medical research opportunities in usa for img

Your Roadmap to a Medical Career in the USA

How to unlock research opportunities as an international Medical Graduate

Research experience and publications are important for keeping international medical graduates worldwide up-to-date and helping them give the best care possible. 

During the USMLE journey, IMGs are confronted with the question of their research and publishing experience. 

As the residency match gets more competitive each year, research experiences and published work can considerably boost one’s residency application. 

However, many IMGs are unfamiliar with the processes of conducting research and getting a paper published. 

There are, of course, numerous paths to doing research and getting published, including applying for research positions in the US.  

However, as it’s only an option for some IMGs, I’d like to share alternative research and publication methods. 

Interested? 

Let’s dive in!

Research experience VS individual research

First, it’s crucial to distinguish between research and publication. 

What I mean by that is, only some research results in publication and only some publications count as the result of research experience on a resume. 

So, what is the difference, and why does it count? 

Research experience:

Research experience is any professional or academic research done while working for an institution. 

In other words, it implies that you hold or were holding a position in an establishment. 

Besides potentially publishing the results of your work, research experience has many advantages, including the following:  

• You’ll benefit from the guidance and experience of mentors and fellows, which is especially helpful if you have no experience with research and publishing.
• Positive impact on a resume and ERAS application, regardless of whether or not the research resulted in publication.
• Opportunities to make connections.

Depending on whether it’s funded research or unfunded research, the flip sides of both research experiences are that: 

• Unfunded research proposes only unpaid positions. Therefore, you’ll have to sustain yourself financially throughout the research experience.
• Funded research offers paid positions. However, there are fewer positions for a large pool of applicants, and it usually requires applicants to have previous research experience and a solid resume to be considered.

What are the remaining options for IMGs who cannot sustain themselves financially to apply for unfunded research and do not have enough research experience to apply for funded research?

One answer to this question is – Individual Research!

Individual research:

So, what do we mean by individual research? 

Individual research can be conducted without working with an institution and results in the publication of an article.

Individual research won’t be considered as research experience; however, it’s a good compromise for IMGs and an excellent opportunity to acquire the skills to conduct research and get more familiar with the process of getting published. 

So, what are the key elements of conducting individual research? 

Which study type best fits individual research?

As you won’t hold a position in an institution, you won’t have access to a laboratory or direct access to patients to conduct the study. 

Therefore, the most straightforward way to run individual research is to work on existing data, which results in either conducting a Systematic Review or a Meta-Analysis.

The systematic review:

A systematic review involves the collecting, critical assessment, and synthesis of previous research on a particular topic.

The meta-analysis:

A meta-analysis is a systematic scientific approach that, using a repeatable process, combines the findings of numerous independent investigations on a specific issue. It’s a statistical synthesis of the research that was a part of a systematic review. By analyzing many cases and reaching a general conclusion, meta-analysis enables a more accurate interpretation of the data.

Here are some links that will guide you in the process of conducting a meta-analysis or a systematic review: 

• A Meta-Analytic Methodology Guide from frontiersin.org
• A very interesting article on how to run a systematic review from ncbi  

From topic selection to publication

Once you have decided which type of study you want to conduct, it’s time to start taking concrete actions. 

So, where do you start?

Select a subject

This step is crucial and shouldn’t be taken lightly. 

Taking the time to select the appropriate topic is vital. You don’t want to invest time and effort into something only to realize halfway through that your chosen topic is irrelevant and unfeasible. 

So, what is a good subject? 

Ideally, the topic you decide to investigate should revolve around an interest of yours. For example, if you are interested in dermatology, look for a subject in that field. 

Also, writing articles in the field you want to work in will help your application significantly. 

Once you have defined the field you want to research, you’ll have to clarify the research question, which is, in my experience, the trickiest part! 

To determine the research question, you must first go through what’s already been done and what new questions the researchers have brought to light.

Reading the trending articles in Pubmed or highly-accessed journals can help you in this step and familiarize you with how research is conducted, how results are presented, how a paper is written, and so on.

Don’t hesitate to reach out to doctors or medical residents in your home country or elsewhere to ask about what subject they think is worth investigating. 

I recommend you use the PICO method to formulate a research question.

What are the steps to publish a paper?

Form a team:.

Although we’re talking about “individual”  research, publishing a paper is a result of collective work. 

As you determine the tasks that need to be accomplished to achieve the goals of your study, you can start reaching out to individuals who possess the necessary skills and establish clear roles and responsibilities for each team member, as well as a system for communication and collaboration.

With your team, you’ll have to complete the following steps: 

Conduct a literature review:

Conducting a literature review will allow you to highlight what’s already been established and documented, and confront the study you’re conducting with the previous one. 

Define the design of the study:

Your research design is like your house’s foundation: Essential. 

Study design refers to the methods used to collect and analyze the data and ultimately represent the quality of your work. 

Collect the data and do a statistical analysis:

The data correspond to the articles selected to be integrated into your systematic review and meta-analysis. 

Once you have collected all the data, you will have to do a statistical analysis of the results.

Although you can task a statistician to do the statistical analysis, I highly recommend you learn and do it yourself as you will acquire a new valuable skill and get a better ,broader perspective of the study you are conducting. 

You can find courses on Coursera or Udemy .

While writing, pay special attention to the following: 

• Vocabulary and grammatical errors

Do not hesitate to ask mentors or fellows to proofread your work, or use professional tools to assist your writing, such as Grammarly. 

But remember that it’s not enough to proofread with this kind of tool. It’s better to seek assistance from a professional proofreader who’s a native English speaker. Feel free to contact us as we work with several native writers.

Identify a journal

The final step of your publication journey is to identify a journal where you want your work to be published.

However, don’t be too quick to shout victory, as this step can be daunting. 

Once you’ve identified a list of potential journals, I recommend you read their specific guidelines to ensure your research fits within the journal’s scope before submitting your work. 

Keep in mind that some journals have a longer turnaround than others and that the process can take many months. With that in mind, choose a journal that aligns with your timeline for publication. 

How to make it to the next level

Besides maximizing your chances of getting matched with your dream specialty, getting published is a unique opportunity to learn, acquire new skills, and make new connections.  

As you define a study question worth investigating, use it as an opportunity to contact doctors who have conducted studies on a related topic and, if possible, suggest a collaboration. 

Email the institution you want to apply to with your project study, motivations, goals, and an attached resume. 

Again, this is not just about getting published to put it on ERAS, but rather a chance to start taking action and building a network.  

Besides good scores and US clinical experience, research and publications have become much more important in the matching process. 

Since getting a research position might not always be an accessible option for all IMGs, individual research represents an excellent compromise to get started in research and publishing. 

Selecting the appropriate subject and acquiring the necessary skills to publish your first piece of work is key in the USMLE journey. It will help you match 

with your dream specialty, and it also presents a unique opportunity to start reaching out to hospitals and making new connections. 

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Dr. Zineb Moustaatif

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The Best Research Opportunities For IMGs

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Medical students, notably IMGs on the USMLE path, have plenty of research opportunities. These internships enrich classroom learning by fostering critical thinking and clinical judgment while offering a shot at contributing to science, but they also create important networking opportunities that can be valuable for residency matching. 

We previously discussed various research opportunities available for IMGs . However, it is crucial to choose a program that aligns with long-term goals, as options range from basic lab sciences to analyzing patient data and studying disease trends over time.

Summer internship programs explicitly designed for IMGs are available even at highly respected institutions like Harvard University’s Global Clinical Scholars Research Training Program.

Benefits of Participating in research while studying medicine

Partaking in medical research can greatly benefit a student’s study period – it deepens disease understanding and forms professional skills. Additionally, it sharpens analytical abilities, enabling students to comprehend complex science literature and diagnose challenging cases. 

It also offers an advantage in residency selection as programs highly value such experiences, thus broadening career paths. Moreover, it provides opportunities for global networking with professionals, potentially leading to future project collaborations and medical guidance.

Types of Research Available To Medical Students and IMGs

Each type of research offers distinct advantages and challenges that greatly enhance patient care and deepen our understanding of diseases. Here are a few types of research you can engage in.

Conducting clinical trial studies at universities/research labs

Conducting clinical trial studies at universities and research labs is a significant component of advancing medical knowledge. These institutions provide crucial environments for conducting rigorous, systematic investigations into novel interventions or therapies. 

Clinical trials are inherently multi-disciplinary, requiring diverse teams of clinicians, biostatisticians, and pharmacologists to collaborate to develop new disease treatments. Participants in these university-based trials often gain first-hand exposure to cutting-edge technologies and methodologies while contributing directly to advancing patient care procedures. Thus enriching students’ education and providing invaluable expertise in shaping an individual’s professional trajectory within medicine or scientific research domains.

Publishing Scientific Papers in Peer-reviewed journals

Publishing scientific papers in peer-reviewed journals is a critical aspect of medical academia that validates and disseminates your research findings. The process involves rigorous scrutiny by independent experts to ensure accuracy, credibility, and contribution to the existing knowledge base. It commands depth of understanding, meticulous application of research methodology, and clear articulation of conclusions drawn from data analysis. 

Achieving this milestone not only adds prestige to one’s professional portfolio but also significantly influences future investigations in the respective discipline while promoting collaborative opportunities for researchers globally – thereby fostering collective advancements within healthcare sciences.

Participating as a co-author or assistant author on existing projects

Participating in existing projects is an excellent starting point for IMGs and students in the field of research. This engagement offers an opportunity to understand the processes and methodologies used in clinical or experimental settings. It equips students with the necessary skills required for academic writing, including data interpretation, manuscript drafting, editing, and literature review. 

Additionally, this role fosters professional networking and enhances interpersonal competencies which are highly valuable during the residency match process. Furthermore, being credited as a co-author substantiates your contribution to the scientific community while significantly amplifying one’s research profile – ensuring higher visibility within the medical fraternity.

Carrying out independent surveys & qualitative research methods

Conducting independent surveys and utilizing qualitative research can optimize data collection by allowing researchers to gain detailed insights into specific topics. This approach enables one to understand human behavior, perceptions, attitudes, or experiences that are often missed out in quantitative studies. Independent surveys offer flexibility; they can be tailored towards a certain demographic group or topic of interest and deployed through various channels like online platforms or face-to-face interactions.

Shadowing experienced researchers within the field

It is an exceptional opportunity that provides aspiring medical professionals with direct insight into a research-oriented career. Shadowing allows one to observe first-hand how hypotheses are formulated, experiments designed, data interpreted, and results communicated effectively within the scientific community. 

Besides exposing participants to various methodologies and ethical considerations associated with research practices, this immersive learning experience enhances the technical skills in executing rigorous studies while fostering the critical thinking aptitude required for innovative problem-solving strategies. Additionally, it fosters relationships with experts, which can result in potential mentorships or collaborations – facilitating both professional development and academic growth.

Gaining experience through summer internships and fellowships programs

Gaining experience through summer internships and fellowship programs can be a transformative stepping stone for IMGs. These short-term experiences provide immersive exposure to various medical specialties, offering hands-on clinical training under the guidance of experienced mentors. IMGs have the chance to improve their technical skills and gain insight into advanced patient care in a variety of healthcare settings. The experience adds value to a candidate’s CV and helps them stand out during a residency match.

Common Challenges Faced by IMG When Pursuing Research Experiences

Pursuing research opportunities can be a complex journey for IMGs. They frequently encounter language and cultural barriers, significantly hindering their communication skills and adaptation to a new environment. Adjusting to unfamiliar dialects, especially scientific terminologies, and absorbing foreign customs often leaves them walking on shaky ground.

Finding professional contacts who could potentially guide them through these knotty issues is equally challenging due to geographical restraints and the lack of an established network. Compounding these challenges are financial limitations that emerge from expensive relocation or course fees despite available scholarships. These obstacles require resilience but become stepping stones toward success in their chosen field.

The landscape of research opportunities available to IMGs is vast. These extend from core laboratory-based scientific explorations to large-scale clinical trials or public health-related epidemiological studies. Programs specifically designed for such groups, like Harvard University’s Global Clinical Scholars Research Training Program, add immense value by providing a comprehensive learning experience under expert mentorship.

To make the most of these experiences, IMGs must choose projects that resonate with their career interests.

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Research Electives

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Research electives are programs that IMGs can enter into, but you should remember that these are very rarely hands on, and not considered to be a clinical experience. Research electives are a great way for an IMG to undertake academic, publishing, and/or authorship credit. These offer a student to gain a LOR, and in combination with a USCE can be extremely beneficial to a medical student’s CV/resume.

Find a research position

Where do I find research position?

Finding a research position is not an easy task within US. You have to try hard enough to find a research position, so be patient. If you know someone currently working on a research project, offer him/her voluntary service and help. If they are pleased with your dedication and hard work, they may offer you a position in no time. But don’t be hopeless if you don’t have any connections, look up for the institutions known for conducting research projects, especially the subjects you are interested in. We will provide some organizations list on the later part of this article. Dig deep into the institutions’ websites and find out email addresses of the professors and researchers. Their title might be like as – clinical researcher, or clinical research coordinator, post-graduate research fellow, research associate, etc. After you have obtained the email addresses, start emailing them. Introduce yourself, write about yourself, your educational background, subject areas of research you are interested in (carefully look onto the subjects they are currently doing research work). Don’t forget to also write about your goal, how you will manage your living cost like accommodation, food if the position is voluntary. You might have to send hundreds of email before getting any reply. You can have a sample letter or email; you can write from the following link-  http://research-opportunities.blogspot.com/p/sample-letter-for-research.html . Once you get a reply, you are set. They may want to take an interview of yours; so decide whether or not it’s worth traveling. Only if the position is as like you are looking for and also you have the time and you can manage the expenses, take it, because another opportunity might not arise. But if you are not interested and think you can’t manage everything, then let them know.

Remember there are two types of research work-

• Lab research
• Clinical research

We will prefer clinical research. In lab research you have to be sitting on the lab and work all day long; thus you will not get chance to meet people who can help you to get residency. Although sometime you can convince your supervisor to give you some time to get into some interviews but in clinical research, you will get chance to interact with clinical life and doctors working on residency program more often.

As we said previously, now we are going to provide a list of organization and website from where you may get some opportunity for research work. You can also get some stipend or get a position of paid research. This is an updated list of places and websites to get some stipend or get a position of paid research. USMLE scores or ECFMG certificates may not be required and many of these institutions may also not be sponsoring your visa.

• Harvard faculty of medicine: The Harvard faculty of medicine conducts many research projects around Boston. There are total six academic basic science departments, which are the heart of Harvard Medical School. Harvard medical School appoints many faculties to their 17 affiliated institutions. Total 50 departments of Harvard conduct huge amount of basic and clinical research.
• University of Pittsburgh/ Department of Medicine: Almost all division of the department of Medicine conduct research work and research opportunities are available on- Cardiology, Clinical Pharmacology, Endocrinology and Metabolism, Gastroenterology, Hepatology and Nutrition, General Internal Medicine, Geriatric Medicine, Hematology/Oncology, Infectious Diseases, Pulmonary, Allergy, and Critical Care Medicine, Renal-Electrolyte, Rheumatology and Clinical Immunology.

