Foreign medical graduate applying to psych (US citizen, US college graduate)

[shoenberg3]

Hello,

I graduated from a HYPS university and, for personal reasons, attended medical school in South Korea.
Now, I am considering coming back to the US for residency, specifically for psychiatry.

I understand that it's never that easy for FMGs to match into a US residency. I have the following two questions:

1. Since I am US citizen with complete fluency of the language and essentially only went abroad for medical school, would that confer some advantage over other FMGs when it comes to matching? Specifically, I am looking to match into any program in psychiatry in Northern California. I understand that it's a competitive region (and that psych has gotten more popular recently) but if I obtain above average USMLE scores, would I have a good shot?

2) I understand the two main things I have to do is to take the USMLE and gain 4 weeks (?) of clinical experience in the form of clerkship or subinternship. Is there anything else that I should prepare in advance for the transition, for psychiatry in particular perhaps?

Thank you so much for your help.

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[TexasPhysician]

The west coast is the most competitive region in the US. Cali is not guaranteed to anyone with merely average stats. As a US IMG, you’ll need to do well on all of the Step exams to have much of a chance at all. Unfortunately, I wouldn’t call it a good chance. You should apply to at least all states in a 4 state radius.

 

[Merovinge]

I think dating metaphor's might make this a bit easier for you to relate to.

Hey guys, I used to be a 9, but due to personal reasons couldn't continue at the gym and now am around a 6. I am exclusively looking to date other 9-10's, since I used to be a 9 does that confer some advantage to me as a 6? I'd like for you to make me feel better about my decision to only pursue 9-10's and then feel wildly hurt when I get shot down.

For actionable advice: you need to slay the USMLEs if you are insistent on a very competitive and narrow geographic region. If you simply do above average, apply broadly, there are many many good psychiatry training programs in this country and the Bay Area will still be happening in 4 years.

 

[dl2dp2]

Score well on USMLE 1 and 2 would help. As would some research experience and networking. I would do lots of away rotations, not just 4 weeks. Perhaps you do well on standardized exams given you went to HYPS.

There are not that many spots in Northern California given the size of the population, so I would apply broadly.

To be honest, I don't know why you'd want to return to Northern California:

Authorities Investigating Homeless Mattress Blaze Near Site Of 5-Alarm San Francisco Fire

Hours before a 5-alarm blaze erupted, roaring through nearly a block of commercial buildings, a San Francisco fire crew extinguished at late-night mattress fire at a homeless encampment in the neighborhood, officials confirmed Wednesday.

sanfrancisco.cbslocal.com

The Bay Area is somehow managed to score in what are usually contradictory things 1. being a 3rd tier toilet location. 2. being utterly unaffordable. NYC metro used to be worse, and now it's not even close. Quality of life is by far better in South Korea.

 

[shoenberg3]

I think dating metaphor's might make this a bit easier for you to relate to..... I'd like for you to make me feel better about my decision to only pursue 9-10's and then feel wildly hurt when I get shot down....

Hmm.. Not sure what triggered the rather acerbic attitude of some on this thread.

I acknowledged that it would be an uphill battle, but what I wanted to gauge exactly how formidable it would be -- and what I could do to maximize my chances.

I have looked at the NRMP match statistics for psychiatry residencies and for IMG (both US and non-US) they were above 90 percent. I am aware that applying only to Northern California locations (not necessarily Bay Area) would significantly reduce those odds.

Thus far, the consensus seems to be that I would need to do really well on the USMLE and go above and beyond with USCEs/research/networking -- in order for me to have a decent shot in Nor Cal residency.

I do have some publications under my name, but in internal medicine not in psychiatry. Not sure if those would help...

As for why I would want to return to the states, my family still resides in California. Also, residency training in Korea is long and miserable (5 years with 100+ hour weeks), which is probably less worse than psychiatry residency in the states.

I truly appreciate all the responses I have gotten so far and would love to hear some more advice.

 

[ERK123]

I am not sure where you are getting the numbers indicating that there is a 90% match rate for IMGs in psychiatry. That is just not even close to true. Also, NorCal is a difficult place to feel confident about matching even for top applicants because there are very few residency spots. Saying that you are willing to not be in the Bay Area doesn’t do a whole lot to increase your options as that only adds UCSD Fresno and UC Davis. Take your shot, but if you want to return to the US for residency then I think you should also explore whether you would be open to more locations because the chance of NorCal working out is likely pretty slim.

 

[TexasPhysician]

I acknowledged that it would be an uphill battle, but what I wanted to gauge exactly how formidable it would be -- and what I could do to maximize my chances.

