduce chances there ;-) I don't believe scores should be low for the Family Medicine seeker - but here are some points to ponder to get an edge over other better profiles that might be using Family medicine as a 'backup' and show that you really mean to stick with Family Medicine.
1. Strive to have at least one Letter of Recommendation (LOR) from a U.S.-based Family Medicine physician. A LOR from a University-based Family Practice doc would probably be an important thing to concentrate on after scores. A private practice doc's LOR might do you more good in the local residency programs rather than other states. 2. You can derive point 2. from point 1. = Try to keep your clinical Experiences specific to Family Medicine (Called Community Medicine or Preventive and Social Medicine in some countries).
3. Let your Resume ( on MyERAS, that is) show ample volunteering experience and clinical work in community / public health domain.
4. For IMGs considering the GRE Route to enter the USA, an MPH degree might be the best choice. During the program, gathering experiences in epidemiology, field studies and teaming up with people in the program that publish a lot of articles in public health medicine is a plus. To allow you ample time to do all that during the course, make sure you take Steps ! and Step 2 CK BEFORE you land in the USA.
5. Any field or medical specialty is great if you are sure you will enjoy it and are stimulated by it. So, be really sure you want to be in Family Medicine. Google information on job descriptions, pros, cons and interviews with Family medicine docs, etc. to learn about the field. You also might read my post about Choosing a medical Specialty ;-)
6. On the interview if asked about if you applied to Internal Medicine - you can always say either no or that you only applied to primary care program tracks in Internal Medicine, which you should if you like family medicine.
7. And of course, the usual technical tips apply - try to apply 1st September with Step 1, Step 2 CK and CS already reported and other tips like I mentioned before.
How To Choose Your Specialty : A Funny Perspective
Probably many of you web-savvy medicos of today have already seen it. I have no idea of its source, so if any of you people happen to know, kindly point it out to me.
Check out this flowchart :
It's amusing - but does cleverly point out of some facets of the personalities of physicians in those respective specialties.
I can bet a few bucks for guessing this is male artwork - since Obs+Gynecology is distinctly absent ;-)
On a more serious note, for those of you keen on determining which specialty is best for you, Take this free online Medical Specialty Aptitude Test hosted by the University of Virginia Health System. Take those results as a rough guide though - not a bible ! After all, for career satisfaction I believe that what you WANT to do is probably more important than what you CAN do. Another good one would be : Pathway Evaluation Program by the Duke University School of Medicine.
[Note: If you are the owner of this picture, do email me with documentation of ownership at digitaldoc2002@gmail.com if you would like to see this removed OR if you would like to be credited- I received it as an email forward from a friend]
Search keywords to this article:
- "How to decide what medical surgical branch is best for me" - "tips on choosing medical specialty"
Applying to Multiple Residency Specialties : Tips and Basics
As I write this post, it is that magical American summer time again and I can hardly contain my excitement about my upcoming trip to the rich green forests of Great Smoky Mountains in Tennessee, with all those wooden forest cabins, rafting and chopper-rides. When you guys get your residencies and happen to take a break there, make sure you think of me ;-) Maybe I will post a few pictures of my mini-vacation, if those are worth it...
Keeping the Smokys aside for now, let's go over a few quick questions on the matter at hand:
Q. Dude...First of all, can we even apply to multiple specialties using ERAS ?
A. Yes you can ! There are three main reasons why candidates would apply to different speciaties:
a. They are not decided at the time of application b. Applying to other specialties as a 'backup'. (e.g.: Internal Medicine candidates often apply to Family medicine as a backup) c. Because specialties that need pre-requisite prelim years, which not all programs will have, will necessitate the candidate to apply to not only the specific specialty but also prelim medicine or Surgery programs that are a pre-requisite.
Q. Will the Residency Program Directors know that we applied to other specialties ?
A. No, the ERAS program does not allow program directors to find out that you applied to other specialties - forget that - they wouldn't even know how many programs and which programs you apply even for the same specialty ! Having said that, of course there is that slight chance that program directors of different specialties at the same hospital / university discuss your excellent application and realize they are talking of the same guy/gal..lol
Q. Will I be allowed to send different Personal statements and Different Letters of Recommendation to different specialties I apply to ?