Some websites to search for opportunities:

https://projectreporter.nih.gov/reporter.cfm

http://nrc58.nas.edu/RAPLab10/Opportunity/Search.aspx

http://www.centerwatch.com/clinical-trials/listings/

http://postdocs.stanford.edu/prospects/prospects_positions.html

http://info.med.yale.edu/therarad/index.html

http://www.bms.com/careers/job_opportunities/Pages/default.aspx

https://mountsinaicss.igreentree.com/css_external/CSSPage_SearchAndBrowseJobs.asp

http://www.hospitaljobsonline.com/

http://www.hss.edu/employment-opportunities.asp

http://postdocs.columbia.edu/openpositions.html

http://www.arma-cert.org/

http://www.lerner.ccf.org/jobs/

http://jobcircle.com/index.html

http://www.hhmi.org/

http://www.ismrm.org/jobs/

http://www.rfcuny.org/hr/pvn/cgi-bin/show_jobs.asp?category=Research

http://hr.hunter.cuny.edu/jobs/index.html

http://nyp.org/careers/

https://prod.fadvhms.com/bidmc/JobBoard/SearchJobs.aspx?

http://careers.rsna.org/Template.cfm?Section=Look_For_Jobs

http://www.craigslist.org/about/sites

http://careers.naspa.com/c/search.cfm?site_id=190

http://www.simplyhired.com/

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Immigration and Visas

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Research Electives Research electives are programs that IMGs can

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Office of International Medicine Programs

Medical research fellowship program.

The  Medical Research Fellowship Program  (MRFP) at the George Washington University (GW) School of Medicine and Health Sciences (SMHS) provides international medical graduates with the opportunity to enhance their research and clinical skills, preparing them to be strong candidates when applying for U.S. residency programs in the United States. Since the MRFP launched in 2012,  86% of research fellows have successfully matched into U.S. residency positions after completion of the program.

We are now accepting applications for the next program that begins in May 2024! Please refer to the information below for more details.

The goals of the program include providing opportunities for research fellows to:

• Develop a rich and longstanding relationship with a GW faculty member
• Create a network of professional contacts for future support in international medicine
• Develop critical thinking, analytical, and practical inquiry skills utilizing the latest approaches in U.S. healthcare and medical research
• Build a foundation for utilizing evidence-based medicine
• Increase skills in critical appraisal, research design, and understanding of the entire medical research process
• Publish articles or abstracts in peer-reviewed journals and present research posters or papers at conferences
• Gain first-hand knowledge of the U.S. healthcare delivery and medical education system
• Develop personal and group leadership skills necessary for advancement in clinical practice and research
• Develop strategies for communicating clinical research and medical information in spoken and written English
• Gain broad public speaking and presentation experience and participate in at least one professional conference in field of interest

Research : Research fellows attend weekly critical appraisal sessions to increase their knowledge of research methods, analyze the latest in medical publications, and publish letters to the editor. Research fellows also participate in individual and group research projects alongside their faculty mentor aiming to present at a national conference and publish in a peer-reviewed journal.

Clinical observation : Research fellows actively and successfully participate as members of a clinical team. While direct, hands-on patient contact is not permitted, the research fellow engages with the team in all other clinical activities. 

One-on-one mentorship : Each research fellow is matched with a GW faculty mentor in their specialty of choice. Research fellows join the faculty mentor and are integrated into the clinical team, which includes faculty, residents, and students. The faculty mentor provides counseling and guidance through weekly meetings.

U.S. residency application preparation : Research fellows are supported by IMP staff and the Program Medical Director who provide residency preparation interviews and review of curriculum vitae and personal statements. Research fellows can obtain detailed and personalized letters of recommendation from GW faculty members when appropriate. 

Professional development : Research fellows attend regular clinical department grand rounds, conferences, and lectures with their team of faculty, residents, and students. Research fellows are key members of the team and fully participate in department activities. 

Application Process

Research fellows can participate in the program for a duration of 6 months or 12 months and the recommended start date is in May. Earlier or later start dates are also considered on a case-by-case basis. 

Applicants should submit the following required documents to the Office of International Medicine Programs (IMP) at  [email protected] :

• Headshot photograph
• Curriculum vitae 
• Personal statement (1 page)
• Medical school degree
• Medical school transcript
• Three letters of recommendation
• USMLE Step 1 and 2 score reports (if available)

Contact [email protected]  with any questions or to request additional information about the program fees.

How to Apply for Pre-Residency Fellowships as an IMG

Everything you need to know.

Want to know how to apply for pre-residency fellowships as an IMG? A pre-residency fellowship for international medical graduates can be a great first step in how to prep for your residency application and in your post-graduate medical career. For IMGs who want to practice in another country or apply for residencies abroad, a pre-residency fellowship can open more doors of opportunity for you. Applying for pre-residency fellowships are a long and involved process, but we’re here to help demystify it. In this blog, we’ll learn what pre-residency fellowships are, why they are a good choice for IMGs, how to apply, what you need for your application and how to improve your chances of getting accepted to a pre-residency fellowship abroad.

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Article Contents 4 min read

What are pre-residency fellowships for imgs.

As an international medical graduate (IMG), if you’re planning to apply for a pre-residency fellowship, it’s important to understand what your obstacles are and how to overcome. But first you might be wondering, what exactly is a pre-residency fellowship and how can it help further my medical career?

A pre-residency fellowship, as the name implies, is a clinical training program or research fellowship medical graduates can apply for before they start their residency years. A pre-residency fellowship is usually a short-term program designed to provide rigorous clinical training or research experience in a given specialty or discipline. It’s essentially a work-study program for medical graduates. Typically, medical graduates will apply to a medical fellowship after their residency years, so for IMGs, applying for pre-residency fellowships can be the next step in the non-traditional route.

Applying to pre-residency fellowships can be how to get into residency programs as an IMG , it can help you get your foot in the door for a particular specialty or give you a competitive edge if you want to apply for residency programs in another country. A pre-residency fellowship can be a valuable experience to add to your residency CV , too.

So why apply for a fellowship before your residency? Residency programs, particularly in the US and Canada, can be especially competitive. Preference is given to domestic medical graduates and gaining a competitive advantage as an IMG can be difficult, especially in the more competitive residency programs. Applying for pre-residency fellowships can be a good option for US and Canadian citizens, too. If you are a US or Canadian citizen and you attended medical school abroad, you are still considered an international medical graduate and therefore you might be at a disadvantage when preparing for residency.

As an international medical graduate residency applicant, it’s a good idea to give yourself every advantage you can get. Applying for pre-residency fellowship programs can have several key benefits for IMGs:

A pre-residency fellowship can give you an excellent opportunity to explore other cultures, learn new languages and gain international experiences "}]" code="timeline1">

Now that you have your medical degree, figured out how to choose your medical specialty and decided that a pre-residency fellowship program is right for you, it’s time to find out how to apply and what you need to do.

Applying to pre-residency fellowships as an IMG requires several crucial steps. The process may also vary depending on the country you’re applying in, but the steps are relatively the same. For instance, work visa requirements and applications in the US, Canada or UK might look slightly different from each other.

Wherever you plan to apply, you’ll need to do a fair amount of research first. To start, research IMG-friendly residency programs and pre-residency fellowship programs in the country or region you plan to apply. Not all programs will accept international medical graduates, and eligibility requirements may vary from program to program. You’ll also need to check if the pre-residency fellowships are paid or not and if they fit your desired career path in medicine.

This is a general outline of the steps you’ll need to take as an IMG to apply for a pre-residency fellowship program in the US:

These are the very broad steps you’ll take as an IMG applying to a program in the US. We’ll look at some elements of the process to apply for a pre-residency fellowship in the US below.

Visa requirements will vary depending on the country you\u2019re applying to, but for IMGs applying to pre-residency fellowship programs in the US, the most common visas are the H1-B or Temporary Worker visa and the J-1 Exchange Visitor visa. It\u2019s important to note that these visas are temporary, and that once your pre-residency fellowship is over, you\u2019ll need to return to your home country before applying for a residency program in the US or elsewhere. If you decide to apply for a medical residency after you\u2019ve completed your pre-residency fellowship, you\u2019ll need to restart the visa application process.  ","label":"Visa requirements","title":"Visa requirements"}]" code="tab1" template="BlogArticle">

A pre-residency fellowship application is fortunately nearly identical to a medical residency or medical fellowship application and requires many of the same components. It’s still always a good idea to check the individual requirements for each fellowship you apply for, as they may ask for additional components.

For your pre-residency fellowship application, you’ll need to prepare a personal statement, letters of recommendation, exam scores, a resume or CV. All of these can come together to create a strong application and help you as an IMG get into the program of your choice. Below we’ll take a closer look at each component of your application.

For your pre-residency fellowship application, attach your medical resume or CV and include any clinical experience and research experience you have. These experiences will give your application a definite boost. Pre-residency fellowships will be much more likely to accept an IMG who can demonstrate strong clinical skills or research experience. If you have any experience with the health care system in the country you\u2019re applying to, be sure to highlight this. You can also include any English Language Proficiency Tests you\u2019ve completed. Programs will look more favourably on applicants who have fewer cultural or language barriers to overcome, and who are familiar with the health care system and challenges in their country. ","label":"Resume or CV","title":"Resume or CV"}]" code="tab2" template="BlogArticle">

Want some tips for writing a residency personal statement? Watch this video.

How to Improve Your Chances of Getting a Pre-Residency Fellowship

Now that you know how to apply for pre-residency fellowships as an IMG and the key components of your application package, how can you make your application the best it can be? Pre-residency fellowships can be very competitive, and as an IMG you need to work that little bit harder to get your foot in the door. But there are many things you can do to strengthen your app and broaden your knowledge so you’re prepared for not only the application but your future career as a doctor.

As an IMG, you\u2019ll likely be invited for an interview at any pre-residency fellowships you apply to. Accept any interview invitations that you receive and start preparing. Take a look at some medical fellowship interview questions and answers for an idea of what you can expect during an interview and tips for making a good impression. It\u2019s also good IMG residency interview prep for that next step! A pre-residency fellowship interview will look very similar to a residency interview, so it\u2019s not only good practice but it\u2019s your chance to reaffirm that you\u2019re an excellent choice for the program.  ","label":"Sharpen interview skills","title":"Sharpen interview skills"}]" code="tab3" template="BlogArticle">

A pre-residency fellowship is a short-term program designed to provide an international medical graduate with clinical experience or research publications. 

In the US and Canada, IMGs are considered any medical graduates who have graduated from a medical school outside the United States or Canada. Even if you are a US or Canadian citizen, but graduated medical school outside of the country, you are considered an IMG. If you are an international student who graduated from an American or Canadian medical school, you are NOT considered an IMG.

A pre-residency fellowship can be an excellent way for IMGs to gain additional clinical or research experience, and help them secure a medical residency in the future. 

To apply for a pre-residency fellowship you’ll need to become certified through the Educational Commission for Foreign Medical Graduates. You’ll also need to complete any required medical licensing examinations, secure the proper work visa and submit the required documents to pre-residency fellowship programs.

To improve your pre-residency fellowship application as an IMG, be sure to include any clinical or research experience you already have. You can also demonstrate a working knowledge of the American or Canadian health care systems, a proficiency of English and strong interview skills, all of which will help you secure a position in a program as an IMG.

Internal medicine and family medicine are considered the easiest residencies for an IMG to get into. These specialties have the highest acceptance rates for IMGs.

Yes; there are many pre-residency fellowship programs which accept IMGs in the US and Canada. You can find which ones accept IMGs by checking individual program requirements and eligibility.

Pre-residency fellowships, like residency programs, can be quite competitive and often give favour to domestic medical graduates over IMGs. However, there are some programs and specialties that are more friendly and less competitive for IMGs, such as internal medicine or pediatrics.

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Hello, Can you help me with a list of programs that are offering the pre-residency fellowship and also help me with the application. I am ECFMG certified and also I am American citizen. Thank you

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Hello Ashraf, thank you very much for your question. You can reach out to us for a free initial strategy call to discuss how we can help you. 

Swarada Yadav

What all options do i have as a IMG with ecfmg certification?

Hi Swarada! Thanks for your comment. Please read all the details in this blog . 

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Graduate Medical Education Office

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• International Medical Graduates
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The University of Minnesota welcomes International Medical Graduates (IMGs) to GME residencies and fellowships. On this webpage you will find information on IMG Eligibility, IMG Support & University of MN Social Group, ECFMG Certification, J-1 | J-2 Eligibility, J-1 | J-2 Application Process, J-1 | J-2 Application Timeline, J-1 | J-2 International Travel Requirements, & H1-B Visas.

International Medical Graduate (IMG) Definition

An International Medical Graduate (IMG) is a physician who received their basic medical degree or qualification from a medical school located outside the United States and Canada. The location of the medical school, not the citizenship of the physician, determines whether the graduate is an IMG. This means that U.S. citizens who graduated from medical schools outside the United States and Canada are considered IMGs.

IMG Eligibility & ECFMG Certification

+ eligibility.

Per the  Eligibility and Selection of Residents/Fellows Policy , to qualify for a residency/fellowship at the University of Minnesota, International Medical Graduates (IMGs) must meet all criteria found in the policy and provide documentation of one of the following:

• A  currently valid certificate from the Educational Commission for Foreign Medical Graduates (ECFMG) ,  or
• An unrestricted license to practice medicine in a U.S. state,  or
• Successful completion of a Fifth Pathway Program in an LCME-accredited medical school in the United States.

+ ECFMG Certification

Any incoming resident or fellow who is an international medical graduate (img) must be ecfmg certified prior to beginning in their training program, per the institution policy on eligibility and selection of residents/fellows ..

IMGs MUST have their ECFMG Certificate before beginning work in a residency or fellowship program.  Medical students who are concerned about timing should work with their medical schools to request timely verification.  Some medical students have requested and been granted early diplomas by their medical schools, which helps expedite the process.

For more information about ECFMG Certification view the ECFMG Certification Webpage

Canadian & Puerto Rican Graduates

Graduates of medical schools in the United States (including Puerto Rico) and Canada are not considered IMGs and therefore are not required to obtain ECFMG Certification.  An ECFMG Identification Number is issued to graduates of Canadian medical schools only for purposes of Exchange Visitor Sponsorship (J-1 visa).

Visas (J-1 Alien Physician | H1-B Employment Visa)

+ j-1 visa application process | application timeframes.

J-1 Application Process

The University of Minnesota's ECFMG Training Program Liaisons (TPLs) will guide you through the J-1 visa application process via email and a detailed checklist.

Your J-1 application process starts when your program notifies the UMN TPL that you will be joining or continuing in the program for the coming academic year.  After the program has confirmed you, the application process proceeds through these steps:

• The TPL will contact you (via email from [email protected] ) with instructions and a link to the appropriate application checklist. More information on checklist material can be found on the ECFMG website.
• The applicant will collect the documents and information outlined in the checklist and submit them to the TPL (via email to [email protected] ).
• Once ALL application documents are received, the TPL will initiate your online application in ECFMG's EVNet system, upload the supporting documents, and notify you by email of your next steps.  Read more about ECFMG's online application system here .
• The applicant will log into their OASIS account to review their online application.  The applicant will complete all remaining required information and pay the administrative/application fee.  The application cannot proceed until the applicant complete their online portion in OASIS.
• ECFMG will review the application, working through the TPL to address any questions or gather any additional documents needed from the applicant.
• Once ECFMG has approved the application, they will create a DS-2019 and mail it directly to the TPL.
• The TPL will notify the applicant via email that the DS-2019 has arrived and outline your next steps to receive it.  

J-1 Application Timeframes

The earliest ECFMG can issue your DS-2019 is six months prior to your start date.  In October, the TPL will email all continuing and known new UMN J-1 trainees to share application instructions (see Step 1 above).  New residents matching via the national Match Day in March will receive their instructions via email during the first week in April.

If you have a J-2 spouse dependent who is working, it is very important that you submit your J-1 and J-2 dependent application to the TPL as soon as possible.  Please note that for those J-2 dependents who need an Employment Authorization Document (EAD) card, the renewal process for the EAD card is lengthy and can take up to 6 months.