I have looked at the NRMP match statistics for psychiatry residencies and for IMG (both US and non-US) they were above 90 percent. I am aware that applying only to Northern California locations (not necessarily Bay Area) would significantly reduce those odds.

Thus far, the consensus seems to be that I would need to do really well on the USMLE and go above and beyond with USCEs/research/networking -- in order for me to have a decent shot in Nor Cal residency.

I do have some publications under my name, but in internal medicine not in psychiatry. Not sure if those would help...

I truly appreciate all the responses I have gotten so far and would love to hear some more advice.

The statistics here are incorrect. Matching as an IMG have gotten more difficult in recent years.

Without above average Step scores and away rotations in Cali, I’d place the odds of matching anywhere in Cali at 0.5%. The away rotations will generally get you an audience to attempt to impress them. If you do really well on steps 1-3 and do away rotations in Cali and have some psych research, I’d move your odds of matching in Cali to 10%. Obviously this is unscientific. Many Cali programs without an away rotation will automatically screen out your application for not training in the USA or having completed all 3 Steps. Away rotations may help you avoid the screening process. Then the ball is in your court.

 

[MacDonaldTriad]

I think Kaiser has opened a couple of Frisco / bay area residencies. Oakland and something else I heard, so maybe less difficult than some say. The definition of Northern California is vague at best. above UCSF, you would end up in Oregon before you found another program to apply for.

 

[brazilianpsych]

I think dating metaphor's might make this a bit easier for you to relate to.

Hey guys, I used to be a 9, but due to personal reasons couldn't continue at the gym and now am around a 6. I am exclusively looking to date other 9-10's, since I used to be a 9 does that confer some advantage to me as a 6? I'd like for you to make me feel better about my decision to only pursue 9-10's and then feel wildly hurt when I get shot down.

For actionable advice: you need to slay the USMLEs if you are insistent on a very competitive and narrow geographic region. If you simply do above average, apply broadly, there are many many good psychiatry training programs in this country and the Bay Area will still be happening in 4 years.

I laughed so much at this.

I'm on a similar boat to the OP, however I'm not american. My step 1 wasnt so great (226) but I'm hopefully that my previous experience will help me with my application. Also I will pretty much apply to everywhere.

 

[dl2dp2]

As for why I would want to return to the states, my family still resides in California. Also, residency training in Korea is long and miserable (5 years with 100+ hour weeks), which is probably less worse than psychiatry residency ...

It’s far easier to move to Northern California for a job after residency than matching there for residency at an IMG, especially if you are willing to take a jog few wants to take (ie state hospital, etc). You don’t have to be close to mommy daddy for 4 years.

 

[shoenberg3]

Thank you all for your responses. It is somewhat disheartening but I needed some honest perspective.

I was referring to this match data when speaking about the 90%+ match rates:

https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/01/420_MRS.pdf

Perhaps, I am misinterpreting the data..

I wasn't completely aware that Northern California would have such few residency spots for psychiatry. Are there none in the central valley outside Fresno and Davis? I am surprised there would be none in Sacramento, for example.

According to the responses, it also appears that matching has become more difficult for IMGs recently AND psychiatry has become more popular. Both of these seem to be rather recent developments.

How I would fare if I extended my application to Ohio region, specifically near Cincinnati (lived their a few years and liked it)?

Again, thank you all for your help.

 

[ERK123]

The match data you linked is for psychiatry fellowships, which is a completely different ballgame...

UC Davis psych residency is in Sacramento. Psychiatry has certainly gotten more competitive recently, but I am not sure there was a time in recent history when matching a NorCal psychiatry spot as an IMG would have been a safe bet. I mean several years ago there were even fewer residency positions in NorCal because those Kaiser programs are quite new.

 

[shoenberg3]

The match data you linked is for psychiatry fellowships, which is a completely different ballgame...

UC Davis psych residency is in Sacramento. Psychiatry has certainly gotten more competitive recently, but I am not sure there was a time in recent history when matching a NorCal psychiatry spot as an IMG would have been a safe bet. I mean several years ago there were even fewer residency positions in NorCal because those Kaiser programs are quite new.

Ah, I see. That was stupid of me haha. Thanks for the clarification.

I knew from the onset that it is not going to be safe bet.
However, there is also a real difference between 0.5 percent chance (quoting another poster here) -- in which case I am probably not going to even give it a shot -- and having somewhat of a chance. That is what I was trying to gauge here. But the consensus seems to be that it would be tall order, which is quite discouraging.

 

[SquibDell]

Hey Shoenberg3, I'm in a sort-of similar position to you, though I'm not a citizen and have completed step 1 and 2. Take the following with a grain of salt because I obviously haven't matched yet. Happy to be corrected by more senior/knowledgeable members.