A. Yes - In fact you are allowed to have a separate customized Personal Statement for each program (highly recommended) and a different set of LORs for each program too. Unfortunately, though, you can only have one common application form - Read below.
Now, here are some points to note:
1. While ERAS is magnanimous enough to allow you apply to as many specialties as you like, there's a catch - the SAME Common Application Form (CAF) application will be sent to each of those specialties - of course you can send different Letters of Recommendation and different Personal Statement, your 'resume' that the programs will receive in the form of CAF, will remain the same. So let's say, you concentrated on applying to Pathology and made your resume look perfect for Pathology with pathology observerships, pathology research, etc. it may look wierd for Internal medicine and you cannot hide it from them!
[Personally I feel it is unfair that candidates are not allowed to restructure their resumes as per the specialties - I mean even when we apply for regular jobs, we customize the resume to highlight the job-specific strengths, don't we ? Hmmmm]
2.The Common Application Form, once submitted, cannot be changed ! Which means, after applying to a specialty, if you decide on applying to additional specialty, you CANNOT alter the CAF to customize it for the second specialty :-(
3. This does not mean that you are totally disadvantaged. Use the Personal Statement to explain the experience in the 'other specialty' and how it helped you for the specialty you are applying for. For example, guys with Internal medicine observerships applying to psychiatry as a backup could write on their personal statements how the personal connection with the patients you encountered and the impact of the illness on their perceived happiness and quality of life has drawn you psychiatry..something like that - gotta use your imagination here ;-)
4. Speaking of applying for backups - I often note how IMGs await interview calls from their main specialty of interest...and when calls don't seem to come, they hit the panic button and apply to their backup specialty in late November - which is not strategic ! Coz' the same Applying on September principle applies to the backup specialty too...
Moral of this post:
1. Applying to multiple specialties is allowed 2. It would probably would be to your advantage to apply to related specialties. 3. Use the personal statement to explain the connection of those disconnected thingies on your resume 4. Apply for backup specialties the same time you apply for your main specialty and do so very early in September :-) 5. Smoky Mountains is a great vacation place..LOL
Make no mistake, it's not all that easy as other branches for IMGs.
- It's often labelled as a "lifestyle" field, with good academic feel, free weekends, excellent pays and with minimum job stress with almost no emergencies (the only calls are frozen section diagnoses and some autopsies and most program allow residents to be "on call" from their home ! - which, well, makes it competitive
- Add to it the fact that residency positions are much less in number ! Some programs even have just a single position per year, while average is 3 to 4 per program. There maybe about 30 pathology residency programs offering H1b visas, the rest do J1 ..and waiver jobs in Pathology are tougher than compared to waiver jobs in family medicine and internal medicine. (Waiver jobs are generally more in primary care, mental health and dental health - Read more about J1-Waiver Sponsors and Specialties Here)
- Good scores, recommendation letters from US Pathologists, a PhD in related fields or Post-Graduate degrees in Pathology from home-countries are generally preferred. To get a more clear picture, have a look at the Point-system criteria that University of Iowa uses to screen applicants for their pathology residency, Click Here. Research does seem important to many programs - as Long Island Jewish Medical Center Pathology puts it on their Requirements : "Favorable consideration is also given to clinical/research experience, publications in peer-reviewed journals, previous residency training and local references."
Pathology is fast going the same way as Dermatology (near impossible for IMGs) in maybe 5 years.... for it's attractiveness to American medical Graduates as a "cool & paying branch". The other day I met this IMG Neurology resident who seriously contemplated switching into Pathology and I did meet some American surgery residents who switched to pathology! But then, let's not forget, that you gotta really like Pathology to do it. On the flip side, pathologists at times have to deal with being labeled as 'not real doctors' and are confined to labs without much patient contact. But again, they are also known as "Doctor's consultants" and as far as I think after speaking to several Pathology Residents and faculty, it is a very satisfying and fulfilling career.