Average J-1 application processing times

Standard applications (for ACGME-accredited programs):

• 4-6 weeks (during the busy season--March, April, May, June, July)
• 2-4 weeks (during the non-busy season)

Non-standard applications (for non-accredited programs and any applications requiring Department of State review):

• 6+ weeks (during the busy season--March, April, May, June, July)
• 4-6 weeks (during the non-busy season)

Please submit your application materials early to avoid processing delays!

+ J-1 | J-2 International Travel & Travel Validation on DS-2019

ECFMG strongly discourages international travel unless absolutely necessary.

World events of the last few years have introduced changes that have a direct effect on international travel for foreign nationals. Security and background checks, along with other security-based initiatives have, in some cases, caused delays in visa issuance at U.S. consulates. These delays have in turn compromised physicians’ return to the United States in a timely fashion. 

If travel is absolutely necessary, it is important that, prior to any departure from the United States, ECFMG-sponsored physicians are aware of the documents they and their dependents must have in order to reenter the United States in J-1 or J-2 status.

The following sections provide basic information on some of the more popular travel-related questions asked by J-1 holders and program coordinators. 

View more detailed information on international travel on the ECFMC website . The preparation for International Travel dropdown will outline all of the appropriate documents you will need to be readmitted in the US in J-1 status.

Canadian Citizens 

Canadian citizens do not require a J-1 visa stamp in their passport. It is easy for customs to assume that you are traveling to the US as a visitor. If you travel to Canada from Minnesota over the border, or at the airport, ensure that your I-94 states J-1 status and not a visitor status. J-1 status allows the University of Minnesota to employ and pay you.

• It is good practice to check your status every time you return from Canada on the I-94 website.
• USCIS Boarder Control Contact Center 

Travel Validation on DS-2019 Form

Ensure that the travel signature and date on your Form DS-2019 on the bottom right hand corner is valid. The date is good for one year once signed by the Responsible Officer at ECFMG (Ex. Signed 5/24/2023- Good until 5/23/2024).

If your travel date has expired or will expire when you are abroad, you must request a duplicate DS-2019 form. Please allow 30 days for this request to be processed.

• Fill out the Request for Duplicate DS-2019
• Send the filled out form to the TPL at [email protected]
• The TPL will sign and upload the document to your OASIS Appointment Profile for ECFMG review
• Once reviewed ECFMG will send the DS-2019 form with travel validation signature to the TPL
• The TPL will notify you once it arrives and where to pick it up

+ J-1 Eligibility

The J-1 alien physician visa is sponsored by the Education Commission for Foreign Medical Graduates (ECFMG) and is the preferred visa of University of Minnesota Medical School residencies and fellowships. 

Please check the program manual of the program you are interested in to verify if J-1 visa sponsorship is allowed in your program. 

Eligibility

International Medical Graduates (IMGs) and non-IMGs (i.e. graduates of LCME-Accredited U.S. or Canadian Medical Schools) who require visa sponsorship may be eligible for J-1 visa sponsorship.  For more information, please see the UMN-GME Institution Visa Sponsorship Policy and the UME GME Eligiblity and Selection Policy.

Note: All IMG J-1 Applicants must be ECFMG-certified before applying for J-1 visa sponsorship.

+ H1-B Employment Visa

The J-1 alien physician visa is the preferred visa of University of Minnesota Medical School residencies and fellowships.  As an institution, the University of Minnesota also allows for residents and fellows to be sponsored on H-1B visas.  However, each program determines whether H-1B visas are appropriate for their program.

When interviewing, applicants should use the GME Visa Sponsorship - Applicant Information form as part of their conversation with the program regarding visa sponsorship needs.  Not all programs offer H-1B visas, so it is important to discuss your visa needs openly and early so you and the program can plan appropriately.

Review our Visa Sponsorship Policy for further information about H-1B requirements.

IMG Social Group | Resources

The IMG Social Group is made of IMGs (international medical graduates) residents/fellows/medical students/residency applicants who want to support IMG healthcare professionals orient themselves in the new US environment and integrate them in their new role at the University of Minnesota (UofM).

• The IMG Social Group provides content for the IMG Resource Google Site. Questions you may have on how to connect with the group via Whatsapp, DEI initiatives in your program, J-1 specific information, travel information, moving to Minnesota, all can be found on this site.
• Template for Rounding - This template was created by a UMN IMG trainee and offered for use by other IMGs: "Could help organize your thoughts and can guide you about what you should know about the patient."

+ Information and Resources

• Educational Commission for Foreign Medical Graduates (ECFMG) Certification Requirements
• The IMG Social Group provides content for the IMG Resource Google Site.
• Join the IMG Social Group Whatsapp Chat
• ECFMG Resources 
• Pre-Arrival Information for J-1 resident and fellows

International Medical Graduate (IMG) Orientation

Each summer the GME office holds a special IMG Orientation Session for all incoming residents and fellows who are IMGs, new to the University of Minnesota, and also new to the US Medical System. 

University of Minnesota IMG Social Group

• The IMG Social Group provides content for the IMG Resource Google Site.   Questions you may have on how to connect with the group, DEI intiatives in your program, J-1 specific information, travel information, moving to Minnesota, all can be found on this site.

Template for Rounding  - This template was created by a UMN IMG trainee and offered for use by other IMGs: "Maybe it will help them to organize their thoughts and will also guide them about what they should know about the patient."

International Student and Scholar Services (ISSS)

The  ISSS website  contains a wealth of information to support international students throughout their time at the University, including:

• English Language Opportunities at the University of Minnesota
• Identification Documents

+ Related links

• ECFMG Website   
• U.S. Citizenship and Immigration Services  
• University of Minnesota International Student & Scholar Services  
• U.S. Department of Homeland Security website  
• U.S. Department of State website  
• U.S. Department of State J-1 Visa Exchange Visitor Program website

Institutional Policies Regarding IMGs

• ECFMG/J1 Visa Holders: Documentation Requirements for FMLA
• Institution International Medical Graduates Policy
• Institution Visa Sponsorship Policy  

Education & Training

• Incoming Residents & Fellows
• Current Residents & Fellows

J-1 Visa questions:   Contact Christy Illig via email at [email protected]

Orientation session for IMGs (International Medical Graduates) questions:   Contact Christy Illig at [email protected]

Application questions: Contact the  individual program  to which you plan to apply for information about eligibility and their application process.

A Guide to Pursuing a Medical PG in USA for IMGs

• Oct 30, 2023   MOKSH Academy

Share With :

Introduction to pursuing a medical PG in USA for international medical graduates

Pursuing a medical postgraduate (PG) education in the United States can be a significant milestone in the career of international medical graduates. The USA offers a world-class medical education system, advanced research opportunities, and a diverse patient population. This guide aims to provide a step-by-step approach for international medical graduates on how to navigate the process of pursuing a medical PG in USA.

Benefits of pursuing a medical PG in USA

There are numerous benefits to pursuing a medical PG in USA for international medical graduates. Firstly, the USA has a well-established medical education system that is highly regarded globally. Obtaining a medical PG from a reputable institution in the USA can enhance an individual's professional prospects and open doors to a wide range of career opportunities.

Additionally, the USA provides ample research opportunities in various medical specialities. With cutting-edge technology and extensive resources, international medical graduates can contribute to the advancement of medical knowledge and make a significant impact in their chosen field of study.

Furthermore, gaining exposure to a diverse patient population in the USA allows international medical graduates to develop clinical skills, cultural competence, and a global perspective on healthcare. This experience can be invaluable for personal and professional growth.

Understanding the US Medical Residency System

Before embarking on the journey of pursuing a medical PG in USA, it is crucial to understand the US medical residency system. Residency programs in USA provide postgraduate training in various medical specialties and serve as a pathway towards obtaining a medical license to practice independently.

The US medical residency system follows a structured hierarchy, starting with the first year of residency known as the intern year or PGY-1 (Postgraduate Year 1). The duration of residency varies depending on the speciality, ranging from three to seven years. During residency, international medical graduates work under the supervision of experienced attending physicians and gain hands-on clinical experience.

It is important to know that the competition for residency positions in the USA is high. International medical graduates must meet specific requirements and successfully complete the United States Medical Licensing Examination (USMLE) to be eligible for residency programs.

Steps to take before pursuing a medical PG in USA

Before pursuing a medical PG in USA, international medical graduates need to take several important steps. Firstly, it is crucial to research and understand the requirements for medical residency in USA. Each speciality and residency program may have specific prerequisites and criteria that applicants need to fulfil.

Secondly, international medical graduates must pass the USMLE exams to be eligible for residency in the USA. The USMLE is a three-step examination that assesses a physician's ability to apply medical knowledge and principles in clinical practice. It is essential to prepare thoroughly for each step of the USMLE to achieve a competitive score.

Another crucial step is researching residency programs in the USA. International medical graduates should identify programs that align with their career goals, location preferences, and speciality interests. It is advisable to consider both academic medical centres and community hospitals when exploring residency programs.

Requirements for Medical Residency in USA

To be eligible for medical residency in USA, international medical graduates must meet specific requirements. These requirements may vary depending on the speciality and individual residency programs. However, some common requirements include:

• Medical degree : International medical graduates must have successfully completed their medical degree from a recognized institution.
• ECFMG Certification : The Educational Commission for Foreign Medical Graduates (ECFMG) certification is mandatory for international medical graduates seeking residency in the USA. This certification verifies the authenticity of the medical graduate's education and ensures eligibility for the USMLE exams.
• USMLE scores : International medical graduates must achieve satisfactory scores on all three steps of the USMLE exams. Competitive scores are essential to secure residency positions.
• Letters of recommendation : Strong letters of recommendation from clinical supervisors, attendings, or professors are crucial to showcase an applicant's clinical skills, work ethic, and character.
• Personal statement : A well-written personal statement that highlights an applicant's motivation, career goals, and unique qualities can make a significant difference in the residency application.

USMLE exam and its importance for international medical graduates

The USMLE exam is a critical component of the residency application process for international medical graduates. It is a three-step examination that assesses a physician's ability to apply medical knowledge, skills, and principles in clinical practice.

Step 1 of the USMLE focuses on understanding and applying basic science concepts to patient care. It tests an individual's knowledge and understanding of foundational medical concepts.

Step 2 of the USMLE consists of two parts: Clinical Knowledge (CK). The CK component assesses clinical knowledge and its application in patient management.

Step 3 of the USMLE assesses a physician's ability to apply medical knowledge and principles in an unsupervised clinical setting. It tests the candidate's decision-making skills and their ability to manage patients independently.

Achieving competitive scores on the USMLE exams is crucial for international medical graduates to stand out among their peers and increase their chances of securing residency positions in the USA.

Researching Medical Residency Programs in USA

Researching Medical  Residency Programs in USA is a crucial step for international medical graduates. It is essential to identify programs that align with an individual's career goals, location preferences, and specialty interests.

When researching residency programs, it is advisable to consider both academic medical centres and community hospitals. Academic medical centres provide opportunities for research, teaching, and exposure to complex cases. On the other hand, community hospitals offer a more hands-on approach and may provide a broader range of clinical experiences.

International medical graduates should explore program websites, attend virtual or in-person information sessions, and reach out to current residents or program directors to gain insights into the program's culture, curriculum, and resident support.

Additionally, it is important to consider the program's track record of accepting international medical graduates and their success rates in securing fellowships or job placements after residency.

IMG friendly residency programs in USA

International medical graduates often seek IMG friendly residency programs in USA to increase their chances of obtaining a residency position. IMG friendly residency programs in USA are those that have a history of accepting and successfully training international medical graduates.

When researching IMG friendly residency programs in USA, it is important to consider factors such as the program's percentage of international medical graduates, their success rates in securing fellowships or job placements after residency, and the level of cultural support provided to international medical graduates.

Several online resources and databases provide information on IMG friendly residency programs in USA, including the Accreditation Council for Graduate Medical Education (ACGME) website, the International Medical Graduate Training Initiative website, and the FREIDA Online database.

Tips for a Successful Medical Residency Application

Securing a residency position in the USA as an international medical graduate can be highly competitive. Here are some tips to increase the chances of a successful medical residency application:

• Start early : Begin preparing for the residency application process well in advance. Research programs, gather required documents, and start studying for the USMLE exams early.
• Seek mentorship : Find mentors who can guide you through the residency application process. They can provide valuable insights, review your application materials, and offer support and encouragement.
• Gain US clinical experience : Consider obtaining clinical experience in the USA through observerships, externships, or research opportunities. This can help familiarize yourself with the US healthcare system, enhance your clinical skills, and build strong professional connections.
• Network : Attend conferences, seminars, and medical events to network with physicians, program directors, and residents. Networking can provide valuable opportunities for recommendation letters, research collaborations, and exposure to potential residency programs.
• Be proactive : Take the initiative to reach out to program directors or current residents to express your interest in their program. This demonstrates your enthusiasm and can help you stand out among other applicants.
• Prepare for interviews : Practice for residency interviews by participating in mock interviews and researching typical interview questions. Be prepared to discuss your motivations, career goals, and experiences.
• Be flexible : Consider applying to a wide range of residency programs in different locations and specialities. Being open to various options increases your chances of securing a position.

Resources and support for international medical graduates pursuing a medical PG in USA

International medical graduates pursuing a medical PG in USA can benefit from various resources and support systems:

• Educational Commission for Foreign Medical Graduates (ECFMG) : ECFMG provides valuable resources, guidance, and support to international medical graduates throughout the residency application process. Their website offers comprehensive information on certification, exams, and residency programs.
• Professional Associations : Join professional associations such as the American Medical Association (AMA) or specialty-specific organizations. These associations offer networking opportunities, educational resources, and advocacy for international medical graduates.
• International Medical Graduate Training Initiative (IMGTI) : IMGTI is a collaborative effort between several organizations to support international medical graduates. Their website provides information on IMG-friendly programs, mentorship opportunities, and professional development resources.
• Online forums and communities : Join online forums and communities specifically designed for international medical graduates pursuing a medical PG in USA. These platforms offer a space to connect, share experiences, and seek advice from peers.
• Resident support services : Many residency programs offer support services specifically tailored for international medical graduates. These services may include cultural orientation programs, mentorship programs, and assistance with visa and immigration processes.

It is crucial to take advantage of these resources and support systems to navigate the challenges and maximize the opportunities during the journey of pursuing a Medical PG in USA.

Pursuing a medical PG in USA can be a transformative experience for international medical graduates. It offers access to world-class education, research opportunities, and exposure to a diverse patient population. By understanding the US medical residency system , meeting the requirements, and preparing a strong residency application, international medical graduates can increase their chances of securing a position in their desired speciality and location.

While the process may be challenging, the rewards of pursuing a medical PG in USA are immense. With dedication, perseverance, and the right resources and support, international medical graduates can embark on a fulfilling and successful career in medicine in the USA.

You can contact with Moksh Academy at +91 9699360370  WhatsApp us at 8269900555  or Visit mokshacademy.com .

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International Medical Graduates in the United States pp 227–244 Cite as

The Role of International Medical Graduates (IMGs) in the US Healthcare System

• Michael G. Fitzsimons 3 , 4 &
• Bruna Maria Castro de Oliveira 3 , 5  
• First Online: 05 January 2021

625 Accesses

Physicians that received their medical education in countries other than the United States comprise approximately 25% of the doctors currently practicing within our borders. These international medical graduates (IMGs) must overcome a variety of geographical, cultural, legislative, and academic hurdles in order to enter into graduate medical education (GME) that graduates from United States Medical Schools (USMGs) are not subject. Upon completion of training, these individuals often endure questions of their competence while facing discrimination even though the quality of care delivered is at least equal if not superior to that of USMGs. This chapter addresses the history of the IMG system, debate regarding their role, educational and employment status, policy and regulation, quality of care delivered, as well as impact within academic medicine, and individual experience.