The match data you're looking for is here (note the separate data for US and international graduates):

Residency Data & Reports

The latest Match results and data for the Main Residency Match.

www.nrmp.org

The average step 1 and 2 scores for US citizen IMGs that matched into psychiatry are 213 and 226 respectively. Considering only step scores, the proportion of US IMGs that match doesn't budge much above 0.5 until the 241-250 bracket. This corresponds to about the 80th-90th percentile for step 1, and a bit lower for step 2.

Other factors are considered in the link, mainly research and other graduate degrees. More research doesn't seem to increase the chances of matching. This might be due to a lot of what people list as research experience not being substantial. E.g. a single first author psychiatry paper is likely to do a lot more for your application than a handful of posters from summer internships. If the paper is in a top journal and you can sell a good story on it during interviews, even better.

It's not clear from your post whether you've already graduated or not? If so, are you working as a doctor currently? Experience working as a doctor in Korea will probably help your application but being a year+ post-graduation without working in medicine is likely to hurt it. That said, if you haven't had any US clinical experience before graduating medical school, it may be extremely hard to get any meaningful experience now.

I'm not sure if international medical schools outside of e.g. Oxford and Cambridge are regarded in the US at all, but it might help your application if you went to a top Korean school. From what I've read, a lot of the stigma about IMGs is due to the perception that they weren't able to get into a US school, so making it clear that this isn't the case might help.

Having citizenship is a big factor in your favour. Having a US undergraduate degree is also good as it should help with any language or cultural concerns. The HYPS pedigree can't hurt either, well done.

Good letters of recommendation from US clinicians and/or contacts at particular residency programs are the other big factors that may make or break your application.

People often say that psychiatry residencies are more holistic in assessing applicants than other specialties and that a 'good story' can make up for some deficiencies in an application. Completing undergrad in the US and med school in SK sounds like the start of a pretty good story to me. If you get decent scores and letters and can show a proven interest in psych, then I would have thought your chances of matching in the US would be quite good.

Limiting yourself to a small percentage of the available residencies will obviously reduce your chances considerably. If your situation is so good in SK that you can be that picky about where in the US you apply to, then you might reconsider whether applying is worth it.

Preparing for and completing the step exams is extremely stressful. Pursuing USCE was a Kafkaesque nightmare before travel bans and COVID and is only likely to have gotten worse. I shudder to think of the work involved in completing the final application, and balancing interviews with full-time work in a different country. And it's all very expensive. If If I could go back, I'm not sure if I would do it all again but I'm here now and hoping that it will pay off.

Good luck with whatever you decide.

 

[TexasPhysician]

Ah, I see. That was stupid of me haha. Thanks for the clarification.

I knew from the onset that it is not going to be safe bet.
However, there is also a real difference between 0.5 percent chance (quoting another poster here) -- in which case I am probably not going to even give it a shot -- and having somewhat of a chance. That is what I was trying to gauge here. But the consensus seems to be that it would be tall order, which is quite discouraging.

In 2020, US IMG’s had a 39% chance of matching somewhere in the US in psychiatry. That’s not 0%. You can graduate from anywhere and get a job literally anywhere. Now most of those IMG’s applied across the US to dozens of low competition locations/programs. Most will match to low competition programs.

Rounding: There are about 1850 spots. US MD’s are considered the most competitive and take 1200 spots. US DO’s are typically seen as next competitive and take 350 spots. That leaves 300 spots for US IMG’s and FMG’s. Usually these spots are central USA outside of major names/cities. There are many more than 300 applicants for these spots.

If you are average and apply to most of the low competition spots, you had a 39% chance in 2020.

Your question focused on California, one of the most competitive states in which it is rare to match any IMG/FMG’s. Odds are highly against it, but a really good IMG/FMG has a low chance.

I’m not trying to be negative. It would be wonderful if applicants had more choices at their disposal. I hope you match where you are happy and wish you the best.

 

[brazilianpsych]

I still have a hard time understanding why US residencies like STEP 1 so much and use it so strongly to select candidates. I could understand the use of it for pathology or something similar, but for psych? I`m not sure if there`s any correlation between being a good psych and the step 1 score. If I had to guess, I would bet money people with scores >270 are actually worst psychs than average scores.

 

[liquidshadow22]

I still have a hard time understanding why US residencies like STEP 1 so much and use it so strongly to select candidates. I could understand the use of it for pathology or something similar, but for psych? I`m not sure if there`s any correlation between being a good psych and the step 1 score. If I had to guess, I would bet money people with scores >270 are actually worst psychs than average scores.