If you are thinking about a residency in Pathology, Step 1 Scores matter more than Step 2 CK scores for obvious reasons.
One more thing, if you can get thru step 3 before your interview, that's another bonus, since a lot of pathology residents flunk Step 3 exams ! Not surprising, since most of them are not too clinically inclined. Just remember that the residencies are usually 4 years and can extend to 5 years in some places.
Fellowship Options after Pathology Residency ?
Plenty ! Here are the main ones :
- Blood Banking/Transfusion Medicine - Chemical Pathology - Cytopathology - Forensic Pathology - Hematology - Immunopathology - Laboratory Informatics / Information Systems - Medical Microbiology - Neuropathology - Pediatric Pathology - Selective Pathology
How is the job scene in Pathology in USA?
Good ! Excellent Salaries and nice lifestyles. You probably would not get as many job offers as an Internal Medicine Resident or Family Medicine resident or other clinical branches would get, but certainly get a job :-) Less number of job offers also means you have lesser choices in where you wanna be located in the US.
Until the year 2005 Combined Anatomic and Clinical Pathology has been a 5-year residency program, but since 2006, the combined program is now 4 years ! So now, if you think about the job market - the employers which paid you for 5 years of training will be reluctant to pay the same for a 4-year training. Hence the new trend in Pathology is that atleast one fellowship is needed to give yourself that "5-year training label".
It is recommended that you take up combined training rather than just Anatomical or Clinical pathology, since that makes you very marketable for jobs.
Whats PMR ? Stands for Physical Medicine & Rehabilitation ! And what are you called after you finish this residency ? A Physiatrist ...So What's a Physiatrist ? A physiatrist (fizz ee at' trist) is a physician specializing in physical medicine and rehabilitation. Physiatrists treat a wide range of problems from sore shoulders to spinal cord injuries.
Whoaaa ! Am I trying to confuse you here ? No --- Just showing you some light and go beyond thinking of the most common IMG Choices of IM, FP, Peds, Psych and Obg-Gyn. No a physiatrist does not make you a physical / occupational therapist - its very very clinical , academic and respectable with exciting fellowship options ranging such as musculoskeletal rehabilitation, pediatrics, traumatic brain injury, spinal cord injury, and sports medicine. I have an IMG friend who secured a fellowship in Spinal Pain Intervention at a prestigious university program. Pays are good too with the 50th Percentile base salaries in Houson, TX (as an example) hitting about 193,000 $ per annum - Compare this with that of Internal Medicine in the same area which rounds up to 154,000 $ per annum.
The only problem , however, as my pal tells me, might be the fact that most programs need IMG/FMG candidates to complete a year of intenrship / prelim year or transitional year and then move on to the full-fledged residency program.( For example, go through the FAQs section for IMGs on the Spaulding Rehabilitation PMR Residency Programs - which by the way sponsor H1b Visas too). But, visas are usually NOT sponsored for the Prelim year - which means you need to be self-sponsored on the Visa front for this one ! Second, PMR is bound to get tough in the coming years as this branch is one with good money and good smooth lifestyle ....so get thinking...
Beauty is only skin deep and unfortunately, so are the chances for an IMG to get into a Dermatology residency program. But then again, like we spoke in Radiology, it may be possible to eventually land a residency in Dermatology after "getting into the system" through a residency in Internal Medicine , Family Practice, etc.
Lotsa things contribute to making Dermatology very very tough :
1. American graduates love the field for the great life-style and the good incomes
2. Unlike the number of seats for specialties like Internal Medicine and Family Practice (Indeed - many programs could build one or more football teams with their Internal Medicine residents ;-)), the number of positions for Dermatology remain very low - like 2 to 5 and rarely more.