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Fitzsimons, M.G., de Oliveira, B.M.C. (2021). The Role of International Medical Graduates (IMGs) in the US Healthcare System. In: Tohid, H., Maibach, H. (eds) International Medical Graduates in the United States. Springer, Cham. https://doi.org/10.1007/978-3-030-62249-7_15

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Career Options for International Medical Graduates

The Educational Commission for Foreign Medical Graduates (ECFMG), through its program of certification, assesses whether physicians graduating from medical schools outside the US are ready to enter programs of graduate medical education in the United States ( http://www.ecfmg.org/forms/certfact.pdf ). The examination requirements for ECFMG Certification include passing a three-step United States Medical Licensing Examination. The process is grueling and expensive. However, passing the exams is just the beginning. Securing residency is the ultimate challenge. Some have waited for years without acceptance into a residency program. Furthermore, those who get accepted have to come to terms with the 80-hour work week (for salaries less than some 40-hour work weeks) for non-degreed positions. This has led many international medical graduates (IMGs) to look into other career options. Even if your goal is to ultimately practice medicine in the US (a process that may take up to 8 years), the suggestions offered in this post can still benefit you. So where do you start?

Start by browsing the jobs posted on this website (HospitalRecruiting.com) . Make a note of positions that interest you and learn more about these positions. There are several websites that offer a full description of careers in healthcare. (Go to http://www.bls.gov/ooh/healthcare/home.htm .) There are opportunities in allied health and non-clinical healthcare professions that are often a good fit for IMGs. Careers as a physician assistant , occupational therapist , or speech language pathologist are just a few of several well-paying career options that require minimal training (when compared to years of uncertainty you may spend in getting ECFMG certified). Trained as a clinician (an IMG), I opted for a career in biomedical research here in the US. If you are research-oriented, one of my recommendations is that you familiarize yourself with Responsible Conduct of Research. Learn the research lingo. Most research positions require that you present your data to an audience that sometimes consists of your peers, medical students, staff, and even Nobel Laureates. There are weekly meetings where you discuss your data and current articles of interest, so good communication skills are vital. If you are not a native English-speaker and communication is a barrier, work in a cell culture lab preparing specimens for research may be ideal. If you don’t mind working with mice, there is always a great demand for persons with a medical background who can work with mice. Remember that preclinical studies that lead to the early phases of the drug development process start with animals (especially rodents). If this is an area in which you might be interested, start by viewing the information on this website: http://microsurg.hs.columbia.edu/index.html. They offer training in rodent microsurgery.

Apply for a career training grant. There are many grants available for educational expenses and career training. There is so much to choose from. Become familiar with funding agencies. Find out whom they fund. Look beyond government and federal grants. There are foundations and private sources that give grants for research and educational purposes. Most career training today can be done online, so you can essentially pace yourself. Trained as a clinician, I opted for a career in the biomedical sciences at the Children’s Hospital of Philadelphia and The University of Pennsylvania. I became a recipient of several awards (grants), including NIH’s National Research Service Award for training in Molecular and Cellular Biology. (This is one of the most prestigious awards in the sciences.) In this position, I acquired skills in writing scientific manuscripts and grant proposals. After my academic career, I transitioned to the pharmaceutical industry, where I contributed to new drug applications and other FDA correspondence. Now an entrepreneur, I currently offer a full range of services, including career coaching services, through my service-based business Consult To Aspire ( www.consulttoaspire.com ). A career training grant opened the door to many opportunities.

Another option I have shared with a client (who was also an IMG), is taking a course in Introduction to the Principles and Practice of Clinical Research (IPPCR). The IPPCR course is offered yearly at NIH’s Clinical Center in Maryland. A certificate is awarded upon successful completion. It is of interest to physicians training for a career in clinical research (http://www.cc.nih.gov/training/training/ippcr.html ) Whether you decide to get into residency and train as a Physician Scientist or to explore a career in industry, the IPPCR training will still be of benefit.

In summary, the path from an international medical graduate to a successful career in the US is not an easy one. However, with planning, self-motivation, and persistence, it can be done.

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About Christiana Davis, MD

As an International Medical Graduate (IMG) Consultant, I offer career advice that only an IMG can give. I know of your stories and your struggles. When I immigrated into the United States, I did not know where to start. I knew of no blogs, no career consultants, and no mentors. Looking back, there were roadblocks, but I did not give up. Today, the web and social networks have made our world much smaller. You can learn everything there is to know about succeeding in the United States without leaving your house. Some of the services I offer include:

• Help defining your career vision
• Expert advice on alternative career paths
• Help with standardized testing
• Advice on making the best of your residency and fellowship training
• Help with writing career documents, including personal statements, CVs, and resumes

Email me at [email protected]. Read more of my articles and leave a message at https://internationalmedicalgraduate.wordpress.com/. Tell me your story and connect with me on LinkedIn http://www.linkedin.com/in/christianadavis/. Call me at 267-233-7926.

51 Responses

Please sign the petition asking to allow medical graduates to work in medically underserved areas: https://www.change.org/p/texas-legislature-and-governor-help-end-the-doctor-shortage

Hi,I am IMG.now permanent resident here.looking for my future career here in USA. Beside USMLE what’s are other options for me to continue? ? Please help

Hi Qamar, thanks for reading our blog post. The other required steps for you to practice medicine are ECFMG certification, U.S. residency training, and state licensure. You can more info and a few other resources here; http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/international-medical-graduates/practicing-medicine.page ?

Hey Qamar, Have you ever given Pharmacovigilance and Drug Safety or Clinical Research any thought? Lots of IMG’s take this option as it is second best to becoming an actual physician, and it is a very lucrative career. Look it up! I took a Drug Safety Course at Sollers Institute, they helped me a lot and also helped place me. I took it online because I do not live in New Jersey, but it was a live interactive class so I still felt comfortable taking it.

Many organizations self-certify and many are not recognized outside of a specific geographical area, but I liked Sollers because they are certified by the Council on Occupational Education. Also, they were the only school that had actual hands on training with the software Argus. I think this may have given me the edge when I was looking for placement after being certified as a Drug Safety Associate.

Oh btw you can call their advisers I think this is the right number: 331-999-0061 or check out their website!

Hope you find your perfect future career. I found mine! Don’t stress!:) Good luck!!

Greetings, i am an IMG, i have just appeared for the step1 exam and am awaiting the results. i would like to gain some work experience be it clinical or research oriented while i prepare for step 2. i have a B1/B2 visa valid until 2026 what kind of jobs can i apply to as a non-resident of usa? thank you for your help, i appreciate it.

HI i am IMG,Non US citizen can i find a job without ECFMG certification?

Hello Mitul, Thanks for reading our blog. In order to practice medicine in the U.S. you will need to first obtain ECFMG certification, then complete post-graduate medical education in the United States. It may be possible to work in other areas, such as medical research, without ECFMG certification, but not to practice medicine.

Thanks for your valuable response

Hey Mitul. Is this Mitul Modi ?

Hi there, Your post is very encouraging because I am a recent foreign medical school graduate currently applying for residency, but matching looks very bleak so far. I would love to get to know more about the program. Was it easy finding a job once you received the certification in this course? Any details you can provide are greatly appreciated!! Thanks!

Also, what’s the average salary earned for this field?

what jobs are open for IMG in medical research and where to find them. please

Need help with any hints on how to get a residency after I quit my first one when I had medical problems that I had to take care of. Now all I get are rejection letters despite having decent scores on step one and two. I am american but went to foreign medical school. It’s like I have the plaque! Mary d

I will be moving to the US from France soon to join my husband and might want to apply for a job in healthcare (not as a physician) but for example as a medical assistant or go back to school to learn medical coding. I have taken STEP 1 so I am registered with ECFMG but do not intend to take the further steps for now I need to work soon…

I am looking for a way to get my credentials/education recognized in the US to be able to apply for a job in healthcare or to a college course. Can I use ECFMG / EPIC which has already communicated with my university? Do they deliver without going through with the steps some kind of credential information that is valid in the US (EPIC?) Or should I go through a service suche as World education services or ECE Education credetial evaluation?

Hi Janine, Did you get a job after getting certified from them. Does Sollers PV training really helps?

HI THANKS A LOT FOR YOUR ADVISE , I’M 46 Y/O WITH EFCMG CERTIFICATE, I DINT FOUND RESIDENCY , WHAT KIND OF COURSES I CAN TAKE FOR FOUND A JOB, PROBABILITY I WILL PREFER SALES IN A INDUSTRY OF SURGICAL DEVICES ,

Hi i am an img and have been in us since last 4 yrs as a permanent resident. I am a housewife with two kids so adding these responsibilities makes the process of pursuing my career quite slow. I have taken step 1 and ck and now preparing for cs. Despite the fact that getting residency will be very tough and competitive i still dont wanna give up on my career. I am really interested in pathology. I am doing observership at the moment at a clinic with an endocrinologist and looking for more medical related opportunities to add up to my resume. I am already lacking because its been five years since i graduated and its still a long process ahead and what i really need is someone to advise me what suits me best given my circumstances and limitations that i cannot do any full time job due to my resposibiloties at home. I have been asked to look for certain jobs for an ekg tech or a research assistant but again due to lack of networking and guidance i am finding it really hard even how to start looking.I will be very obliged if you can give your expert advise regarding my queries. Thankyou!

Hi I am an IMG recently graduated with also a BS in Biology realized in US territory. I recently move to Houston and I am looking for job in terms to continue studying for my USMLE exams and finally getting ECFMG certification done. What do you suggest me to do? I have apply to many jobs…

Hi, I am an IMG. I have graduated two years back. I have been looking for job oppurtunities in the USA. I am currently preparing for USmle step 1, but not gaining confidence at all. I have minimal clinical knowledge .I would like to take up any job or do research work. Please kindly guide me . Any help would be appreciated .

Sollers make so many promises to get you to enroll. After getting the certificate, you’re on your own. They don’t help you in job placement. Talking from experience.

Hello maam… I am an IMG preparing for USMLE…. I have in the back of my mind regarding the match process… If I don’t get matched in my 1st attempt can I get any JOB like parttime or something to meet my ends till the next match… are there any jobs for img which pay (even if minimal) and provide a boost to my CV…..

Hi! I am an IMG and I got an Registered Medical Assistant certification, RMA, I know it is very basic but it can provide you with some income while you wait.

Hi. I am a certified cardiologist in Brazil, and I’m considering becoming an echo or stress test tech there. I already perform there on a daily vasos, as Brazilian law only allows doctors to perform those exams, but I might need some kind of certification in America. I don’t think I’m willing to go through residency again, so becoming a cardiologist there is out of the question. Do you have any ideas for me? Can I hire you to give me assistance on this matter? Thank you

Hi, I immigrated to the US more than 3 years ago. I am a permanent resident here in the US, but I am a licensed medical doctor from the Philippines. I realized the path to becoming a practicing medical doctor here is long and I graduated 2003, therefore I am an old IMG. I am thinking to give up the USMLE journey which I started taking USMLE 1 last year. I am thinking of becoming a researcher instead. Give me the guidance so I will not anymore waste money and time passing all my USMLEs and wait for residency match which is sometimes nil because I am an old graduate. Do I need to be a US citizen first and acquire further education to become a clinical researcher which I think I am eligible now?

Good day. I am an IMG and I have a B1/B2 visa. I am interested in undertaking a medical assistant training in Knoxville TN or close to that location so that I can be closer to family. Can you kindly guide me please? Thanks…[email protected]

Hi, Im from the ?? too. Can i ask for your email so we could chitchat in private?

hi , am an Img from India . Hasn” t given my usmle steps yet. I want to know if one can be a physician assistant and then train for usmle ..I am a permanent resisdent and live in pennsylvania.

hello janice benny. im in the same situation as you. please share what ever you options and help you get.

im from nepal and im also a permanent resident. havent given any usmle steps.

thank you and all the best.

Hi, my name is Mary, an IMG. I failed step 1 in my first attempt (score 190). I’m completely disappointed. Studied FA two times, Caplan Video, more than 10,000 tests. UWORLD/NBME score>250+ but failed! no idea why ;( I’m on H4 visa right now. please any idea or help to get a research position w/o step 1 🙁

Hi Yazmin. How did you get the medical assistant certification and how long did it take?

Did you get some info about research position?Please share any information.

I am in the same situation like you

Contact me directly at [email protected]

Contact me at [email protected]

Email me at [email protected]

See my message above

Great question.

See my message to Janice

I think you contacted me. If not feel free to email me.

Great question. I’ll be glad to answer that question.

Definitely count the cost before leaving Brazil. Life for most IMGs in the US is anything but comfortable; at least for the first few months, if not years.

To learn more, contact me directly at [email protected]

Abhisek: Hope by now you are working; better yet, matched. If not feel free to contact me directly at [email protected]

Circumstances vary. Contact me directly at [email protected]

Tahira: Hope by now things have settled down some. Stay motivated. As the kids get older you’ll have the opportunity to pursue a satisfying career. To learn more about options you can pursue, or just to brainstorm, feel free to contact me directly at [email protected]

See my comments above; contact me directly at [email protected]

Val: I think you’ve contacted me in the past; if not I look forward to hearing from you. You can start working on your job application package even when you are in France. Contact me directly at [email protected]

Mary: Hope things are better by now. Regardless, I’ll still love to hear from you. Contact me directly at [email protected]

To learn more about specific options and how to prepare for these feel free to contact me [email protected]

To learn about specific options and how to prepare for these contact me at [email protected]

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Expert Consult

Applying for Residency as an International Medical Graduate

By Ole-Petter R. Hamnvik, M.B.B.Ch., B.A.O., M.M.SC.

Published April 6, 2022

The medical profession in the U.S. has a remarkable international flair. One in four U.S. physicians is an international medical graduate (IMG), and every year around 12,000 IMGs apply for U.S. residency positions. But the path to practicing in the U.S. is not an easy one when you must navigate the requirements without the structural support from a U.S. medical school and the mentorship of peers and faculty, especially with the added challenges of language and culture.

In the fall of 2018, NEJM Resident 360 hosted a discussion on applying for residency as an IMG. Participants asked questions that ranged from clarifying the practical steps required to be eligible to practice in the U.S. to seeking advice on experiences that can optimize the IMGs’ chances of obtaining their dream residency position. In this post, I summarize some of the main points from that discussion and provide an outline of the practical steps required to pursue this path. For even more information, you can access the library of resources available from the Educational Commission for Foreign Medical Graduates (ECFMG). 

Why Go to the United States?

The decision to seek training in the U.S. depends on both personal and professional factors. Some common reasons to apply include:

the quality of training in practice environments with high-quality standards,

a predictable career path and employment after completing training

a flexible career structure

opportunities for board certifications that are recognized worldwide

completing a U.S. residency is virtually always required to practice medicine in the U.S. and therefore is a path to immigration.

While the reasons are many, make sure you think through your motivation because it is not an easy path. The practical steps are outlined below, and each comes at a high financial cost. However, with determination, it is within reach!

Apply for ECFMG Certification

To be eligible for a residency spot, you must go through a rigorous process to ensure that you are competent to practice in a clinical environment with the supervision provided by a training program. The ECFMG certification process is the standard for evaluating the qualifications of IMGs entering the U.S. health care system. This process assesses the readiness of IMGs to participate in U.S. residency or fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education (ACGME) . ECFMG sets requirements related to IMGs’ medical schools and medical education, as well as examination requirements.

