Tuesday, June 17, 2014

A non-US citizen international student's chances of matching in surgery

"Brian," a medical student in Egypt, wrote me about obtaining a surgical residency in the US. Due to space limitations, I have edited the email. He will take USMLE Step 1 soon. He has no green card.

He read a previous post of mine about a US citizen international medical graduate (IMG), but still had several questions.

He asked what qualities separate an applicant matching in a categorical position from one matching in a preliminary position?

"Categorical" means, barring any performance or behavior issues, the resident will complete a full 5-year general surgery residency program.

There are two types of preliminary positions. Designated general surgery preliminary positions are 1- or 2-year commitments to residents who have already matched in another surgical subspecialty such as urology or orthopedics. People who match as designated preliminary residents are usually automatically accepted into the one or two year general surgery positions.

Non-designated preliminary positions are 1-year general surgery slots with no guarantee of progression to either a categorical general surgery or subspecialty surgery position. These positions are almost always filled after the match with those who failed to match in a surgical subspecialty or general surgery.

He brought up the results of a 2012 NRMP survey of general surgery program directors that indicated what factors influence them to grant interviews and rank applicants. Link here. See pages 54-60.

Factors used in selecting applicants to interview are numerous and not completely consistent with other surveys, but the two highest responses were letters of recommendation-89% and USMLE Step 1 scores-84%. Other notable parameters were personal statement-74%, grades-78%, dean's letter-63%, visa status-56%, and involvement in research-56%.

Many of the other factors listed scores higher than 50% as well. Since so many were considered important and the response rate was only 30.9%, the value of the survey is questionable. I am highly skeptical that three-quarters of program directors really think a personal statement is important. In my time as a PD, I found most of them to be worthless.

Of respondents, 99% interview US seniors, 73% interview US grads (i.e., those who are already  doing a first year somewhere), osteopathic 53%, Canadian 50%, fifth pathway 35%, US citizen IMG 56%, and non-US citizen IMG 41%.

The average numbers of applications received is 623, number interviewed-68, number ranked-42, number of yearly positions available in the match-5.

All programs require Step 1 scores with 83% having a threshold averaging at least 210. One's chances of getting an interview increase with a score above about 225.

An application from a non-US citizen IMG with a USMLE Step 1 score of less than about 220 would be very likely to be discarded.

I recently blogged about a paper reporting the results of a different survey of surgery program directors with a 65% response rate which ranked USMLE Step 1 scores as number one. That paper placed a little value on research or publications. Some other data from this survey are interesting and illustrate the difficulty that a non-US citizen international graduate will have finding a program.

Another question was about letters of recommendation. Generally, a letter stating that the applicant has waived his right to review it is far more useful than one that the applicant has reviewed.

He asked about grades and class rankings. As I discussed in a previous post, grades and class rankings from US medical schools are fairly useless due to inflated grades and the lack of uniform grading standards. The same applies to international schools.

Regarding the chances of getting a categorical position after doing a non-designated preliminary year. I don't believe there are any data on this. This post of mine attempted to sort out the possibilities.

He asked, "What is the profile of a competitive IMG for categorical general surgery?" I can only give some data and my opinion. To get an interview in a lower tier program, I would say he needs at least a 250 on USMLE Step 1, at least one clinical rotation on surgery in a US hospital, a letter of recommendation or two from US surgeons (preferably one who is known regionally or nationally), a publication wouldn't hurt but I'm not sure it helps, and obviously a very favorable dean's letter or the equivalent from his school.

To be honest, his chances are slim. I could be wrong and hope some readers will comment.


  1. There is some really hard data from NRMP in a new Charting Outcomes document specifically geared to IMG's. This is an "outcomes" based document showing just what it took for IMG's to match into a variety of specialties.

    NRMP-ECFMG-Charting-Outcomes-in-the-Match-International-Medical-Graduates-2014 (pdf).

    Page 15 of the document shows that for non-US IMG's the mean Step 1 score for Gen-surg was about 238. The mean for US-IMGs was around 227. I'm assuming these are categorical positions but could be wrong on that.