3. Thirdly, the American Board of Dermatology requires all residents to have a postgraduate year of medical training, in a specialty approved by the Board of Dermatology (internal medicine, general surgery, family practice, obstetrics & gynecology, pediatrics or emergency medicine) prior to beginning the dermatology training - which basically calls for a prelim / transitional year or even leaving another residency half-way ....Hmmm
4. Life-style Professions are fairly closely guarded, meaning you get an entry mostly through contacts and recommendation letters from other skin docs....
Dermatology in US has got more exciting with the advent of new technologies and with "Teledermatology" where patients far away from the clinic are diagnosed over high-resolution video cams.
Harvard Medical School does have a "International Training Program" in Dermatology meant to train FMGs - to find out more and contact them, Click Here.
An Internist is a physician who completes a residency in Internal Medicine. A good way of describing an Internist is a doctor trained in managing hospital inpatients. It is akin to doing a Post-Graduate(PG) course in "General Medicine" in countries like India.
According to the Association of American Medical Colleges an Internist is : "A personal physician who provides long-term comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults and the elderly. Internists are trained in the diagnosis and treatment of of cancer, infections, and diseases affecting the heart, blood, kidneys, joints and digestive, respiratory and vascular systems"
If a Family Practitioner is likened to a General Practitioner in other countries like UK, India etc. - then an Internist can be likened to a hospital general practitioner !
Why does it remain the top favorite amongst IMGs ?
The lure of Internal medicine lies in the impressive list of specializations that one can pursue in the form of Fellowships in the following fields AFTER a residency in Internal Medicine:
Allergy and Immunology
Cardiovascular Disease
Critical Care Medicine
Endocrinology, Diabetes & Metabolism
Gastroenterology
Geriatric Medicine
Hematology
Hematology & Oncology
Hosptalist (Upcoming Hot Fellowship Option)
Infectious Disease
Interventional Cardiology
Nephrology
Oncology
Pulmonary Disease
Pulmonary Disease and Critical Care Medicine
Rheumatology
Sports Medicine
If you dont do a fellowship, you may work as an Internist - also called as a Hospitalist when exclusively working in hospital settings. A person I heard of notched an earning of 186,000/- as a hospitalist + Moonlighting in Philly after his IM residency.
This reminds me...I was talking to an American generalist physician who was in charge of recruting docs to fill up their Hospitalist position (Hospitalist is an internist or pediatrician or a family medicine physician who devotes more than 25% work time to inpatients - and some even devote 100%). He told me that a lot of IMGs certified as Internists were competing for the position, but he was kinda wary of hiring IMGs because : "as a general rule - IMGs never wanna stay as Generalists, they ALWAYS think of specialization" - meaning he was concerned that they will NOT stick to the job long enough but move on as soon as they secure a Fellowship.
At the same time he understood why that was the trend- he said he knew that IMGs spent a lot of money and hardwork to get here and wish to keep trying to get the best of what they have invested...
Another big, undeniable reason why Internal Medicine remains an IMG favorite is that other high-paying specialties like Anesthesia, Surgery, Radiology, Dermatology, etc. remain favorites of American Medical Graduates and aren't available for IMGs anyways :-) Which means a HUGE number of Internal Medicine programs would go unfilled, had it not been for IMGs !
Definitely tough - but a residency in general surgery ain't impossible. A friend of mine recently got a residency position at the Methodist Hospital System in Houston on a J1 Visa and I shall be putting up advice from him pretty soon.
G. surgery has become kinda easier for IMGs over the past 2-3 years due to a reduced interest by AMGs. who are rather drawn increasingly to Anesthesiology , Radiology, Orthopedics...which bring in good pays pretty early in the profession.
On other hand, it still remains tougher than IM or FP or Ob-Gyn, and it usually is a 1-year "preliminary" position that is granted initially without any guarantees from the program about a position later - which means match participation is needed again for categorical positions. Most categorical programs need incoming residents to have completed either a preliminary year or externships / sub-internship. A good place for Surgery Aspirants to consider is the Surgery Subinternship program offered at the University of Washington at Seattle. The program offers 4-6 visiting student sub-internship positions to IMGs each year. Click here to know more about the program and apply.
