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.

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.

How can I overcome a low USMLE Step I score?

Nemanja (not his real name) writes: I am a fourth year medical student at a US school. I am planning on applying to general surgery in the next month. I have a few concerns and questions about my application and competitiveness. 

I did very well years 1 and 2, all but one honors. I got a 209 on USMLE Step 1 and a 243 on step 2. The caveat about my step 1 score is as follows. I had a family tragedy 1-2 months prior to taking step 1. In retrospect I probably should have deferred and not taken it but hindsight is 20/20.

After that poor step 1 score, I did well on my clinical rotations. I received a high pass in surgery and honors in 4 other clinical rotations with no grade less than a high pass. I expect to receive strong letters of recommendation from my program director and clinical faculty. I am interested in applying to programs in the northeast portion of the US.

How can I let a program director know about my situation (e.g., in my personal statement, in my dean's letter). Some of the people at my institution have led me to believe that this is an important part of my story and something that may provide an explanation for a below average step 1 score. I am afraid that I will be filtered out due to my step 1 score from many university based programs. What do you think is my best approach to this situation? 

Your question is a good one. I am sorry about your family tragedy. 

I suggest you explain it in your personal statement and ask the dean to mention it in his letter too. You need to emphasize the fact that your Step II score is very good. Strong letters of recommendation will help.

If you search PubMed for "USMLE Step I," you can find a fair amount of information about the weight program directors put on it. One paper says it is the single most important factor used by PDs to screen applicants. Another says that a Step I score of < 200 is associated with a higher risk of failing part I of the general surgery board exam.

Here is a link to a PDF from the NRMP about match outcomes. If you go to page 84, you will find some interesting data about the 2011 general surgery match.

I have some screen shots for you. 

Here's a table listing some summary statistics.

This is a graph indicating that a USMLE Step I score of 209 gives you about a 75% chance of matching in surgery.

But here is a chart showing that a Step II score of 243 gives you a very good chance of matching. No graph was provided.

The message is very clear. Get the PDs to look at your Step II score

You may want to apply to some community hospital-based programs to be safe. I think you will match in a categorical position.

Good luck. Please let me know how things turn out.