I'm an img that matched this year, so I can offer you what I learned from the interview trail. I had some time off b/w graduation and my start date (I started during an off cycle start date). I found that almost every director asked what I was doing since I graduated. I had been involved with research and that usually sparked a great conversation with them. I found that most program directors liked the fact that I was involved in research. So, I would try to get involved in some research (PM&R focused).
Secondly, you may want to look into observerships. Montefiore offers one in Bronx. Just take your ERAS list and start emailing residency coordinators regarding yourinterest in doing an observerships. Perhaps you can get a stronger LOR from this experience as well.
I'm sure your persistence and hard work will pay off. Good luck!
Hello Everyone,
Congratulations to those who secured a residency position in the annual Match, and to those who were less fortunate, "keep your head up and don't ever stop pursuing your dream." Reading the posts on forums across the web gives me mixed emotions as I find it difficult to understand why would anyone discourage our fellow physicians from obtaining professional help and residency entry guidance services from REPUTABLE organizations.
Per ECFMG, "there continue to be obstacles and challenges for IMGs and those with whom they interact with respect to their full integration into American culture, American medical culture and the American healthcare system." Reflectively, every year more than 3000 residents fail to finish residency, with anecdotal research that shows that the majority of such attrition may have been avoidable by simply providing a formal pre-residency acculturation orientation to our fellow international physicians. Additionally as clearly evidenced by the greater number of U.S. graduates seeking a relatively unchanged number of PGY-1 residency positions, IMG's are finding it more difficult to secure interviews using USMLE scores and a recent graduation. Per Dr. Pedram Mizani, MD, a Family Physician and our Chief Clinical Officer, "We have been noticing a growing trend of IMG's with high USMLE scores (>90 and 1st attempt) remaining unable to secure sufficient number of interviews to statistically tip the match algorithm in their favour; the same applicants who could secure 7 interviews by applying to 70 programs are finding themselves applying to 150+ programs and securing just a handful of interviews, if fortunate." This all means that all international physicians must step up their game, sharpen their focus and begin to learn what residency directors are looking for in residency applicants using 2010 evidence based research, including the significant emphasis that's being placed on revising the USMLE:
http://www.usmle.org/General_Information/CRU/CRU-2009-06-19.html.
I believe that there are significant confusion circling what residency programs mean by requiring IMG's to show sufficient proof of U.S. Hands-on Clinical Experience prior to applying. Please note the following facts and pearls of wisdom:
A. According to a 10 year retrospective research conducted by American Academy of Medical Colleges, 8 of the top 29 resident selection criteria by Residency Directors had to do with an applicant's performance during their U.S. clinicals, including elective and core specialties
B. Equally as important as hospital experience is an IMG's ability to manage a patient well in outpatient settings, and to help them avoid being hospitalized. This is a VERY important point as most IMG's with little U.S. hands-on clinical experience over-emphasize the need for hospital exposure for the sole reason of obtaining "face-time" with residency decision makers. You must think outside of this box: show that you have U.S. clinical experience in all settings, including Nursing Homes, Intensive Care Units, underserved areas, home health visits (typically during Family Medicine clinicals) so that you'll be viewed as a "balanced" applicant.
C. It is up to the IMG to provide the best type of clinicals possible. The following is typically how clinicals conducted by IMGs are viewed (#1 being the most effective, and #10 as the least effective):
1. Current practicing physician (licensed MD returning to residency, current resident or a fellow)
2. Insured medical student U.S. clinical rotations/clerkships (greater flexibility and educational freedom/understanding, better access to medical facilities and contractual agreements with hospitals, ability to conduct more invasive training under the auspices of being a medical student who needs to learn)
3. Insured hands-on clinical experience (similar to student clinicals, but no invasive procedures or comments about patient chief complaints; cases are discussed with physicians who AT ALL TIMES supervise each trainee during their patient interactions. IMG's do not refer to themselves as "Doctors", or do anything that would give patients the indication that they are responsible in any way in providing care to that patient - in BOTH inpatient as well as outpatient settings)
4. U.S. clinical experience/externships in an ancillary healthcare career through formal U.S. college education (i.e. Certified Medical Assisting, Advanced Medical Assisting, Registered Nursing, paramedics, etc.)