However, ground work is needed - observerships count a lot ! surgical research too counts. Fellowship options after General Surgery ? These include cardiothoracic surgery (one of the highest paid specialties in USA!) , vascular surgery, surgical oncology, plastic surgery, etc.
Here are some places that are known to have offered General Surgery Observerships in the past:
St. Luke's Hospital of Bethlehem (PA) Thomas Jefferson University University of Buffalo University of Iowa University of Michigan University of Nebraska Medical Center University of Pittsburgh University of Tennessee University of Vermont University of Wisconsin Vanderbilt University
According to this 1998 Paper, International medical graduates account for 10% of the academic surgical faculty in the United States
And this is what Sameer Khalid, MD from Khyber Medical College, Peshawar has to say on my Orkut Residency Community :
"Surgery is not as tough to get in as it was previously - both scores in mid or early 90s would just be sufficient for an average community based prelim position in surgery. But it would be a prelim position.. Having said that, your chances of getting a second year position diretly would be very slim until and unless your are very very brilliant. And I know of people, amazing brains , great lors, getting into prelim and just cannot somehow get a 2nd or a 3rd year seat.. If you are really really dedicated about surgery, then forget about how long it takes.. the best method would be to get a research position in some top notch university like harvard ( i know ppl who have got in there ), get the research on an H1 visa, work for 2 to 3 years, get a green card, and then apply for a catagorical position in surgery, that is how your future would be safe.. and you would eventually become a surgeon..
Prelim , I repeat once again, is very risky, and I know of a lot of people who have been forced to leave it after an year or 2. As for orthopedics, well it is very close to impossible to get in, but then where theres a will...the only IMGs from pakistan I know who have gotten into ortho, have done the same thing.. as i mentioned above i.e. get an ortho research, paid on an H1 visa, work hard for a few years and then apply to Ortho. People from Aga Khan Med school have made it through this way ..and i repeat orthopedic surgery and general surgery are different specialties.. and residencies !! good luck, hope it helps .."
There are points that some would differ on, like getting a second year position once you have a prelim year feather on your hat may not be tougher. A person I know accepted surgery on a J1 visa and had information that J1-waiver jobs are not at all impossible for surgery either. Accept contradicting information on this blog as options - and see the best of what's possible in your circumstances...
- "sample letter of recommendation residency matching" - "average usmle score general surgery matched" - "How difficult is it for a FMG to get a gen-surgery residency?" - "is general surgery easy for IMGs ?" - "general Surgery residency possible for IMGs ?"
Everyone and Everybody talks about how tough Radiology is for IMGs (even for AMGs). It sure is, but for those passionate about radiology, it would be wrong to give up the dream altogether. And before you read ahead, I must stress on the two big credentials needed are Very high USMLE scores (preferable 99s) and Research publications in Radiology. The average three-digit scores of candidates matching into Diagnostic Radiology in 2007 were around 230 to 235 in both USMLE Step 1 & Step 2 CK.
Direct residency positions are sure tough for IMGs, making IMGs try indirect routes. I got to speak to a IMG Radiology faculty doc at a University hospital and he told me about his journey and what people these days do to get in. It surely takes more time, but is worth it if that's where your passion lies. He himself did a residency in Internal Medicine first and during those rotations made good contacts in the Radiology Dept. , volunteered to research and off-day observations and got into the program AFTER completing his IM residency.
The other way, which may be easier, is first doing a Radiology residency in your own home country and then applying to Radiology fellowships in USA - Read my post on Direct Fellowships without Residency - not saying Radiology residency is easy in your own countries - Radiology is pretty much a highly sought specialty after all over the world, but a radiology residency back home may be a better way to spend time rather than trying, trying and trying for US residency positions.
The competition sure is tough - even a lot of AMGs with high scores end up doing prelims and transitional years and hope to get into a Radiology program the following year. Do check out USMLEtoMD.com/imgfriendly for updated information on IMG-accepting Radiology Programs. However, remember that even if they do accept IMG applications, American Graduates are always given the first preference. And of course the IMGs with Green cards / Citizenships have an advantage...
