The single easiest place for you to match as a non-Saudi is the United States. Their board exams are difficult but definitely not impossible and most definitely very achievable. Therefore, it is always a good idea to prepare for them regardless, even if you are 100% sure you will not go there, keep it as a backup plan in your back pocket. If you do not end up going there, the knowledge you gain from preparing for the exam will help you regardless of course.
In this week’s post, I will talk about the difference between an American IMG and a Non-American IMG. Many people believe that if you hold the American nationality, you have a better chance of being accepted. This holds merit and is true to a certain degree, but not in the way that you that you’re thinking of. American IMGs don’t get preferential treatment, their nationality isn’t something that gives them an edge in each individual program. BUT, their advantage is that they can apply to more programs. How?
Residency programs can be divided up into those that only accept AMGs (American Medical Graduates, students [regardless of nationality] who graduated from an LCME-accredited medical school), IMG friendly programs that offer visas and IMG friendly programs that do not offer visas. In order to better explain this, let’s take two students: Mike, an American citizen who graduated from Alfaisal and Anwar, a citizen from an Arab country (I don’t want to specify) who also graduated from Alfaisal in the same batch as Anwar. And to make matters simple, they have identical CVs and grades (same Step 1 and 2 scores, same GPA, same electives, same everything).
Example 1: Mike and Anwar both apply to a program notorious for accepting only AMG students. They both will most likely not be offered an interview and of course not be ranked by the program.
Example 2: Mike and Anwar both apply to a program that is IMG friendly and offers a visa to non-citizens. They both will have their applications and CVs looked at very closely and both will probably get an interview (generally speaking, this of course depends on which specialty and how competitive the program is). They will both be given an EQUAL chance at this program.
Example 3: Mike and Anwar both apply to a program that is IMG friendly BUT does not offer an visas. Mike will probably get an interview, while Anwar unfortunately will not get this chance. Not for any racist reasons, but because even is Anwar is the best candidate they get , he will be unable to acquire a visa.
Example 4: Mike and Anwar both apply to a family medicine program. Mike has a ridiculously better chance of getting an interview and matching, even if the program offers a visa. This because when it comes to family medicine, programs will accept American IMGs with low scores and a not that impressive CV just based upon nationality. The US is in need of more general practioners, and American IMGs are more likely to stay in the US and serve the community than Non-US IMGs.
Hope this clears any myths around American vs. Non-American IMGs. For statistics, please go this link.
This is specifically directed at those considering the US for residency. Hopefully this will help you prioritize what is important and what isn't that important. After every match, the NRMP conducts numerous surveys and studies in order to analyze the match. One of them is the Program Director Survey. Here they send out to all the Residency Program Directors that took part in the match and asked them a bunch of questions, mostly on how they chose applicants for interviews and how they picked interviewed applicants. The photo I have attached is the general response from all specialties (1300 responses out of the 3599 programs that participated in this year's round, which is around 36% of programs).
We have the percentage citing factor (how many programs used this criteria, so for Step 1, 93% used it which is around 1209 programs out of the 1300 that responded initially) and what is the average rating (think of it as how strongly it influenced their decision).
Btw, before analyzing, a point to consider. Anything that has to do with a medical school criteria (grades, MSPE, etc.) isn't taken into great consideration for IMGs. That is mostly used to look at American Medical Graduates.
So what do we take from it?
The top of the chart is unsurprisingly Step 1. 93% of programs used it and it had an average rating of 4.2. In other words, the great majority of programs saw that your step 1 score is one of the most important factors in you getting an invitation for an interview. So the Step 1 should be your only and main concern until you finish it.
The second factor listed is letters of recommendation (LORs). Now in order to get a LOR, you need to do an elective in the US, preferably in your selected specialty (LOR from physicians working outside of the US are not as strong as LORs from physicians currently working in the US, regardless of where they did their training). So acquiring and planning an elective should be one of your highest priorities. Also a note, by doing the step 1, getting an elective becomes relatively a lot more easier (note the word "relatively").
There are 39 criteria used to select applicants for interviews (some programs may use more, some may use less). If you glance at the bottom of the list, specifically #30, you will see "Demonstrated involvement and interest in research". Only 44% of programs used it as a criteria and it received an average rating of 3.7. Not many programs require research, unless you're applying to a big university hospital. Most programs like to see your clinical side more. Now that isn't saying research is useless, remember if you do research, it could provide helpful contacts and connections, which are essential sometimes for getting accepted in a program.
This is an extremely brief summary. Please check the document out to see specific specialties and what they look at the most. Good Luck
We will now focus on electives. As I previously said 2 weeks ago, after completing the step 1, electives should be your main priority. This week I will talk about general rules and guidelines you should know about before applying. Next week I will talk about how to choose the best the elective for you.
