In the United States, the residency is the essential final step in preparing physicians to practice medicine independently. It can also be the perfect opportunity for international physicians to gain experience in the United States.

Before undertaking a residency, U.S. students complete undergraduate study, then spend four more years in medical school, earning the Doctor of Medicine (M.D.) degree. Unfortunately, because of relatively small enrollments and high competition for admission, international students have little chance of being admitted to M.D. programs in the United States. Such programs often only enroll residents of particular U.S. states or regions, and even those that are open to international application typically only admit a handful of international students, generally with U.S. bachelor’s degrees. However, many international medical graduates (IMGs) do complete residency programs in the United States.

Residency programs are designed to allow participants to gain expertise in a medical specialty and to gradually take on increasing responsibility for patient care within a supervised clinical environment. Programs typically last three to seven years, depending on the medical specialty chosen. Advanced medical technology and facilities, expert faculty, and the wide variety of programs available (approximately 8,300 educational programs in 126 specialty and subspecialty areas are currently accredited by the Accreditation Council for Graduate Medical Education), can make U.S. residency an exciting opportunity.

You should be aware that the route to residency is not easy and that openings tend to be highly competitive. Before beginning, realistically assess your medical knowledge, English language skills, educational background, ability to travel for required testing and interviews in the United States, and how well your educational plans match home country needs (the ministry of health will be expected to support your final residency visa application). If you then decide that you are ready to join the thousands of IMGs who enter U.S. residencies each year, the outline provided here can guide you in achieving that goal.

Steps to a U.S. Medical Residency

The first essential is to obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG). Testing required for this certification may be begun while still in medical school, though the IMG must receive their final medical diploma and medical school transcript before being actually certified. Here are ECFMG’s requirements (see also www.ecfmg.org):

• Complete at least two years at a medical school listed in the International Medical Education Directory (IMED) of the Foundation for Advocacy of International Medical Education and Research (accessible online at imed.ecfmg.org/).
  
  
• Apply to ECFMG for a USMLE/ECFMG Identification Number by completing the application on their Web site. Once your eligibility is confirmed, obtain a scheduling permit from ECFMG for the three-month period during which you plan to take your first USMLE test.
  
  
• Pass the USMLE Step 1 and Step 2 Clinical Knowledge (Step 2 CK). These computer-based examinations are offered at selected Thomson Prometric testing centers worldwide.
  
  
• Pass the hands-on USMLE Step 2 Clinical Skills examination (Step 2 CS) examination administered by ECFMG in several U.S. locations (currently including Philadelphia, Atlanta, Los Angeles, Chicago, and Houston) throughout the year.
  
  
• All three exams mentioned above must be passed within a seven-year period for the candidate to qualify for ECFMG certification. They can be taken in any order. Candidates who do not pass Step 1 or Step 2 CK can apply again immediately to re-take the test with a maximum of four attempts allowed per year. For Step 2 CS it is necessary to apply for a new eligibility period, and re-take attempts are limited to three per year.
  
  
• No additional English proficiency examination is required. (In the past, TOEFL was required—but no longer.)
  
  
• Graduate from an IMED-listed medical school. Document the completion of all requirements for the receipt of the final medical diploma. Provide ECFMG with copies of the medical diploma and final medical school transcript. ECFMG will then independently verify these credentials with the medical school.

At the same time that IMGs are completing the ECFMG certification process, they can begin investigating residency options and applying to programs. IMGs must be ECFMG-certified before actually starting a residency.

• Consult the Graduate Medical Education Directory, published by the American Medical Association (AMA) and/or the “FREIDA Online” database on the AMA Web site at http://www.ama-assn.org, to choose appropriate programs.
  
  
• Correspond with and, if possible, visit programs of interest. Interviews by phone or in-person are generally an important factor in the admissions process.
  
  
• Apply directly to programs of interest, using their application forms or the Electronic Residency Application Service (ERAS) as the programs specify. IMGs must have obtained an identification number exam through ECFMG (by applying for an exam) to apply through ERAS.
  
  
• Also apply to be matched with programs of interest through the National Resident Matching Program or specialty matching programs (if programs participate). See http://www.nrmp.org for more information.

Finally there is the visa application. IMGs must be ECFMG-certified and accepted to a residency before they can receive a visa for residency study.

• Contact a designated sponsor (ECFMG for a J-1 visa, the residency program for an H-1B visa) to obtain certification to apply for a visa. A curriculum vita, letter from the home country ministry of health, and other materials will be required.
  
  
• Once certification to apply is received, contact a U.S. embassy or consulate to apply for the visa. Be prepared to document study plans, financial resources sufficient for your planned program, and intent to return home.