Take home message: Don't compromise on your scores, apply to Radiology residency programs, but also apply to Internal Medicine, Internal Medicine-Peds and 1-year Preliminary Medicine spots. In case Radiology does not happen, don't lose heart - take up the backup residency, work your towards your goal slowly and strategically through exposure, experience and contacts :-) You got a better chance that way than not taking up any residency at all and wasting a year. And my advice for any tough residency specialty - always have a plan B in your home country for a Radiology residency - coz that way, the option of direct fellowships stays open too.
Q. What are the Fellowship Options After Radiology ? A.
Abdominal Radiology
Cardiothoracic Radiology
Endovascular Surgical Neuroradiology
Musculoskeletal Radiology
Neuroradiology
Nuclear Radiology
Pediatric Radiology
Vascular and Interventional Radiology
Google keywords to this post:
- "interventional radiology residency and imgs" - "Direct radiology fellowships" - "How tough is Radiology for IMGs" - "Radiology and International medical graduates" - "What you need to get into radiology residency"
Bottom line : Orthopedics is tough for IMGs ! Tough enough to prompt advising Orthopedics aspirants to be ready for long periods of waiting and trying before finally getting into a program.
Orthopedics surgery remains extremely tough even for the best of American Medical graduates. The big reasons possibly being that number of residency positions are low and it remains one of the highest paid specialties in USA. In the year 2005, there were 152 Orthopaedic surgery residency programs offered a total of 3085 residency positions. Of these, 2999 positions (97.2%) were filled by American Medical Graduates, leaving a mere 86 slots for IMGs. Compare this with 21,332 positions offered in Internal Medicine of which the AMGs filled up 52.8 % positions. Secondly, There is pretty much a fairly large 'waiting line' of people hoping for orthopedic surgery residencies - these include people currently involved in research, observerships, and even general surgery residency positions (both categorical and preliminary). Often, as I hear, even getting into a preliminary position in some places need a year or more of research work in the field. Combine this with the fact that America is currently seeing a Surplus of Orthopedic Surgeons which is supposed to increase atleast upto the year 2010, which means we will not be seeing an increase in sanctioned residency slots for a long time too.
Finally, a lot of highly trained orthopedic guys from United Kingdom are being forced to look at USA due to the visa rule crisis.
I am not being a pessimist and am not suggesting IMGs should not dream of orthopaedic surgery in US - but practicality must piggy-back with long-term dreams. It is a system that we are trying to break into and rather than cribbing about it, it is best to be patient, strategize and slowly work towards it without being foolish enough to bet and risk everything on it.
Take home points for IMGs planning on Orthopaedic Surgery in the United States:
- Besides Orthopedics, apply to BOTH prelimary and categorical positions in General surgery (Orthopedics needs a year of General Surgery Training before entering the categorical residency program)
- Take up General Surgery if you get it (match or prematch) and then work your way towards the bony brother - because, for tough branches like Orthopedics and Radiology, the unspoken rule is GET INTO THE SYSTEM FIRST rather than keep waiting for the right branch and let other opportunities slip by. There is a second important reason to this - Remember that when you apply for residencies, there's only one Common application Form that you can fill up and submit irrespective of what specialties you apply to. So if you slogged for 2-3 years for building a "orthopedic" resume doing all the right things like research, observerships, externships, etc. , the credibility of your application for other specialties like categorical general surgery may drop down.
- USMLE Scores need to be very high - 240 and above for many programs. If scores are low, then the waiting period will possibly be longer with a need for more US clinical experience and research along with solid US Letters of Recommendation.
- If no US Clinical experience, Post Graduate Training in your Country will certainly help rather than being totally fresh out of medical school with no Ortho experience
Family medicine residency program directors tend to be cautious about applicants with good reason - residents switching over to other specialties after the first year and has been especially true for IMGs.
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