First, some general information. An elective is any clinical experience you do in the US with hands-on teaching (this means that you take histories, perform physical exams and maybe even do a few procedures under supervision) while you are a student and it does not receive a credit on your transcript. A clerkship is the same thing, but it receives a credit on your transcript (so if you decided to do the cardio clerkship in the US instead of here in KSA). An observership is a clinical experience with no hands-on teaching. This can be done while you’re a student or after you graduate. Now the best one on your CV is the elective/clerkship (because of the hands-on teaching). Observerships are not really useful, but they won’t hurt if you do have them.
Second, you cannot, by law, participate in any elective in the US after you graduate. To get things straight, you graduate the second you receive your diploma, which happens after you complete your internship. You do not graduate at the end of 5th year, the ceremony that takes place at that time is just a formality, it doesn’t count towards anything. So while you are an intern, the US will consider you a final year medical student, which is a good thing. Once you graduate, you cannot apply for any electives. You can, however, apply for observerships as a student as well as a graduate. Again, this isn't an institutional policy, this is a federal law across the US.
Third, there are three objectives for an elective. First one is to gain clinical experience and knowledge. Second is to gain letters of recommendation (LORs). These are ESSENTIAL for you to get interviewed, not to mention getting accepted anywhere in the US for any specialty. If you don’t have any LORs, your application and CV end up looking remarkably weak. Again, I have to clarify a point. The LORs you need have to be by American physicians in your desired specialty that are CURRENTLY practicing in the US. So even if you know a doctor in KSA who did his/her training in the US but is currently working here, it isn’t as strong. And of course, a letter from a non-US doctor is the weakest of them all. The third objective is developing connections (this is arguably the most important). A good connection in the specialty you are chasing after is sometimes your ticket into your dream residency. A connection doesn’t necessarily have to be a physician, it could be one of the nursing staff, someone from the administration or any of the hospital’s employees, so be nice to everyone and make sure to stay connected. By the way, a connection is different from a “wasta”. A connection is a means for you to get something you deserve while a wasta is for you to get something you don’t deserve.
Fourth, if you complete the Step 1, you are eligible for many more programs than someone who doesn’t have the Step 1. Actually, once you get your Step 1 mark, the degree of increase of how many programs you can apply to is mind-blowing. Furthermore, elective programs that don’t require step 1 are usually stupidly expensive (a couple of thousands of dollars per month). The ones that require step 1 on the other hand usually ask for an application fee ( a few hundred dollars) and the tuition is in the hundreds if anything at all (meaning that sometimes there is no tuition fee). So do the step 1 first, then apply, because you open many more options for yourself by doing so.
Fifth, when is the best time to do an elective? As mentioned above, the best time is after you finish your step 1. But for chronological purposes, the best time is obviously during your internship. This is due to several reasons. First, LORs are usually only good for 2 years, after that you need to get them renewed by the doctor again. Also, by doing them in the last year, you’ll be fresh on everyone’s mind. But, if you have the chance to do them before your internship, you should absolutely take that chance. However, it is better to focus on your step 1 and getting it over with before your internship.
Sixth, a commonly asked question is how many electives does one have to do? The best answer is as many as you can. If you can do all 12 months of the internship in the US, go for it. If you can only do one, then do your best in it. We have seniors of both extremes (some who did all of it in the US and some who did only one month) and they got accepted. Some programs do require a minimum number of electives though. Harvard, for instance, requires you do at least 12 months of electives in the US (it is Harvard after all) for you to be eligible for an interview. Others want at least 1 or more. Some don’t have any requirements and have a history of accepting IMGs with no electives. So what I advise is that, do as many as you can. Don’t give yourself a limit, let the limiting factor be that you were unable to acquire an elective, not because you said to yourself that I have enough. As an IMG, you can NEVER have enough electives and the more you do, the better chances of you matching in the US.
Last, this is a point I cannot emphasize enough. The elective search process (I will talk about it next week) isn’t one that can be done in a day. You can’t just go to Google, type “US medical electives” hit the “I’m feeling lucky” button and sit there crossing your fingers hoping for the best. This process takes time, effort and patience. You have to dedicate yourself to this, just like studying for your steps. You will get frustrated because of how limited your options can be unfortunately, but you should never give up and you should always have hope. The odds may be stacked against you, but that will only make your success that much sweeter inshallah
Last week we talked about general information regarding electives. Now we will dive into the topic on how to choose the best electives for you as an IMG.
First I have to re-emphasize a point I made last week. This isn’t an easy process that you can take lightly. A well-placed elective could be the deciding factor in your future. The more time you invest in this search process, the better results you will get. Do not rush this, you have to take your time and make a smart decision. But at the same time, start and plan early. Don’t leave this till the last minute and end up frantically applying to anything and making a bad decision. So start early, plan early and make the smart choice for yourself.