5. Clinical exposure to U.S. patients in U.S. military settings (the physicians are trained in the U.S. and the facilities somewhat mimic our national healthcare infrastructure, but limited in cultural dynamics, insurance exposure and civilian style patient care)
6. Clinical exposure in English speaking countries (Canada, England, Ireland, Australia, etc.) that may or may not resemble the patient-centered type of medicine practiced in the U.S.) Please note that unfortunately, the U.S. is a highly litigious society, so your pre-residency training should include exposure and preparation for such events.
7. Clinical research (somewhat limited in exposure to a variety of patients, and variety of settings; typically single problem/subject focused)
8. Continuing Medical Education and retreats (
https://nf.aafp.org/Cme/CmeCenter/Default.aspx?navid=cme+center; but limited in exposure to patients, if any)
9. Masters in Public Health or related fields (the clinical exposure has greater emphasis on the business of medicine and not the clinical aspects, which residency programs care about)
10. Observerships within renowned Graduate Medical Education Departments/residency programs
D. Don't overlook the importance of having your residency documents professionally reviewed, and corrected for accuracy and grammar. An applicant may have the GREATEST clinical experience and personal history, but it doesn't exist if it's not effectively communicated in his/her residency application. A professionally put together application (including review of your Common Application Form and Personal Statements) is imperative to being considered as a viable candidate, versus one that looks identical to the other 30,000+ applicants!
E. NEVER COME IN CONTACT WITH A PATIENT WITHOUT INSURANCE; you should not even risk it as it's not worth losing your entire career over it, when there are legal clinical placement services through organizations. Just remember that there are legal "watch-dogs" all over the U.S. waiting for someone to do the wrong thing; just click on
http://www.google.com/search?source...S357US357&q=malpractice+suits+against+doctors for an example.
F. Do not obtain clinicals with a close friend or a family member (especially if they share your last name), as this may indicate that there wasn't a formal structure such as an affiliation agreement, goals and expectations, formal clinical evaluations and most importantly, insurance against medical liability cases.
G. Do build your network of physicians early, and begin to secure U.S. Letters of Recommendations by no later than 18 months before your planned residency start. According to the Journal of Academic Medicine, 73% of Internal Medicine Residency Directors found foreign Letters of Recommendation "useless"... so why waste your precious allocations of 4 Letters of Recommendation to documents that directors find useless? As a rule of thumb, you may solicit for one Letter of Recommendation per 4 to 6 weeks of hands-on clinical experience.
H. Observerships are just that: you observe! You don't speak, touch, discuss, or interact in any way with a patient. Some states may even forbid you to talk about a patient with the treating physician while the patient is still in the office/hospital (so that no one alters the decision making of a licensed physician). Therefore although this term is well known to all residency directors, it is not an experience that is highly sought after by them (least favourable clinical experience). Additionally, no research has ever been able to prove that conducting Observerships in a teaching hospital equals interviews at those hospitals, or residency placement security. Any LOR obtained will not be sufficient in the eyes of the Program Director because it does not show your clinical abilities and patient interaction skills in any way.
I. Pay particular attention to what LOR's you attach to each program you're applying to: it is generally recommended that your LOR portfolio be relevant to the sequence of specialties that you'll be rotating through in your PGY-1. For example if applying to Family Medicine, send 2 LOR's from U.S. practicing Family Physicians, 1 LOR from a U.S. practicing Paediatrician or Psychiatrist, and 1 LOR from OB/GYN or Internist. Do not send all 4 LOR's from Family Physicians as this would make your application unbalanced.
J. You are applying for a job; don't forget this! Therefore, you will be expected to interview as you would if you were applying to any other professional position (with the exception that of course, you need to show medical expertise for the level that you're applying to). The burden of proof is upon the applicant to show that he/she is not going to be a liability, but rather an asset. The biggest fear of Residency Directors (as put so well in a residency position job offer letter in the 2010 Scramble) is for the incoming intern to "NOT BURN OUR HOUSE DOWN" i.e. have a great attitude and come with experience.
