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.