It's true EQ > IQ in psychiatry. Not too hard to memorize a list of SSRIs or Antipsychotics or rare side effects that clinically never happen.

 

[TexasPhysician]

I still have a hard time understanding why US residencies like STEP 1 so much and use it so strongly to select candidates. I could understand the use of it for pathology or something similar, but for psych? I`m not sure if there`s any correlation between being a good psych and the step 1 score. If I had to guess, I would bet money people with scores >270 are actually worst psychs than average scores.

It does correlate with odds of passing other step exams. If you score 270 on Step 1 in your example, there are very low odds of failing step 3. States (many) have a max number of failure attempts on step 3 to practice medicine. Many programs require step 3 pass by a certain year.

I’ve seen students held back by step 3 failures. There have been students that have failed 3x and are then cut from training as they can’t be licensed in my state any longer.

Additionally, step 1 is a data point to compare in an age where there are very few data points. Many med schools are P/F. Other med schools have such odd grading scales that you can’t easily compare students by grades at all. Many don’t have class ranks as a result. Research is an even more useless metric to determine how good a psychiatrist will become. Dean letters and LOR’s are mostly the same. They merely help identify red flags or irregularities. The result is Step 1 being the lone equivalent amongst med students.

 

[birchswing]

That raises a good question of how can you test whether someone is a good person?

My metric is not something you can figure out with a test. It's after meeting them wondering how safe I would feel leaving my dog with them. Some people I meet not for even thirty seconds.

If there such a dog test for future doctors, I think would be quite useful.

 

[TexasPhysician]

That raises a good question of how can you test whether someone is a good person?

My metric is not something you can figure out with a test. It's after meeting them wondering how safe I would feel leaving my dog with them. Some people I meet not for even thirty seconds.

If there such a dog test for future doctors, I think would be quite useful.

Hence why interview days involve multiple interviews with multiple faculty. Sometimes there are group interviews with scenarios and organized debates.

To get us back on topic, pretend you get 1200 applications to be 1 of your 4 hypothetical primary dog walkers. You can’t interview 1200 people while still working FT and have 4 selected in 1 month. The only constant between all 1200 is they each took a test on dog knowledge. You only have time to interview 100. How do you get to 100 applicants by next week to start interviews?

The medical resident selection process isn’t perfect, but there are too many applicants for few positions. The result is using whatever filters available to reach a safe number to interview.

 

[brazilianpsych]

It does correlate with odds of passing other step exams. If you score 270 on Step 1 in your example, there are very low odds of failing step 3. States (many) have a max number of failure attempts on step 3 to practice medicine. Many programs require step 3 pass by a certain year.

I’ve seen students held back by step 3 failures. There have been students that have failed 3x and are then cut from training as they can’t be licensed in my state any longer.

Additionally, step 1 is a data point to compare in an age where there are very few data points. Many med schools are P/F. Other med schools have such odd grading scales that you can’t easily compare students by grades at all. Many don’t have class ranks as a result. Research is an even more useless metric to determine how good a psychiatrist will become. Dean letters and LOR’s are mostly the same. They merely help identify red flags or irregularities. The result is Step 1 being the lone equivalent amongst med students.

Completely fair, I understand that point. It bothers me, but I guess that when you get 2.000 apps you have to screen them somehow...
I say that because I have a friend who got 265 on Step 1, and I swear to you, I coudn`t make him understand the difference between malingering and conversion disorder. After 30 min he would still say "but she was faking it" lol. I`m not entirely sure if he`s not austitic tho, guy thinks like a brick lol

That raises a good question of how can you test whether someone is a good person?

My metric is not something you can figure out with a test. It's after meeting them wondering how safe I would feel leaving my dog with them. Some people I meet not for even thirty seconds.

If there such a dog test for future doctors, I think would be quite useful.

I think that`s weirdly a very good metric, makes a lot of sense.

 

[Merovinge]

Ah, I see. That was stupid of me haha. Thanks for the clarification.

I knew from the onset that it is not going to be safe bet.
However, there is also a real difference between 0.5 percent chance (quoting another poster here) -- in which case I am probably not going to even give it a shot -- and having somewhat of a chance. That is what I was trying to gauge here. But the consensus seems to be that it would be tall order, which is quite discouraging.

Applying for residency into psychiatry even as a US MD from a top tier medical school with good scores is STILL not guaranteed to just point your finger on a map and guarantee where you will end up, particularly when your finger has a proclivity from California. Every step away from "ideal" candidate you are just makes the process that much harder. People are rightly just helping you understand that if you want to be an American Psychiatrist the best path is to apply broadly. If geographic flexibility is not in the cards for you, you might need to consider a different vocational path.