K. A record 16,000 U.S. senior medical students participated in the 2010 Match, with more than 9% increase in U.S. medical school seniors who will enter residency training in Family Medicine when compared to 2009 alone (
http://www.aamc.org/newsroom/pressrel/2010/100318.htm). Additionally according to the NRMP, 2010 was the largest Match in history: 30,543 applicants participated—655 more than last year and 3,800 more than in 2006. However the number of residency positions has not increased at the same rate: there were 382 more first-year positions available this year than last year, and 1,150 more than were available four years ago… a 3:1 discrepancy when compared to the rise of residency applicants. More than 95 percent (21,749) of the first-year positions were filled during this Match. Therefore, pre-residency U.S. clinical experience is mattering more and more as the number of residency applicants competing for the same number of residency positions continues to increase.
L. Certain medical boards have strict limitations on what types of clinicals may be conducted by IMG's prior to residency, if any. For example, California, Pennsylvania and Puerto Rico strictly forbid IMG's from conducting any sort of clinicals by IMG's, unless in a formal teaching institution or in a certified profession (i.e. Registered Nursing, Medical Assisting, etc.)
M. Research shows that physicians tend to end up practicing within 20 miles of where they establish their physician mentor network, so pay particular attention to where you would like to ultimately practice medicine in relation to where you request to conduct your clinicals. AmeriClerkships Medical Society members has more than 550 Affiliations with U.S. clinical sites, including formal agreements with hospitals, teaching hospitals, nursing homes and surgical centers so to be able to provide you with the most well balanced combination of clinicals as possible. Our trainees get to choose where they'd like to conduct their clinicals, therefore the statements made by the previous writer/post alleging that "IMG's will be in a rural areas" is not true (at least not true for Americlerkships Medical Society). The only place we cannot provide hands-on clinical experience is in California, Puerto Rico and Pennsylvania, due to state specific regulations in accordance with the limitations imposed by their respective Medical Board.
N. Contrary to common belief, insured U.S. hands-on clinicals are VERY AFFORDABLE and the MOST EFFECTIVE measure an IMG can take in order to distinguish him/herself from the record number of residency applicants: at an average out of pocket cost of $8.50/hr (which includes IMG specific hands-on medical liability insurance and clinical coordination/scheduling/management), an IMG is able to gain immediate access to fully supervised clinical settings and begin their U.S. clinical experience, while letting AmeriClerkships manage the relationships, agreements, insurance and logistics of each clinical assignment.
O. Not all medical liability insurances are the same: we have seen insurance companies selling "Ancillary Healthcare Medical Liability Insurance" to MEDICAL GRADUATES, as if they were medical students, nursing students or medical assistants. This will not provide you coverage for hands-on clinicals as someone who's already graduated from medical school. Make sure that your insurance binder provides explicit language for protecting you against any negative event during your clinicals as a Graduate, and during "hands-on" experiences (not just Observerships). Also, the medical malpractice insurance of your supervising attending physician will not cover you; it only covers the licensed physician.
P. Last but not least – according to the Journal of Academic Medicine, there are 3 Main IMG Internship Performance Indicators: performance on standardized examinations (USMLE's), type and qualify of clinical exposure during the 24 months immediately preceding your anticipated residency (please refer to the 10 types of clinicals above), and your performance during the actual interviews. Do well in all 3 and you should be considered as a top contender for any residency position.
Q. Ask, if you have any questions: Its always free to ask any of AmeriClerkships
Therefore please, PLEASE get professional help if you don't know the U.S. healthcare system and the process of residency entry (plus all the newest tips). Don't attempt to set up clinicals on your own as most likely you'll end up regretting your decision, since not all physicians are friendly to the concept of IMG's conducting hands-on clinicals. Please always ask physicians who recently secured residency positions about residency; a physician who secured a residency 15 years ago and is not currently a player in the field of medical education/residency will most likely have out-dated information. Last but not least, you can always contact us for free help and direction; I do not suggest you go about getting into residency on your own.
Best wishes to all aspiring physicians.
Tony Saba
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