  2. qtipp, thanks for the valuable comments and the link. I am certain that the page you referred to (page 15 of the PDF or page 9 of the actual document) refers to categorical general positions.

  3. Hi Skeptical Scalpel,
    I just got my USMLE Step1 Score of 214/90 and to say the leat I am devastated.I would want to know my chances of getting in Preliminary Surgery as I am an IMG.
    It would really help to get a reality check from someone on the other side of the table.I have 2 months of USCE and two LOR's to back it up.

    Thank you so much.

    1. Nothing is ever completely hopeless Your score is a little below average. A lot depends on where you went to med school. You could apply to some lesser community hospital programs and see if you get any interviews. I would have a backup plan such as family medicine in mind. There are always many unfilled prelim general surgery positions. You could try to get one of those after the match or even apply to match as a prelim. It is not always the path to a categorical spot, but it may be worth a try.

    2. I do not see myself doing anything else but Surgery as my field of choice and being an IMG from India with such a score has shook me up.I need to know that I am on the right path and there is hope at the end of it.

  4. Thank you so much for your valuable time and experience.I shall keep that in mind when I apply.I have my Step 2 CK in four weeks time and will give it my best shot.

  5. I am an IMG from Nepal and have given the Step 1 exams and I scored 262 on the step and I am also a surgery graduate from the country. What chances do I hold of getting a residency in surgery in US...

  6. Your score is excellent. You will need to go to the ECFMG website to see what requirements are needed to be eligible for a US residency.

    Here are two posts that may also help: http://skepticalscalpel.blogspot.com/2016/07/what-are-residency-prospects-for.html and http://skepticalscalpel.blogspot.com/2016/04/faqs-from-imgs-about-applying-for.html

    The longer it has been from the year you graduated medical school, the less your chances of getting a US surgical residency especially if you have no recent clinical experience. Also, pay attention to the answer to the question about observerships in the FAQ post I linked to.

    Good luck.

    The unknown variable is what the Trump administration will do about visas. I know citizens of Nepal are not currently a banned from entry but who knows about the future.

  7. Hi Sir,
    I am a final year medical student from India, I just received by step 1 score which was a 264, I plan on doing the step 2 soon and hope to do better. I am probably going to do a total of 4 electives in general surgery and 1 in neurosurgery, and applying for general surgery residency. I have worked extensively in Neurosurgery for a year (while in medical school) and have been appreciated by the Chair of the department, for my work ethic, knowledge base and surgical presence of mind. While there I have assisted on decompressive craniotomies and performed tracheostomies independently along with other basic procedures. I have also accumulated significant experience in other fields of surgery by scrubbing in for everything i could. I am very driven and I really love the art of surgery.
    My concern is my lack of research experience, which I plan on improving significantly by the time I have to match. I am petrified of matching into a prelim position because many say that it is a dead end and the chances of matching into a categorical position are slim at best, is this true? What are my chances on a categorical program? How should I go about becoming a perfect candidate? What are my options if I don't match into a categorical program after 1 or 2 years of prelim?

  8. I am petrified of matching into a prelim position because many say that it is a dead end and the chances of matching into a categorical position are slim at best, is this true?

    Yes, your chances may not be great, but they are not 0. I don't know your age, but if you don't mind investing a year or two in the process, you may get lucky. Your USMLE Step 1 score is a big help.

    What are my chances on a categorical program? Again, your USMLE score will probably get you some interviews. You need to send out applications to mostly community hospital programs that have histories of taking international graduates. You will know from the number of interviews you get whether your chances are good. Based on no data, only a guess, if you get 10-12 interviews, you will probably match.

    How should I go about becoming a perfect candidate? I'm not sure what a perfect candidate is. I don't think anyone knows. If you have great letters of recommendation and maybe turn out a paper or two during the next few months, your application will certainly be enhanced.

    What are my options if I don't match into a categorical program after 1 or 2 years of prelim? The only option I know of would be to change into a different specialty. What I don't know is how family medicine or internal medicine will view a candidate who spent one or two years as a preliminary surgical resident. Most of the other medical specialties are pretty competitive and may not even acknowledge your application.

    Good luck.