 

[shoenberg3]

Thank you all for some much needed perspective on this issue.

Other factors are considered in the link, mainly research and other graduate degrees. More research doesn't seem to increase the chances of matching. This might be due to a lot of what people list as research experience not being substantial. E.g. a single first author psychiatry paper is likely to do a lot more for your application than a handful of posters from summer internships. If the paper is in a top journal and you can sell a good story on it during interviews, even better.

It's not clear from your post whether you've already graduated or not? If so, are you working as a doctor currently? Experience working as a doctor in Korea will probably help your application but being a year+ post-graduation without working in medicine is likely to hurt it. That said, if you haven't had any US clinical experience before graduating medical school, it may be extremely hard to get any meaningful experience now.

I'm not sure if international medical schools outside of e.g. Oxford and Cambridge are regarded in the US at all, but it might help your application if you went to a top Korean school. From what I've read, a lot of the stigma about IMGs is due to the perception that they weren't able to get into a US school, so making it clear that this isn't the case might help.

Good letters of recommendation from US clinicians and/or contacts at particular residency programs are the other big factors that may make or break your application.

People often say that psychiatry residencies are more holistic in assessing applicants than other specialties and that a 'good story' can make up for some deficiencies in an application. Completing undergrad in the US and med school in SK sounds like the start of a pretty good story to me. If you get decent scores and letters and can show a proven interest in psych, then I would have thought your chances of matching in the US would be quite good.

I pored thorough the match data and found that there is a relative wealth of Northern California spots, including those in Visalia, Davis, Fresno etc in the Central Valley (which would be just fine, also) and I am certainly glad that the Kaiser spots in the Bay Area have been added recently.

6 spots in Kaiser Santa Clara, for example, which is literally 5 minutes away from home! What a dream that would be! Interestingly, in 2020 only 5 of the 6 spots in Kaiser Santa Clara have been fulfilled. Wonder what the story is there..

It is unfortunate that I am currently in my fourth year and due to the COVID situation, I don't think I will be able to get a rotation in. Would doing an observership(s) in hospitals that I would like apply to be directly helpful in increasing my chances there?

Also, in my case, I did receive acceptance from 1 US MD school + 2 DO schools but decided to go to Korea instead. Unusual choice, I know...
Not sure if something like that would be worth bringing up in an interview situation/application?

I tend to think I have a somewhat interesting story, having double majored in Biology and Music in undergrad and pursuing a lot of interests/projects outside medicine. Hopefully, weaving in these aspects into my interview/application would be somewhat helpful in standing out from other IMGs.

It is interesting that even having publications didn't seem to affect the odds of matching for psychiatry. Out of the criteria mentioned, only STEP 1 and especially STEP 2 scores seem to have some correlation. There appears to be advantage in scoring above 230 and above 240 seems to be a significant factor in increasing the chances of matching.

Again, thank you so much for your help! I am starting to see that I have to be realistic with my chances yet still not lose hope in the process!

 

[shoenberg3]

The statistics here are incorrect. Matching as an IMG have gotten more difficult in recent years.

Without above average Step scores and away rotations in Cali, I’d place the odds of matching anywhere in Cali at 0.5%. The away rotations will generally get you an audience to attempt to impress them. If you do really well on steps 1-3 and do away rotations in Cali and have some psych research, I’d move your odds of matching in Cali to 10%. Obviously this is unscientific. Many Cali programs without an away rotation will automatically screen out your application for not training in the USA or having completed all 3 Steps. Away rotations may help you avoid the screening process. Then the ball is in your court.

Thank you for your realistic assessment.

Do you know how strict they are with their screening process? And in general, which institutions enforce these measures (UCs? Kaiser?)

Thanks again.

 

[TexasPhysician]

Thank you for your realistic assessment.

Do you know how strict they are with their screening process? And in general, which institutions enforce these measures (UCs? Kaiser?)

Thanks again.

All programs have a screening process, but it can change year to year. For instance, a program I was associated with developed a policy against taking anyone without full funding at the institution level. Every program immediately screened out every applicant trying to do a 2nd residency and transfers without full funding. An elite transfer from Harvard with 100 publications could be the only applicant for a PGY-2 position at this institution and get denied.

I’ve seen psych programs have an absolutely no IMG/FMG policy up until a hurricane effects the area. The AMG’s get scared off for 1 year. There could be a class with all IMG/FMG, and then the policy is reinforced again 1 year later. The policy can be so strict as to keep out family of faculty that trained outside of the US.

Some programs purposefully interview 10% IMG and rank them bottom 10% as an insurance policy against the SOAP system.