The definitive source of information on ECFMG Certification is the ECFMG Information Booklet and is required reading for applicants. ECFMG issues the Standard ECFMG Certificate to applicants who meet all requirements for certification. Approximately 10,000 IMGs receive certification annually, representing only about 60% of IMGs who initially apply.

The following is a summary of the main steps involved to receive ECFMG certification:

Ensure that your medical school meets ECFMG requirements .

Apply for a United States Medical Licensing Examination ( USMLE)/ECFMG identification number .

Complete the Application for ECFMG Certification , including the notarized Certification of Identification Form.

Pass the USMLE Step 1, Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS). These three exams are the same examinations U.S. medical students must pass for medical licensing. Step 1 and 2 CK are computer-based exams that are offered at Prometric testing centers worldwide. Step 2 CS is a live, clinical-encounter exam featuring standardized patients and is only offered in U.S. testing centers (requires a trip to the U.S.)

Provide ECFMG with your final medical diploma; they will verify the diploma directly with the issuing medical school and at the same time request a copy of your final medical school transcript. This process can take some time, depending on how responsive your medical school is to the verification request. 

Consider Visa Options

Unless you already are a U.S. citizen or permanent resident (with a Green Card), you will need a visa to participate in a graduate medical education program in the U.S. Although you need to think about your visa options early, you do not actually apply for a visa until after you have matched into a residency program.

The J-1 Visa for physicians is sponsored by ECFMG and is the most common visa for those pursuing graduate medical education. The J-1 physician category is specifically meant for trainees (you can’t work as an attending or moonlight with this visa) and can be extended for a total duration of 7 years.

If you are pursuing a J-1 visa, ECFMG will issue a DS2019 form or Certificate of Eligibility for Exchange Visitor Status. This form tells the consulate that you have met J-1 visa sponsorship requirements. The American consulate in your home country decides whether to issue the visa. The Ministry of Health/Health Department of your most recent county of legal residency must sign a document indicating the need in this country for physicians trained in your prospective specialty. J-1 visa applications are usually processed quickly, although some countries have a longer processing time.

However, this visa comes with a home residency requirement that dictates that you must go back to your home country for at least 2 years before being eligible to apply for any other U.S. visa status. This requirement is important to consider because, although you may plan to go back to your home country when you apply for residency, your plans may change by the time you complete your training in 3-7 years. For example, you may be offered a good career opportunity or meet a U.S.-based partner. If you end up in this situation, you can try to obtain a waiver for the home residency requirement. Unfortunately, the waiver is complicated, competitive, and limits the types and locations of potential jobs.

The H-1B Visa is sometimes preferred by trainees because of the difficulty of obtaining a waiver for the home residency requirement for the J-1 visa. The H-1B Visa is a so-called “dual-intent” visa because it is a nonimmigrant visa that you can have while you apply for permanent residency status. Another advantage is that there is no 2-year home residency requirement. The H-1B visa is also not restricted to training activities only; an employer can also use it legally for other opportunities (including moonlighting). This visa is sponsored by the institution that hosts the training program. As a result, some training programs (both residencies and fellowships) are reluctant to sponsor an H-1B visa because it requires more work than the ECFMG-sponsored J-1 visa and is more likely to be delayed. Many programs will reverse their position on H-1B visas if you talk to them or the international office at the institution. However, to be eligible for this visa, you must pass USMLE Step 3 .

You are only eligible for Step 3 after you have obtained your medical degree, passed USMLE Step 1, Step 2 CK, and Step 2 CS, and obtained the ECFMG certification. As a result, you can only take this examination after medical school, delaying your application for residency for 1-2 years. Step 2 CS and Step 3 are only offered in the U.S. (requiring you to travel to the U.S. on two separate occasions to take these exams).

If you plan for an H-1B visa, delays may occur. Once you match, you need to apply for a state medical license to be eligible for this visa followed by 2 to 3 months for visa processing. As the residency match happens in March, and residencies begin in June or July, there is little time to get the paperwork completed. The institution that hosts the residency program may choose to pay for expedited visa processing to shorten the processing time to just a few weeks.

The Diversity Immigrant Visa lottery  is one of the few ways to obtain permanent residency (Green Card) in the U.S. without first entering on a visa. The lottery provides residency to a random selection of applicants who are from countries with low rates of immigration to the U.S. 

Other visa options may be available for different circumstances. Speaking to an immigration lawyer might be helpful if you think you have a unique situation. Immigration lawyers can also provide you with the most up-to-date information about your visa options.

Select a Specialty

Before applying for residency, you need to choose a specialty. For guidance on choosing a specialty, see the NEJM Resident 360 blog post on How to Choose a Specialty . The primary care specialties (family medicine, internal medicine, pediatrics, and psychiatry) have traditionally been most popular for IMGs, in part because these programs have the most spots and are therefore less competitive. Although some applicants apply for several specialties, this practice is generally frowned upon because it gives the impression that you are not fully committed to any one specialty. If you are applying for a more competitive specialty (e.g., many surgical specialties), consider applying for a preliminary general surgery residency. This is a one-year residency for programs to see how you perform before committing to training you for the entire duration of your residency.

Select Residency Programs

Once you decide on a specialty, you need to choose the residency programs you want to apply to. Many considerations come into play, including answers to the following questions:

Is geography important (urban vs. rural, East Coast vs. Midwest, etc.)?

Are you looking for an academic program with a heavy emphasis on research or a clinical program with high clinical volume?

How important is residency reputation?

How competitive is your own application?

Are you moving with a spouse who will also seek employment?

With so many considerations, you will need to assess your options and discuss them with colleagues and mentors who know you and in your field. The AMA Residency & Fellowship Database ( FREIDA ) is a good resource to help narrow your search and obtain contact information. For internal medicine, the American Board of Internal Medicine (ABIM) also provides residency program pass rates for medicine certification examinations as an indication of how well the programs prepare residents for the board exam. 

Submit the Residency Application

All residency applications are submitted to programs using the Electronic Residency Application System ( ERAS ). To register for ERAS, you need to go back to your old friend ECFMG to obtain a residency token and gain access to ERAS and register.

Once registered with ERAS, you will provide your resume information in a standardized curriculum vitae (CV) template, enter a personal statement, upload a photo, and submit your examination transcript, dean’s letter, and letters of reference.

Be sure to include all your experiences in the application, including teaching experiences, membership in academic organizations, and extracurricular activities. This is also an opportunity for you to highlight how your unique background can enrich the residency program if you match there.

Designate the programs you wish to apply to. Your application will be electronically submitted to these programs.

Register for the Match

Residency applicants also must register for the National Resident Matching Program (NRMP), also known as the Match. NRMP is a separate organization from the ERAS application service and thus requires separate registration. As discussed in more detail below, the Match is where the preferences of applicants and program directors are entered and matched by an algorithm.

Overview of the Process for Applying for Medical Residency in the United States

Optimize Your Chances of Success

While many programs are accustomed to assessing applications from IMGs, some programs may not consider any IMGs or have a higher threshold for interviewing an IMG. Programs may not recognize the name of your medical school, may not know your recommendation letter writers, or may not understand the grading system at your medical school. Therefore, you need to be proactive to ensure that your application is as strong as possible.

Here are some tips for optimizing your chances of success:

Have good grades: High scores on the USMLE examination and your medical school tests can only be helpful. Some institutions use USMLE cut-offs (particularly Step 1 scores) and may not look at applications with low USMLE scores.

Prepare your letters of recommendation: Make sure that you have clinical faculty members who are willing to write you strong letters of recommendation. American letters are often more positive in tone than those from other countries. For example, describing a candidate as “a good clinician” is a red flag when adjectives such as excellent, outstanding, stellar are more common. Therefore, explaining this difference to your letter writers could be helpful and consider providing examples of U.S. letters (for examples, see Tips for Writing Strong Letters of Recommendation and Writing Letters of Recommendation for Residency ).

Obtain clinical experience in the United States: Most residency programs value true clinical experiences from the United States. This will also give you the opportunity to request and submit a letter from the faculty member who supervised you and who is familiar with expectations of U.S. residency programs.

If you are in medical school, most U.S. medical schools offer a visiting student or clinical away elective. Some programs are free, but most require a fee. Your best bet is to search the Web for “visiting students” or “clerkship” and the name of the medical school that interests you. Most programs have a dedicated site with information for prospective students. Often, the hospital where you rotate is likely to offer you an invitation to interview for their residency program, so take that into consideration. Keep in mind your competitiveness as a candidate. If you are competitive for the top-tier program, then a rotation at a top-tier institution will be a helpful. If not, you may want to consider a rotation at a less competitive program. Make sure you prepare for your rotation. If you will be doing a rotation in infectious diseases, then read up on infectious diseases topics beforehand so you can impress the faculty during your rotation.

If you are no longer in medical school, then your opportunities for clinical experiences in the United States are much more limited. Very few medical schools or hospitals allow visiting physicians, but you may be able to use your medical school alumni network or other contacts. One option is the American Medical Association (AMA) Observership Programs. If you can only do an observership, some ways to show your skills include offering to help the interns by calling consulting services; give daily 5-10 minute presentations on questions that come up on rounds; accompany the interns during admissions and ask to present these admissions during rounds; and write up case reports, case series, and review papers.

Ask mentors to advocate for you: A personal call from a mentor that knows you well can help get your application looked at by the residency program director. Use this sparingly because you don’t want to overwhelm your mentor or the residency program, but asking the mentor to advocate for your application with one or two programs is reasonable.

Consider doing research: Doing research is a good way to improve your application, at least for programs that are focused on developing future researchers. If you do research at a U.S. hospital, it may also be a way to get a foot inside the door. Your research mentor may be able to provide you with clinical opportunities, and may know the residency program director and advocate for you. However, if you spend many years doing research, residency programs will be worried about the steep learning curve of reintroducing yourself into clinical medicine. In addition, community-based programs may not value research experience as much. 

Advocate for yourself: You can reach out to programs to ask for early decisions because of international travel or coordination with other interviews. It is usually best to contact the program coordinator (contact details are in FREIDA) rather than the program director because recruitment season is a busy time of year. You should also make sure that the program downloaded your application (which you can track in ERAS), and you can contact the program for updates if you have not received an invitation or a rejection. 

Once you receive a request for an interview, see the NEJM Resident 360 blogpost on Applying for Residency for information and guidance on the interview process. 

Program Ranking and the Match

After interviews, applicants rank programs in the NRMP’s Registration, Ranking, and Results (R3) system . As noted above, you must register with the NRMP (the Match). Applicants submit a list of programs where they wish to train, ranked in order of preference. At the same time, program directors submit a list of applicants, ranked in order of preference, whom they have interviewed and wish to train. The final preferences of applicants and program directors, as expressed on their rank order lists (ROLs), that determines the Match outcome.

Registration for the Main Residency Match opens September 15 through the third week in February. You will owe a late fee if you register after November 30.

Ranking opens on January 15.

Results of the Main Residency Match are released the third week in March. 

Eligible applicants who do not match to a program can participate in the Supplemental Offer and Acceptance Program (SOAP), in which positions left unfilled after the matching algorithm has been processed are offered to eligible applicants. NRMP provides resources on participating in the Match, as well as data and reports on results of the Match that can be helpful as you consider your options and your competitiveness.

Once you have a spot in the program, you will apply for a state medical license and a visa and start packing! Good luck!

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Analyzing international medical graduate research productivity for application to US neurosurgery residency and beyond: A survey of applicants, program directors, and institutional experience

Giancarlo mignucci-jiménez.

1 The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States

Lena Mary Houlihan

Dimitri benner, jubran h. jubran, ann j. staudinger knoll, mohamed a. labib, teodoro forcht dagi.

2 Mayo Medical School, Rochester, MN, United States

Robert F. Spetzler

Michael t. lawton, mark c. preul, associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The authors investigated perceived discrepancies between the neurosurgical research productivity of international medical graduates (IMGs) and US medical graduates (USMGs) through the perspective of program directors (PDs) and successfully matched IMGs.

Responses to 2 separate surveys on neurosurgical applicant research productivity in 115 neurosurgical programs and their PDs were analyzed. Neurosurgical research participation was analyzed using an IMG survey of residents who matched into neurosurgical residency within the previous 8 years. Productivity of IMGs conducting dedicated research at the study institution was also analyzed.

Thirty-two of 115 (28%) PDs responded to the first research productivity survey and 43 (37%) to the second IMG research survey. PDs expected neurosurgery residency applicants to spend a median of 12–24 months on research (Q 1 -Q 3 : 0–12 to 12–24; minimum time: 0–24; maximum time: 0–48) and publish a median of 5 articles (Q 1 -Q3: 2–5 to 5–10; minimum number: 0–10; maximum number: 4–20). Among 43 PDs, 34 (79%) ranked “research institution or associated personnel” as the most important factor when evaluating IMGs' research. Forty-two of 79 (53%) IMGs responding to the IMG-directed survey reported a median of 30 months (Q 1 -Q 3 : 18–48; range: 4–72) of neurosurgical research and 12 published articles (Q 1 -Q 3 : 6–24; range: 1–80) before beginning neurosurgical residency. Twenty-two PDs (69%) believed IMGs complete more research than USMGs before residency. Of 20 IMGs conducting dedicated neuroscience/neurosurgery research at the study institution, 16 of 18 who applied matched or entered a US neurosurgical training program; 2 applied and entered a US neurosurgical clinical fellowship.

The research work of IMGs compared to USMGs who apply to neurosurgery residency exceeds PDs' expectations regarding scientific output and research time. Many PDs perceive IMG research productivity before residency application as superior to USMGs. Although IMGs comprise a small percentage of trainees, they are responsible for a significant amount of US-published neurosurgical literature. Preresidency IMG research periods may be improved with dedicated mentoring and advising beginning before the research period, during the period, and within a neurosurgery research department, providing a formal structure such as a research fellowship or graduate program for IMGs aspiring to train in the US.

Introduction

Professional neurosurgery organizations in the United States (US), such as the American Association of Neurological Surgeons (AANS), Neurosurgery Research and Education Foundation, Congress of Neurological Surgeons, American Board of Neurological Surgery, Society of Neurological Surgeons, and various regional and state associations, continue to advocate for dedicated research time during neurosurgical training, with a full year of research designated within the residency structure. The founding departments of US neurosurgery training programs have been, and continue to be, leaders in neurosurgery and neuroscience research within the US. This trend continued as most other neurosurgery departments and training programs were established. Thus, in addition to developing training technology, the human factor of performing research continues to be of major importance for neurosurgery education and residency applicants to US programs, especially in the ever-more connected international world of neurosurgery. Indeed, applicants may spend years in research before residency, involving significant professional and life planning. International medical graduates (IMGs) with an outlook toward US neurosurgery residency in the next 10 years may already be involved in such career decisions.

The question that follows is, “Why do IMGs apply for neurosurgery training in the US?” The answer is multifactorial, but it can be inferred that the IMGs believe that either the training or quality of life in the US is superior to that of their home country. Previous papers have focused on IMGs' perceptions of neurosurgery residency in their own country, especially in low to middle-income countries (LMICs). Deora et al. ( 1 ) sent a questionnaire through social media to all neurosurgical residents in LMICs, asking general questions about their perspectives on their training programs. Significant differences between US and LMIC residency programs were found in work-hour regulations and subspecialty training. Substantial gaps in residency experience were noted; 40% of respondents did not report substantial residency experience in any of the queried subspecialties (i.e., endovascular, epilepsy, deep-brain stimulation/lesioning, minimally invasive surgery, radiosurgery, or deformity surgery). The lack of subspecialty training in a candidate's respective country could be a major factor in their decision to pursue US-based training. The US training system is perceived as organized, complete, and accepting of IMGs. The training programs in LMICs are inherently limited due to local, geographical, infrastructure, and economic factors ( 2 ).

