Thursday, May 8, 2014

US citizen IMG surgery prelim resident needs advice

Maicon, a non-designated preliminary general surgery resident, writes

I read with interest your post on matching rates for international medical graduates. I am a US citizen IMG, born here, but grew up (since 2 years of age) in another country and completed my medical school there a few years ago.

My USMLE scores are step 1 - 235, step 2 - 251, Step 2CS and Step 3 passed on first attempt. Knowing that general surgery was hard to get, I worked (unpaid) in the surgery department at a large Northeastern academic center.

I got a prelim spot at a decent program with a program director I respect. I worked my ass off, studied hard, and got in on research projects early.

ABSITE: 1st year - 90th percentile (highest in our class), it got me a 2nd year at the same program, 2nd year - 79th percentile.

Did a ton of research with a couple of publications and presentation, and won a teacher award by med students. My evals were good, and I got great recommendation letters. I thought I covered my bases.

My program doesn't have a spot for a 3rd year and am unable to find one, despite the good intentions of my mentors. It is frustrating that, try as I might, I am still out of a residency on June 30th of this year.

Should I continue to pursue the surgical field, do a research fellowship which I have seen from previous blogs/articles doesn't help much, do a subspecialty fellowship (Cardiothoracic ICU/critical care/Burns), or switch to medicine or FP? From, your previous posts, I feel you will probably suggest to switch.

Thanks for reading my blog and for your email. I am sympathetic to your plight. I've seen it many times.

I wish I was still running a program. It sounds like I could have used someone like you.

If you have no financial or other pressure to get on with your life and are young enough, I suggest you take a fellowship in one of the clinical areas you mentioned such as critical care. An accredited one is preferred because you could take the board exam when you finally get through a 5-year GS program. Even a non-accredited fellowship in a clinical area is better than doing research. Your chances of obtaining a categorical spot are enhanced by taking care of patients instead of test tubes.

 If you do a good job with the fellowship, you might be able to sneak into a categorical slot somewhere. Make sure you take the ABSITE again too. The scores are really important.

Have your program director keep an eye on the program directors' list serve. Categorical slots open up frequently—even into June.

Good luck.


  1. I agree with the recommendation to consider a fellowship, although I'm not quite as down on the idea of a research fellowship (perhaps because of my academic bias). Also, if you are willing to repeat a few years and truly love general surgery, you may step back to another P1/P2 year or even try to go through the match again as a categorical R1.

    If you can't find that, and still want to stay procedural, consider IM residency as opposed to FP - you could follow that with a procedural specialty like GI.

  2. Andrew, I have nothing against research. I just think that most program directors would prefer to hire replacement residents with recent clinical experience.

    I agree that going back through the match is a possible option, but in a recent post [], I pointed out that surgical program directors who were surveyed said that the least important factor in ranking applicants in the match was whether an applicant had done a preliminary year.

    For the reason you stated, I agree 100% with your advice to do internal medicine if surgery doesn't work out.

  3. Why are non-designated prelim spots even offered? Is it to provide a large pool of spares in case categorical residents drop out late?

    I am not tryimg to be snarky here.

  4. Anon, it's a good question. Honestly, non-designated prelim spots exist only for service and coverage. A few lucky prelims secure categorical positions, the rest are cast adrift.With the attrition rate of categorical residents holding steady at about 20%, there does need to be a pool of non-designated prelims. Does it need to be several hundred? No.

  5. Frankly, prelims are used as cheap labor. In my program, they were loved by the adjunct faculty because most of them were trained surgeons who were trying to branch into the states. Patients were taken care of with minimal teaching really required. However categoricals were from US Medical schools and had less clinical training. Some of the prelims would have made excellent surgeons. Just my opinion... I was one of those categoricals

    1. You are correct on all counts. They are very cheap labor. Who else would work 80+ hours/week for $50K and no guarantee of reaching their goal of becoming a surgeon. In many places, the prelims also get more time on the crappy rotations. Some of them would make excellent surgeons.

  6. I am happy to report that Maicon has secured a categorical position in general surgery.

  7. Congrats Maicon and thanks skeptical scalpel for letting us know. Being an IMG who wants to get into surgery myself, this gave me a ton of hope!