In a 2018 study, IMGs represented 24% of the US physician workforce and 1 in 4 trainees in US residency programs ( 3 ). These numbers are likely to rise in the coming years as major physician shortages develop due to increased health care demand, workforce shortages due to the recent COVID-19 pandemic and government mandates, and an aging workforce. The projected US physician deficit is 139,160 by 2030. A well-recognized shortage of neurosurgeons is likely to increase similarly, as 46% of practicing neurosurgeons are 55 years of age or older ( 4 , 5 ).

IMGs account for 13% of practicing physicians, 6% of neurosurgical residents (8% in 2018), and 11% of academic neurosurgeons ( 3 , 6 , 7 ). The need for neurosurgeons is met by USMGs and IMGs, which reflects the competitive nature of the neurosurgery residency match, with 66.8% (211/316) and 65.2% (211/322) of allopathic USMGs matching in 2020 and 2021, respectively. In contrast, 28.6% (18/63) and 25.8% (17/66) of IMGs matched in 2020 and 2021, respectively, as reported by the National Resident Matching Program (NRMP) ( 8 , 9 ). Among IMGs, 25% (12/48) and 22% (11/50) were non-US IMGs in the 2020 and 2021 match cycles, respectively. Overall, USMGs, including graduates from both allopathic and osteopathic medical schools, comprised 92.2% (214/232) and 92.7% (217/234) of applicants who matched in 2020 and 2021, respectively. Conversely, US and non-US IMGs comprised only 7.8% (18/232) and 7.3% (17/234) of matches ( 8 , 9 ). These numbers show the discrepancy between USMGs and IMGs.

Neurosurgery is uniquely intertwined with scientific work, and an overwhelming majority of training programs are affiliated with major academic institutions. This characteristic contributes to neurosurgery applicants having the highest research productivity of all medical specialties in the US ( 10 ). IMGs seeking to overcome the difficulty of matching with a US neurosurgical residency program view high-level research as critical to overcoming this difficulty. IMGs perceive higher h-indices and numbers of published articles as an advantage for matching with a US program ( 11 ).

Nonetheless, studies have reported biases affecting IMGs in the US neurosurgical matching system ( 7 , 11 , 12 ). Sheppard et al. ( 12 ) reported that IMGs are more likely to match at unranked or lower-ranked residency programs compared to USMGs despite high research output, publications, and the research impact. The likelihood of a USMG vs. an IMG matching into a ranked program was almost 3 times higher (OR = 1.7 vs. 0.59). Khalafallah et al. ( 7 ) conducted a retrospective review of 2,749 residents spanning 50 years. They reported that IMGs were significantly more likely than USMGs to have completed a research fellowship after medical school and before residency (16% vs. 2%). Chandra et al. ( 11 ) reported that from 2009 to 2017, the number of IMG applicants increased without a significant increase in submitted applications or matched IMGs over this period. These individual findings reveal that research productivity is important for matching into a neurosurgery training program. However, IMGs are still limited in their acceptance into a ranked training program (e.g., U.S. News & World Report “Best Hospitals for Neurology & Neurosurgery” ranking) ( 13 ).

Although the geographical location where IMGs received graduate education and the characteristics of success in their neurosurgical match have undergone recent analysis ( 6 , 11 ), an investigation into IMGs' neurosurgical research, coupled with the program directors' (PDs) expectations, has yet to be reported. Neurosurgical and basic science laboratories of neurosurgery departments are the mainstay of departmental research productivity and commonly host postdoctoral researchers from home and abroad. We obtained successful IMG matching data for those who conducted dedicated research in our institution's neurosurgical laboratory.

Some researchers have accessed publicly available databases to analyze broad trends and outcomes for IMGs applying to neurosurgery residency programs, which have required large sample sizes ( 7 , 11 , 12 ). However, we desired a more focused and granular study of the features of a successful IMG application to residency programs. We sought to assess the research productivity of IMGs—both from their perspective and that of PDs—using direct, anonymous surveys to understand the personal aspects of researchers that cannot be ascertained from publicly available databases. For this study, IMGs comprise all individuals who received medical degrees outside the US, irrespective of their nationality. This survey was limited to the most recent 8-year span (July 2013 through June 2020) of IMGs currently or recently matched in US neurosurgery residency programs and a separate survey encompassing all 20 IMG neurosurgery research fellows from our institution who applied and were successfully matched into neurosurgery residency programs or who entered neurosurgery clinical fellowships. The findings elucidate the key research period-related components of a successful IMG application and compare the research experience of IMGs with that of USMGs who successfully matched with US-based neurosurgery programs.

Materials and methods

Data collection.

No protected health information and no individually identifiable information were collected. No patients were involved in this study. Therefore, no institutional review was sought or required.

A search for all neurosurgical residency training programs in the Directory of the AANS and the Association of American Medical Colleges (AAMC) for the 2020–2021 match cycle revealed 115 training programs. Every PD identified through the AANS directory ( 14 ) was provided a survey including qualitative and quantitative questions, focusing on all applicants, their experiences with IMGs in a research environment, and how IMGs relate to USMGs. Later, every PD was contacted again and provided an additional survey, focusing on the importance of different factors associated with an IMG applicant's research productivity.

All Accreditation Council for Graduate Medical Education–approved neurosurgery residency programs in the US listed by the AAMC for the 2020–2021 cycle were identified using the AAMC's online portal ( 15 ). All programs older than 7 years (i.e., had graduated at least 1 resident) were then identified, and individual public websites were reviewed for the most updated list of current residents. An IMG was defined as any resident who had completed his or her primary medical degree (MD, MBBS, MBChB, or others) at a medical college outside of the United States. In addition, public residency websites of all identified programs were reviewed for up-to-date information on their current residents. Residents who received their medical degrees abroad were identified, and publicly available information was collected. A search before and after residency graduation in June 2020 revealed 8 residency classes and 79 IMGs. A questionnaire with both qualitative and quantitative questions on their research experiences before and after the neurosurgical match was sent to the 79 IMGs.

Data regarding IMGs who successfully matched in either a US residency program (i.e., neurosurgery or other) or entered a clinical fellowship program and conducted a dedicated research period at Barrow Neurological Institute (Barrow) from 2000 through 2020 were collected with the permission of the Director of Neurosurgery Research at Barrow. All IMGs completed a research fellowship, and some completed an additional integrated interdisciplinary neuroscience PhD program. Research program type, research focus, match specialty (i.e., neurosurgery, other, or clinical fellowship), months of research, geographical region, h-index, and the number of publications associated with Barrow before residency, 1 year after matching, and 2 years after matching into a residency program were collected and analyzed. A retrospective bibliographic search was done for these Barrow IMGs using PubMed. A publication was added to their total count if the IMG was the first author or co-author and the publication was associated with Barrow. The Scopus author profile database ( 16 ) was used to determine each author's h-index.

Survey content

The first PD and IMG surveys were delivered between April 2020 and January 2021. The second PD survey was delivered in April 2022. The first PD survey contained 5 questions that assessed: (1) the number of years PDs believe IMGs should spend on research before their residency application; (2) the number of peer-reviewed publications any neurosurgery residency applicant should have published; (3) whether PDs believe IMGs complete more research than USMGs before residency; (4) whether PDs believe IMGs complete more research than USMGs during residency, and (5) whether PDs believe nonresident research fellows (i.e., full-time research fellows) or residents were more productive in scholarly research than US research fellows and residents if their program supported such research programs. The second PD survey contained 1 question, asking the PD to rank from 1 to 4 the importance of the following factors when evaluating an IMG applicant's research productivity: (1) the research institution or associated personnel, (2) the impact of the research, (3) the number of publications, and (4) a structured research period or theme.

The IMG survey contained 12 questions. Two were demographic assessments of sex and country of origin—the country of origin was later categorized as a geographical region (i.e., North America, South America, Europe, Middle East, North Africa, South Africa, South Asia, and East Asia) to protect the identity of residents. Three questions inquired whether the IMG spent time on research in a neurosurgery laboratory, the length of their neurosurgery research experience, and whether they spent time in more than one laboratory. The remaining 7 questions dealt with (1) their training background before obtaining a neurosurgical residency, (2) their motivation in seeking neurosurgery research, (3) the degree this research impacted their future career, (4) if they would recommend dedicated research time to peers and future applicants, (5) what their current position was at the time of the survey, (6) how many papers they published before residency, and (7) how many papers they published after beginning residency.

Collected respondent survey data was stored on a password-protected computer and backed up on an encrypted drive. Data of respondents were given an anonymizing number code for identification. Qualitative answers were reported in full whenever their content diverged from others in a meaningful way. Specific sample means in the PD and IMG-directed surveys were analyzed. Data were expressed as medians with first and third quartile ranges (Q 1 -Q 3 ) and absolute ranges and then compared using the Mann-Whitney test. The means, medians, and minimum and maximum responses of the PDs were compared to the responses of the IMGs. GraphPad Prism version 9.3.1 (GraphPad Software, San Diego, California, USA) and Microsoft Excel version 16.58 (Microsoft Corporation, Redmond, Washington, USA) were used for data analysis.

Program directors

Of 115 programs contacted, we received 32 nearly complete responses (28%) to the first PD survey. These PDs responded that neurosurgery residency applicants should spend 12 to 24 months (Q 1 -Q 3 : 0–12 to 12–24; minimum range, 0–24, maximum range, 0–48 months) on research ( Figure 1 ). They also expected the applicants to have published a median of 5 articles (both minimum and maximum medians = 5) (Q 1 -Q 3 : 2–5 to 5–10; minimum range 0–10, maximum range 4–20) before applying ( Figure 2 ). Two PDs stated that the answer to both questions was variable. One suggested taking additional factors into account when evaluating the research capabilities of applicants, such as the research opportunities their medical school offered. Furthermore, 22 (69%) PDs answered that IMGs completed more research than USMGs before residency. When asked whether IMGs are engaged in more research than USMGs once they enter residency, 11 (34%) PDs answered yes. In comparison, 14 (44%) PDs believed that IMGs were not more productive during residency, and 2 (6%) emphasized the IMG's character rather than the residents' respective medical school location. Seventeen (53%) PDs stated that their program regularly supports research fellows, 10 (31%) PDs responded that research fellows are more productive than residents, while 3 (9%) assessed residents to be more productive than full-time research fellows. Four others (13%) suggested generalization is impossible or that IMGs' and USMGs' productivity did not differ.

Box and whisker plot of the length of dedicated research (months) completed by international medical graduates (IMGs) before matching into neurosurgical residency, compared to the expectations neurosurgical residency training program directors (PDs) have of applicants. The X represents the mean. The horizontal line (if visible) represents the median. Whisker lines represent the maximum and minimum values. Additional dots represent outliers that did not fit the model. (***) Represents statistical significance ( P  < 0.05). Used with permission from Barrow Neurological Institute, Phoenix, Arizona .

Box and whisker plot of the number of publications of IMGs before matching into neurosurgical residency, compared to PD applicant expectations. The X represents the mean. The horizontal line (if visible) represents the median. Whisker lines represent the maximum and minimum values. Additional dots represent outliers that did not fit the model. (***) Represents statistical significance ( P  < 0.05). Used with permission from Barrow Neurological Institute, Phoenix, Arizona .

In response to the second PD survey of 115 programs, 43 (37%) PDs provided complete responses. Thirty-four of the 43 (79%) PDs responded that the prestige or reputation of the research institution or associated personnel was the most important factor when evaluating an IMG's research productivity. Nine (21%) PDs responded that the impact of research was the most important factor. Twenty-eight (65%) PDs responded that a structured research period or pursuing a thematic research topic was the third most important factor. All 43 (100%) PDs responded that number of publications is the least important factor when evaluating an IMG applicant's research productivity ( Table 1 ).

Neurosurgical residency training program director ( n  = 43) ranking of research productivity evaluation factors.

International medical graduates

Responses came from 42 of 79 (53%) residents contacted for the IMG-directed survey. Of those 42, 13 (31%) were from the Middle East, 12 (29%) from Europe, 7 (17%) from South Asia, 5 (12%) from South America, and 2 (5%) from North Africa; 1 (2%) each was from North America, South Africa, and East Asia ( Figure 3 ). Thirty-nine (93%) respondents were men, and 3 (7%) were women. All respondents participated in resolute neurosurgical or neuroscience research before their match. Twelve (29%) spent time in multiple research laboratories.

Geographic data of IMGs’ home countries by region. Small countries of origin were categorized into regions to protect the identities of IMG residents who come from such countries. Copyright made available under the Creative Commons Attribution-ShareAlike 4.0 International (CC BY-SA 4.0) ( https://creativecommons.org/licenses/by-sa/4.0) .

Asked about the degree to which their research in a neurosurgical laboratory impacted their future career, 26 (62%) IMGs responded with “A great deal,” and the other 16 (38%) with “A lot.” A total of 35 (83%) would recommend dedicated research time to their peers and future neurosurgery applicants, whereas 7 (17%) would not. Their respective year in training (i.e., postgraduate year) was removed from analyses to protect the identity of each respondent. Among the 42 IMGs, 11 (26%) completed a neurosurgery residency training program abroad, and 14 (33%) attended foreign postgraduate training without completing a neurosurgical residency (4 with incomplete neurosurgical training, mandatory rural service, master's degree, or surgical internship). In contrast, 17 (40%) received no postgraduate training before coming to the US to apply to a residency program ( Figure 2 ).

When asked about the primary motivation for their research work, 12 (29%) IMGs stated that they wanted to improve their chances of a neurosurgical match, and the remaining 30 (71%) commented on their passion for neurosurgical research. Before beginning their neurosurgical residency, 42 IMGs reported a median of 30 months (Q 1 -Q 3 : 18–48; range 4–72 months) spent in neurosurgical research and 12 published articles (Q 1 -Q 3 : 6–24.3; range 1–80), with 1 vacant answer ( Figures 1 , ​ ,2). 2 ). Thirty IMGs reported their research productivity before and after successfully matching into residency ( Figure 4 ). The number of publications differed significantly before and during residency ( P  < 0.001). Of the 30 IMGs reporting this information, 25 (83%) had more publications before than during residency. The median number of publications per year for an IMG before matching was 6.8 (Q 1 -Q 3 : 3.3–12.5; range 0.2–40), while the median number per year for an IMG during residency was 3 (Q 1 -Q 3 : 2–4; range 0–6.4). Only 5 of 30 (17%) IMGs published more articles after entering residency ( Figure 4 ).

Graphical representation of the number of publications per year of IMG residents that were completed before (i.e., during their dedicated research time, blue ) and after matching into a neurosurgical residency ( orange ). Residents entering postgraduate-year 1 and those who chose not to answer the question were excluded from this analysis. Used with permission from Barrow Neurological Institute, Phoenix, Arizona .

Comparison between PD recommendations and IMG performance

The minimum and maximum recommendations by PDs for months of research and the number of publications before matching were combined and compared to actual IMG performance for each variable. The PDs' median recommended research period was 18 months, and the median recommended number of publications was 5. The median IMG-performed months of research (30 months) and the number of publications ( 12 ) before matching were both significantly larger than the recommended PD values ( P  < 0.001 and P  < 0.001, respectively).

Barrow IMG matching results

Twenty IMGs who spent dedicated research time at Barrow during the study period were evaluated ( Table 2 ). All 20 completed a named neurosurgery research fellowship of the hospital institution. In addition, 3 (15%) of these IMGs were part of a nationally-ranked integrated interdisciplinary neuroscience PhD program with a local major state university. Sixteen (80%) Barrow IMGs applied to US neurosurgical residency programs, 2 (10%) applied for residency in another medical specialty, and 2 (10%) applied for US neurosurgery clinical fellowships. All 20 IMGs matched or entered the specialty of their choice. All 3 IMGs who completed the PhD program were matched into a US neurosurgery residency program. Three (15%) IMGs were accepted into a residency upon their second application, with two continuing a research fellowship in the meantime. Another was accepted into a preliminary general surgery year and was then admitted 2 years later into a vacated neurosurgery position. Four (25%) of the 16 IMGs who applied to neurosurgery were accepted into the Barrow neurosurgery residency. However, the other 12 (75%) were all admitted to competing top neurosurgery residencies.

Characteristics and research data of international medical graduates (IMGs) who completed a dedicated research period at Barrow Neurological Institute.

Abbreviations: BI, brain imaging; BTI, brain tumor immunology; CF, clinical fellowship; ET, endovascular technology; FT, fluorescence technology; NS, neurosurgery; SA, surgical anatomy; SBM, spine biomechanisms; SCI, spinal cord injury; SCP, spinal cord physiology; ST, surgical technology; VNTs, varied neurosurgical topics.

For all IMGs at Barrow, the median number of research months was 24 (Q 1 -Q 3 : 24–36; range: 12–70). The median number of total publications was 31 (Q 1 -Q 3 : 4.8–55; range: 1–103), with a median number of publications before residency of 6 (Q 1 -Q 3 : 1.3–39; range: 0–88). The median h-index was 13 (Q 1 -Q 3 : 9–19; range: 2–43). The data for IMGs who completed a research fellowship only vs. those who completed the PhD program is shown in Table 3 .

Data for international medical graduates (IMGs) who conducted research at Barrow Neurological Institute overall and by research fellowship and PhD program participation.

Research demographics of IMGs in neurosurgical residency

Matching into neurosurgery is among the most difficult career choices for USMGs, let alone for IMGs, who face additional scrutiny during the residency matching process. Attempting to set themselves apart, IMGs often invest in years of dedicated research after graduating in their home countries. The median number of months IMGs in our study spent performing dedicated research before entering neurosurgery residency was 30 (Q1-Q3: 18–48). They produced a substantial quantity of published research, with the median number of publications per person being 12 (Q1-Q3: 6–24). The largest proportion of IMGs came from the Middle East (31%); 7% of all respondents were women. Thus, our cohort had demographics similar to the previously described demographics of originating countries and those of the American Board of Neurological Surgery-certified practicing neurosurgeons who are IMGs (6%). Currently, about 19% of US neurosurgical residents are women ( 17 ). Many IMGs genuinely enjoy their research activities. Despite the short timeframe to produce a competitive body of work, our results show how valuable IMGs perceive their research experience to be and how much their research experience positively impacted their careers.

Program director perceptions

This study is the first to investigate neurosurgical residency PDs regarding their views on the value of research as part of the IMG neurosurgery residency application and to compare their expectations with data from successfully admitted IMGs. IMG residency applicants surpassed PD expectations for dedicated research time (12–24 months) and the number of published articles ( 5 ). Additionally, we acknowledge that the numbers of peer-reviewed publications do not consider the academic quality, research productivity, or global impact of the published articles. Nor do these data consider the actual contribution of the applicant to the final work (i.e., first author vs. co-author).

Our assessment goes beyond the NRMP Charting Outcomes in “The Match” report ( 18 ) that displays the cumulative number of research experiences, abstracts, presentations, and publications included in successfully admitted IMG applications entered in the Electronic Residency Application Service. According to the 2018 NRMP Charting Outcomes in “The Match,” non-US IMGs averaged 3.9 research experiences and 46.6 abstracts, presentations, and publications, whereas USMGs averaged 5.2 research experiences but only 18.3 abstracts, presentations, and publications ( 19 ). These data mirror the perceived rise in research productivity of neurosurgery applicants depicted as an “arms race” in the neurosurgery application process ( 20 ). Wadhwa et al. commented on a similar trend. They noted the stark difference between the upward trends of the NRMP-reported research numbers and the actual number of peer-reviewed articles published ( 20 ). The 5 published articles that are expected of neurosurgery applicants, according to the PDs surveyed, are similar to the previous report of an average of 5.5 publications per neurosurgery postgraduate-year 1 residents in 2018 ( 20 ).

These observations suggest that, on average, across all neurosurgery residents, research expectations for future residents are met at the time of application ( 20 ). However, other publications that reported data for USMGs and IMGs noted an average of 2 publications by USMG applicants and 5 in the admitted IMG applicant cohort before residency matriculation ( 11 ). Given this evidence, it is reasonable to infer that IMGs markedly affect the overall number of publications of medical students who match into a neurosurgery residency program.

To address the qualitative characteristics of an IMG's research productivity instead of absolute numbers, the PD directors were given a 1-question survey at a later time ( Table 1 ). When given the task of ranking research productivity evaluation factors from 1 to 4, most PDs (34/43, 79%) ranked the research institution and its associated personnel as the most important factor. The second most important was the impact of research (i.e., impact factor of journal or h-index). More compelling, all PDs (43/43, 100%) ranked the number of publications as the least important factor. This result brings to light a divergence in the perception of research between IMG and PD that has not been emphasized thus far: the quality of research outweighs the number of publications. This could explain the marked difference in research numbers reported in previous publications, by national databases, and in the present study. Therefore, although an IMG reports a significant amount of research, the data suggests that PDs look beyond the numbers and instead focus on the associated institution and the overall impact and quality of the research work.

Discrepancy in background and experience between match candidates

An IMG's situation is entirely different from that of a USMG applicant for a neurosurgery residency. Certain IMGs aspire to train in the US for various reasons, including some unrelated to training, such as socioeconomic, political, or quality-of-life motives. They opt to enter research posts and spend years improving their portfolio because it is likely necessary in order to become competitive within the US residency matching system. USMGs complete undergraduate degrees before medical school, prolonging their preclinical and potential research period. In addition, the research opportunities and facilities that US students can access during their undergraduate and postgraduate programs are superior to those of candidates who earn their medical degrees in LMIC countries. According to Sheppard et al. ( 12 ), applicants from the top 20 or top 40 US medical schools had higher preresidency publication counts. Applicants with higher preresidency publication counts were also matched at residency programs with highly ranked affiliated hospitals.

In addition to published work, as one of the PDs explained, applicants' research opportunities before the residency match vary greatly, and this variability increases the difficulty of evaluating neurosurgical residency applicants. The importance of an applicant's opportunities is supported by the fact that a significant difference is seen in the number of publications by USMG applicants who graduated from the top 20 medical schools (per U.S. News & World Report “Best Research” ranking in 2018), compared to those who did not (9.40 vs. 4.43) ( 20 ). In addition, attendance at a top 40 National Institutes of Health–funded medical school was a distinct characteristic associated with successful neurosurgery residency matching ( 21 ), with other competitive specialties reporting similar importance of medical school ranking on success in their residency match ( 22 ). For example, 40% of US neurosurgery applicants who successfully matched from 2011 to 2018 came from medical schools ranking in the top 40 for research based on the 2018 U.S. News & World Reports rankings ( 12 ). Furthermore, the opportunities provided by an applicant's medical school are made even more important by a recent change to the United States Medical Licensing Examination (USMLE) Step 1 exam to a pass-fail format. In one study, PDs across all specialties agree that medical school prestige will be considered more important in the evaluation of an application after the change in the USMLE Step 1 scoring format ( 23 ). Regarding neurosurgery residency programs, more than half (71%) of the 48 PDs responding to a survey believe that medical school reputation will become more important in resident selection, and 63% of PDs believe it will put IMGs at a disadvantage because of the change ( 24 ).

The importance of the research post also translates to the international setting. A higher-ranked medical school seems to similarly impact IMG applicants. In theory, a greater proportion of countries known for their scientific prowess produces more IMGs who are successful in the neurosurgical residency match. The variability of foreign-home institutions, ranging from well-known and research-intensive European centers to those in LMICs with relatively low exposure to scientific work, is represented by applicants ( 6 ). In this study, the Middle East accounted for most IMGs in US neurosurgical residency programs (13/42 [31%]). However, about 40% of all Lebanese medical graduates in the past quarter-century have migrated to the United States ( 25 ). Arguably this specific example is the exception but again highlights how socioeconomic and environmental aspects, as seen in the Lebanese and Middle East communities, influence international migration. For critical inferences to be made, an analysis of the geographical distribution of all neurosurgical applicants would give a more accurate picture of the country-specific success rates of foreign neurosurgery applicants.

Additionally, while medical school prestige and research opportunities impact a candidate's professional trajectory, elements such as the alignment of foreign medical school curricula to those in the US and collaboration or exchange programs with US institutions, as suggested by Chandra et al. ( 26 ), could help explain the observations that specific countries or schools produce more IMGs who successfully enter US neurosurgical residency programs.

More than a subject of professional competency

The subject of international migration based on professional development is complex and multifaceted. While the US has developed an independent assessment of international professionals, other nations have done the same. Labor ideals, such as free movement and working rights in Europe, have mandated that means be established for assessing international candidates equal to their native counterparts ( 27 ). Acceptance of foreign applicants impacts the workforce, resources, and service provision aspects of the neurosurgery profession. Professional immigration has also been the subject of political debate.

The situation for IMGs in the US depends on federal policies, where congressional appropriation for medical training results in appropriate and substantive federal input into the fabrication of residency infrastructure given the government's financial contribution. Graduate medical education programs funded by US tax dollars support the development of the nation's citizens, serve the American public, and USMG and US residency programs. This reality emphasizes the infrastructure's educational, financial, and legislative components to determine the appropriate distribution of resources for training. It provides an infusion of new ideas, rewards for diligent and high-quality professional contributions, professional opportunities, and compatibility with the nation's view of immigration.

The visa requirement to enter and study in the US is a critical component of the neurosurgery residency application process for many IMGs. Because of the length of US neurosurgery training programs, IMGs require a permanent residency permit (“green card”) or other semi-permanent or permanent work authorization. This type of immigration work status can require months to years to acquire, thus impacting the length of an IMG's research period before applying to a neurosurgery residency program.

It is also important to note that professional associations and boards have specific policies regarding training and acceptance. Comparative frameworks include the European and UK systems. Medical graduates of the European Union and other countries with bilateral agreements, such as Switzerland, Norway, and Iceland, are not considered IMGs when applying for residency in these countries. It is particularly important for IMGs to obtain a work permit and accreditation for their medical degrees. This hurdle is comparable to attaining Educational Commission for Foreign Medical Graduates (ECFMG) certification in the US. These accreditations count as the initial basic requirements for practicing medicine in the US.

A “Kenntnisprüfung” in Germany and the Professional and Linguistic Assessments Board (PLAB) in the UK are required to prove sufficient medical knowledge to practice medicine and are only mandatory for foreign graduates (as of January 1, 2021, the PLAB is required of EU citizens) ( 28 ). Language requirements, however, are not bound to labor agreements in the European Economic Area due to its multilingual landscape. In Germany, C1 medical language proficiency and B2 German proficiency as per the Common European Framework of Reference for Languages are required ( 29 ). This requirement aligns with the Occupational English Test now required by the ECFMG after it canceled the Step 2 Clinical Skills examination for foreign graduates ( 30 ).

Furthermore, in the UK, the concept of “experience limits” is a stark difference from the US system of training doctors. In the UK, postgraduate experiences in a medical specialty that exceed certain limits may lead to the status of overqualification for the applicant and ineligibility for residency training. For neurosurgical training, these limitations are as follows: clinical experiences that do not exceed a timeframe of 24 months, with a maximum of 12 months in neurosurgery, neurology, neuroradiology, and neuro-intensive care combined ( 31 ). Such a requirement could pose a significant limitation for IMGs if the US had such a directive. This requirement would affect foreign applicants in our cohort, with 5 residents who received some form of foreign training and 5 who completed a neurosurgery residency before entering US residency. In this scenario, IMGs may view the US as an easier or more accessible pathway into postgraduate training programs. Although a maximal preresidency specialty limitation does not apply uniformly to all tracks that may lead to neurosurgical qualifications in the UK (Certificate of Eligibility for Specialist Registration (CESR), CESR-Combined Program), it pertains to the main national training curriculum of an 8-year neurosurgical residency.

The UK exercises annual recruitment for neurosurgical residency similar to the US matching system. As pointed out by Solomou et al. ( 32 ), obtaining a neurosurgical specialty training position in the UK was highly competitive in 2018 with 152 applicants for 34 positions and in 2019 with 157 applicants for 24 positions. They noted that proof of early interest in the neurosciences, substantive academic productivity, and undergraduate achievements constituted significant components of a competitive application. Conversely, in Germany, a standardized national process for hiring residents does not exist, and prospective IMGs need to focus on acquiring their work permit and medical accreditation before directly applying to training programs.

The path to residency training for IMGs in the US is well structured. European models appear less well delineated in their residency trajectory. Poorly delineated application processes for achieving professional competency can also hinder international migration and deter potential candidates who favor a more formal approach.

Benefit of IMG research years beyond their research period

Not only do the research opportunities before the residency application substantially contribute to a successful application, but also factors such as a well-established faculty for mentorship play a role. This point is in line with reports that letters of recommendation (LORs) for the neurosurgical match hold more importance as an admission criterion than the applicant's research, according to PDs ( 33 , 34 ). Obtaining a recognized, appropriate, or meaningful LOR, which is often as difficult to obtain as for IMGs in their home country, is an additional reason to complete dedicated research time in a US neurosurgical department ( 35 ). This time is vital for the advancement of research acumen and ancillary reasons such as producing publications and presentations, attending conferences, networking, building relationships, and time spent as a clinical observer within the research period. IMGs are also evaluated during a research period because the IMG represents an unknown, especially not having been through the standard USMG progression to residency application. These evaluations may include assessments of seriousness, dedication, and persistence—essentially a test of whether the IMG is a good fit for a program. Often, a USMG who does not match may be in a similar situation. Many IMGs enter a US academic environment inexperienced in quality research. Thus, a central question is: “How do IMGs learn research?” Centers should be equipped to offer excellent periods of research where IMGs accomplish research through mentorship and coaching.

Aside from standardized tests for ECFMG certification, it is difficult to determine the quality of international medical curricula and, therefore, the medical education that IMGs receive. In addition, LORs from research mentors abroad are much harder for PDs to evaluate than those from domestic colleagues in the more familiar US neurosurgery community. The time spent on research fellowships in a US neurosurgery department allows an IMG to build rapport with potential future mentors and colleagues and acquire LORs from established US neurosurgeons.

The currently established pathway for IMGs who intend to match into US neurosurgical residency primarily revolves around several dedicated research years. The influences the research years have on the competitiveness of their applications go beyond the quantity of research they produce. Our results suggest that the heavy focus on research might not be warranted or worthwhile in the long term. IMGs often spend onerous time in research that may take on the characteristics of indentured servitude. Thus, the institutional environment must be one of support, mentorship, and positive accomplishment. Information on financial support was not consistent and is variable. Although research project costs are covered, institutions may provide minimal financial living support, requiring the research IMG to establish sufficient personal funds for their stay at the institution. Many institutions now require such individuals to be paid by the institution at levels consistent with National Institutes of Health postdoctoral levels or to establish comparable personal funding, which the US Department of Labor may regulate. IMGs often go into dedicated work positions in laboratories led by a primary investigator working on an established research topic where they are paid from a grant or funded project.

Although most PDs in our survey believed that IMGs produced more work before residency than their USMG counterparts, this impression is not preserved once IMGs enter residency. Although IMG and USMG publication numbers are not available for comparison for the period of neurosurgical residency training, we contrasted the median number of publications by IMGs in residency with those completed before residency (3 articles per year vs. 7 articles per year; Figure 4 ). This decrease in publications is not surprising because IMG residents are bounded by the same clinical duties and time constraints as USMG residents.

Previous studies found that the academic careers of fellowship-trained vascular, endovascular, and oncological neurosurgeons are primarily associated with the h-index during residency ( 36 , 37 ). Similarly, Daniels et al. reported the number of publications produced during residency was associated with academic career progression in neurosurgery, whereas the number of publications preresidency was not ( 38 ). However, residents who devoted a dedicated research period before their application had better academic career trajectories, but this finding was not differentiated between USMGs and IMGs. However, the input of PDs seems to indicate that the research contributions of IMGs have an impact beyond merely the h-index for their publications.

It is difficult to assess and directly compare USMG neurosurgery applicants who do not spend lengthy dedicated time on research but produce research articles and balance medical school duties with IMGs who work full time on research and do not have clinical responsibilities. In an analysis of burnout in neurosurgical trainees, IMGs score high in resilience ( 39 ). A study on general surgery interns found their performance to be of equal quality to USMGs ( 40 ). Regarding research, there was no difference in h-indices between IMGs and USMGs during or after residency ( 7 ). The analysis of this situation may be more about the assessment of the individual background of the IMG, as more than half of the successfully admitted IMGs had previous neurosurgical training (10/17) in addition to their LORs and US-based research period. IMGs who have experienced previous neurosurgery training may understand the demands that are expected of them and may be committed to seeing their opportunity through to completion. US neurosurgery has had a history of training foreign neurosurgeons who have been successful in academic and private practice environments. Foreign neurosurgeons have also become leaders in American neurosurgery.

The interview process, USMLE scores, and LORs are commonly ranked as more important than research, which supports the sentiments that a well-rounded application of every neurosurgery applicant is of the greatest importance. This finding might encourage future applicants to invest more time in clinical and voluntary work or expand upon their professional connections through neurosurgical meetings and observerships. However, starting at the end of January 2022, the USMLE Step 1 will no longer be graded on a 300-point scale. Instead, it will become graded as pass-fail. A recent study conducted by Huq et al. indicates that most PDs expect the involvement in research and the number of publications to increase among the applicant pool due to the change in the USMLE Step 1 exam format ( 41 ). Thus, research performed to gain a neurosurgery residency position may become more consequential.

In addition, barriers are increasing to clinical work for temporary or transient foreign neurosurgeons or medical students in US hospitals due to liability and other legal issues. Clinical or clerkship opportunities are uniquely available to IMGs from Caribbean medical schools due to their location and the fact many are US citizens (i.e., US-IMG) ( 42 , 43 ). Thus, the research period for IMGs continues to be an opportune means to demonstrate the resourcefulness and accomplishment to support a neurosurgical residency application. With a better understanding of expectations in the most personally controlled component, i.e., a dedicated research period, this study clarifies the cardinal aspect of a successful residency application and how the research period impacts the optimal pathway of IMGs toward neurosurgery residency programs.

Contributions of Barrow Neurological Institute to IMG development and matching into a US neurosurgery residency program

Another critical question is: “How can the time spent in research as an IMG be made worthwhile?” Several PDs who responded to our survey noted formal neurosurgery department support of IMGs for their research period to be important. One PD cited their American Council for Graduate Medical Education recognition and accreditation for IMG research time. Most PDs in the second survey ranked a candidate's “institution or associated personnel” as the most important factor when considering research productivity. Because their tenure may be years or at least 1 year, involvement of the IMG in a structured, mentored research fellowship or graduate program may be an answer. In 2012, the neurosurgery research laboratory at Barrow (i.e., The Loyal and Edith Davis Neurosurgical Research Laboratory) was a founding member of an integrated interdisciplinary neuroscience graduate PhD program partnership between the hospital institution (Barrow Neurological Institute) and the major local university (Arizona State University), supporting one of the top neuroscience programs in the country. The laboratory supports 2 funded neurosurgery research fellowships per year, with at least 1 one of these positions dedicated to the support of a research fellow in the neuroscience graduate program that lasts from 3 to 5 years, culminating in a PhD in neuroscience. Other research fellows beyond the two positions must self-fund with support verified by hospital human resources administration and be of an amount in line with NIH postdoctoral levels. The laboratory funds all projects, meetings, presentations, and publications costs.

Additionally, neurosurgery research fellows who spend 1 year at Barrow are enrolled in a named research fellowship of the laboratory and institution and receive a formal certificate of research fellowship at the successful completion of their program. They become part of the heritage of the institution, imparting legitimacy to their work and tenure. Thus far, all 3 graduates of the neuroscience PhD program who applied to neurosurgery residency were readily accepted. Furthermore, all 20 IMGs who have worked in the research laboratory since 2000 and applied for residency or a clinical fellowship have been accepted. The duration spent in research by these IMGs is comparable to that reported in the present survey (both 30 months).

The leadership of an in-depth, research-experienced, chair-endowed neurosurgeon engaged full time without clinical duties who directs and coordinates all phases of the laboratory experience, projects, and collaborations, and who skillfully mentors and assesses the research fellows (both IMGs and USMGs) likely plays a major role in applicant acceptance into a neurosurgery residency. A long-established dedicated international outreach toward education in neurosurgery by Barrow's retired and current institutional directors also supports this success.

With a stance similar to Wilder Penfield's viewpoint for training his first research fellows and later residents, [ 44 – 46 ] he and William Cone, and later Arthur Elvidge, allowed trainees and research fellows to develop according to their strengths and interests while providing support and mentorship to help shape their careers. Indeed, attracting research fellows, i.e., IMGs, to become neurosurgery residents is only the beginning. A program director needs to have the skills and resources to inspire these trainees to come into their own. Otherwise, it is a waste of talent and precious career time. Research fellows in the Barrow program are enveloped in a productive environment that focuses on creativity and promotes resourcefulness and innovation.

Interestingly, of our 3 IMGs who were not admitted to a neurosurgery residency program upon the first application, 1 had just arrived in the US a few months earlier and submitted a late, underpowered application. This applicant submitted an excellent application with guidance the next year and was admitted to a prestigious residency. Another elected to continue after 2 years at another institution, at which 2 applications were necessary for residency admittance, without exact details. The third research fellow did not engage in a concentrated or thematic evolution of research but was admitted to a preliminary postgraduate year of surgery and was then admitted to a vacated neurosurgery residency position 2 years later. The common theme of these 3 and the 13 other first-round successfully matched research fellows from our program experience is that all IMG research fellows who were engaged in a structured or thematic line of excellent research, skillfully mentored, and who submitted excellent applications while at Barrow were admitted upon their initial application to a first-rate residency program. Given the success of the IMGs who conducted dedicated research at Barrow, we believe our current model provides a possible solution to the challenges and biases faced by IMGs who desire to train in the US.

Solutions to possible biases affecting IMG applicants to neurosurgery

IMGs face several institutional biases when applying to a US neurosurgery residency program. These biases result in IMGs being more likely to perform a research fellowship after medical school and matching into an unranked program. In addition, from 2007 to 2019, there has not been a significant increase in the number of IMGs accepted into programs, even though the number of positions has significantly increased and the proportion of IMGs applying has increased.

Although it is beyond the scope of this paper, we believe there are possible solutions to these problems exemplified by our institution. For example, all neurosurgical programs with a dedicated research department or laboratory could foster positions for IMG applicants. This action may even include a graduate program (e.g., PhD program) that extends the IMG's research period and focuses on a specific topic or theme. In our analysis, PDs found this research activity more important than the overall number of publications, which may be on scattered topics or simply one-off clinical papers. Furthermore, these research positions should be more available at highly ranked institutions, which, on average, have more residents per year and resources for performing high-impact research. This outreach may target the bias of not being able to match at a ranked program because from 1968 to 2018, 25% of IMGs who completed a research fellowship stayed at the same institution to complete their residency training ( 7 ).

It is somewhat disappointing that only 4 research fellows have been matched into the Barrow residency program, with 2 of them entering vacant positions. Senior staff and faculty believe that the research fellows were not well known by the residents or that the residents do not want to “take a chance” on an IMG in the residency program, perhaps believing they would not fit “the team.” Several research fellows expressed disappointment with not being in the top residency position consideration cohort at Barrow when they had been there for years performing outstanding research or performing a clinical rotation, but where other candidates less familiar and experienced were accepted. These research fellows, however, matched into programs where they stated their research and clinical experience were valued. Fifth-year residents at our institution are critical leaders of future resident selections. Many of our research fellows have won major acclaim for their research work and have already fully trained in neurosurgery at demanding foreign programs, such as Russia's renowned Burdenko National Medical Research Center of Neurosurgery, yet are ranked relatively low. None of the research fellows have had personality issues and have been held in the highest esteem and befriended by department and hospital staff.

Notwithstanding the above, the Barrow fellowship program has achieved success with its structure and reputation. Uniquely, the program has matched 2 foreign fellows in the same year to prestigious residency programs on their initial application, and 2 fellows were matched into the same top residency program over successive years. Although research fellows give presentations, attend rounds, institutional, national, and international conferences, and educational and social events with the residents, solutions to this problem at our institution include further integrating the fellows with residents to apprise them of the full scale of fellows' backgrounds and impending residency applications.

Limitations

Although our findings portray an interesting component regarding compelling aspects that have evolved in US neurosurgical residency programs, the data presented are limited. These data concern IMGs in US neurosurgery training programs only. The response rate to surveys was about 50% for IMGs and 28% for PDs; thus, it is reasonable to argue that the opinions obtained do not accurately represent the complete resident demographic and PD opinions and policies. Our data do not derive from social media or publicly available databases, which may yield large numbers but few personal details. However, the data are sufficient. Our sample size is sufficient considering the actual size of the denominator (78 or 79). First, a search before and after residency graduation in June 2020, revealed 8 residency classes and 79 IMGs. Second, after collecting archived data from the NRMP from 2013 to 2020 (8 years), we found that 95 IMGs had been accepted into US neurosurgical residency programs, of which 78 were non-US IMGs. Our study only surveyed non-US IMGs. Lastly, the 79 IMGs (from before and after resident graduation) and the 78 non-US IMGs (from the NRMP archive data) do not accurately represent the number of non-US IMGs who conducted dedicated research as fellows before applying to US neurosurgery residency programs. This number cannot be accurately determined but is less than 78 or 79. Therefore, our already high response rate (53%) for non-US IMGs who successfully matched into US neurosurgery residency programs most likely represents an even more significant percentage of non-US IMGs who conducted research through a fellowship and were accepted into a US residency program, perhaps as high as 80%. In addition, no previous study has included information from neurosurgery residency PDs.

Respondents were cautious with some of their responses to questions (i.e., country of origin and number of publications during residency). As such, the data might not be representative of the cohort due to a lack of responses from some residents. The present paper only describes the results regarding IMG research productivity, and it does not address all the questions given in the questionnaires. Other survey results will comprise additional studies. We used as much accessible NRMP and published literature as possible for comparison. In cases where similarities were identified, the findings suggest the continuity and the legitimacy of the representative trends.

Furthermore, some important questions cannot be addressed by the present study but merit answers. Is the neurosurgical training system in the US the best in the world? If so, does it allow weaker candidates to become excellent neurosurgeons? Is the international community lacking excellent potential neurosurgeons? Regarding the PD role, do PDs require qualities (i.e., aptitude, passion, predisposition, teamwork, or ambition) that cannot be evaluated through an IMG's research productivity? Is a research fellowship necessary for an IMG, or could an IMG and USMG apply under the same conditions? Is neurosurgical attitude associated with the prestige of the home institution of a candidate? Lastly, how can the system be improved to offer all IMGs a similar condition when applying? All these questions are critical and, unfortunately, outside the scope of the present study due to its strict focus on the IMG research period from the perspective of both IMGs and PDs. We acknowledge that a focused editorial on such a topic would be justified.

Conclusions

The IMGs surveyed reported significantly longer periods invested in dedicated research and more published articles before their US neurosurgery residency match than the expected numbers reported by the PDs surveyed. PDs perceive IMGs to be more productive in their research than USMGs until they enter residency. At that time, many PDs stop seeing a difference in research productivity between IMGs and USMGs. This impression is in accordance with our finding that there is an understood decrease in published work by IMGs upon entering residency. Many IMGs complete a dedicated research period in a US institution before their residency application, unlike USMGs. This dedicated period allowed them to surpass the research productivity expectation of PDs and enhance their neurosurgery residency application. This study highlights that the research requirement is more than satisfactorily achieved by IMGs, and to improve their competitiveness, IMGs may be better served by completing more clinical placements. However, with limitations in clinical positions and neurosurgery's tradition of research involvement, neurosurgery residency training in the next decade will be defined as much by advances in technology as by the opportunities afforded in neurosurgery training and the labor shifts in the overall profession. As neurosurgical education and technology advance worldwide with growing interconnections between neurosurgeons of different countries, potential changes in the requirements and policies of training programs may open training positions for successfully and comparatively educated IMGs in various countries.

In 1928 when he arrived at McGill University's Royal Victoria Hospital under the aegis of Edward Archibald, Wilder Penfield pioneered what would be a remarkable achievement 6 years later with the opening of the Montreal Neurological Institute. He sought nothing in the way of nationalism, only a pursuit of excellence—his first research fellows arriving in 1929 were from San Francisco and London, with one woman—the future famed neuropathologist Dorothy Russell—and his residents were as well international, contributing brilliantly in the next decades to scientific neurosurgery ( 44 , 45 ). In fact, up until the mid-1990s, McGill had trained more department chairmen of US neurosurgery programs than any other single institution ( 46 ). McGill trained the first African American neurosurgeons during a period of intense racial segregation in the US, “enabling subsequent African Americans to enter and enhance the field of neurosurgery.” Up until 1997, a unique, close relationship existed between American and Canadian neurosurgery since famous institutions of the two countries were among the founding centers of neurosurgery in North America, with activities, training, faculty, and programs constantly shared. Unfortunately, unresolved training, practice, and economic issues since have designated Canadians as ordinary IMGs to the US neurosurgery system. For many years, Americans went abroad for research at various times related to their residency period, although most returned to the US for clinical training. Although the notion of protecting national interests is crucial and socioeconomic attractions are a powerful attractant to the US medical practice environment, might we take an altruistic lesson from Penfield, that excellence and the deserving, no matter what human form, are just as critical to the progress and improvement of neurosurgery and its training milieu. A delicate balance is also necessary between the workforce and national interests. We hope that our findings will benefit future applicants and PDs alike and encourage further investigation of IMG applicants to neurosurgery training programs.

Acknowledgments

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

This study was funded by the Newsome Chair in Neurosurgery Research, held by Dr. Preul, and the Barrow Neurological Foundation.

Data availability statement

Ethics statement.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

Author contributions

*GM-J—primary author, study conception, data generation, data analysis. YX—assistant author, study conception, data generation, data analysis. LMH—assistant author, study conception. DB—assistant author, data generation. JHJ—data generation. AJSK—data generation. MAL—data generation. TFD—study review, secondary author, paper review. RFS—study review, paper review. MTL—study review, paper review. MCP—study conception, supervision, paper revision, paper review, and approval. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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