So the first step you need to consider is what electives do you want? The electives you do abroad in the US should be in the specialty you want to specialize in. If you want to go to medicine, it would be best to do internal medicine electives abroad, not OB&GYN. If you want to do surgery, then it wouldn’t make sense to do pediatrics. Do the electives in the specialty you plan on matching in. Now if you did some electives in the specialty you want and get the chance to do an elective in another specialty, you would be stupid to refuse it. Any elective is better than no electives, but an elective in your specialty is better than any other elective.
After you made your choice regarding what specialty(s) you want to do electives under, the next step is getting the list of residency programs of that specialty. This is available on the NRMP website here.
The next step is the long and hard process. This is the part where it is frustrating. You need to go through EVERY single residency program. What are you looking for? You are looking to see if that the hospital offers electives to students, and if it does, are they available for students from international schools? Most programs unfortunately only offer them to American students. If they do offer them to international students, it’s usually either to all international schools, affiliated schools only (the G&D has the list of all the affiliated hospitals with Alfaisal) or through GHLO (contact the G&D for the GHLO coordinator). Now why should you go through all the residency programs? Electives are usually only offered at hospitals with residency programs in them to begin with. There are a few exceptions, but this is the trend. But why pick based upon residency programs? Remember that table I explained 3 weeks ago? The one about how program directors pick applicants. Look at criteria #14 “Audition elective/rotation within your department“. This means that if you do an elective at a hospital, you have a better chance at matching at that hospital’s program.
Now that you have a list of all the residency programs that offer international students electives, you now need to rank this list. The first thing you need to do is rank it based on whether or not a program is IMG friendly or not. What you need to know is that there is no white and black when it comes to this point. No program is officially IMG-friendly and no program will officially announce that they will only accept graduates from American Medical Schools either. But how do we know if a program is IMG friendly or not? Every residency program has an “Our Residents” or “Meet the Residents” page on their website where they list the current residents. They list their names and what school they come from. To ease everyone, let’s consider that a program can be considered IMG-friendly if they have at least one resident who is an IMG (for those who will object to this rule, please bare with me for now). The ones who don’t have any IMG residents, we will consider them not IMG-friendly. A point to consider, a program this year may accept 4 IMGs and for the next 10 years not accept a single IMG. And another program may have never accepted any IMGs in its history but this year it decided to accept 3. Programs are very random and change based on the applicants they receive every year. Also if a program didn’t accept any IMGs this year, look to see the older residents (R2 and above) and see if any of them are IMGs. If at least one of them is an IMG, then this program has a history of being IMG friendly.
So now your list is divided based on whether the residency program is IMG friendly or not. Now for those who objected to my rule above, I will put you guys at rest. You now need to rank that list based on the percentage of IMGs in that program. So if a program has 1 IMG out of 10 residents, it has a 10% acceptance rate for IMGs. But if it has 3 out of 9, it has a 33% acceptance rate. So rank it based on percentage, with the more IMG friendly programs on the top and the less friendly near the bottom. These percentages will of course change from on a year to year basis, so always update them after every match. Again, don’t forget to look at the older residents. Maybe the IMG acceptance rate this year was low, but the overall IMG percentage throughout is high.
The next step is to further rank it based on other requirements. This is dependent on you. You may have a limited budget and some programs are too expensive. Most require Step 1 and if you don’t have it, those programs are unavailable to you until a time you complete the exam. The criteria on how to further rank your list is based on you, you set the criteria and how important each one is for you.
Now you have your completed elective list. The next step is just to plan when to go and apply early. Keep a checklist of what you need. Put a timeline of when you need to apply (check the application deadlines for each program) and when you need certain requirements. For the convenience of everyone, all programs require: medical checkup (more or less the same one you provide when you go to the hospitals in the 4th year), TOEFL score (has to be recent), transcript, proof of you being a medical student and medical malpractice insurance (a bunch of online insurance companies will provide this and most hospitals accept it). Some programs have additional requirements, like criminal background checks, letters of recommendations (go to any doctor you worked with and they can give you one), Step 1, Step 2CK, dean’s letter (go to Mr. Sharif and he’ll give you one from Prof. Khalid) and more. Stay organized and prioritize what you want.
A last piece of advice. The programs that you excluded that don’t offer electives to international students; go through them and see how IMG friendly they are. For some odd and peculiar reason, when I was doing this, the more IMG friendly a program was, the less likely it would offer international students electives. Why? I don’t know. But, if you found a program that was very IMG friendly and it doesn’t offer electives to international students, you could try emailing them and seeing if they would make an exception for you. It has a low chance of working, but the worst case scenario is them saying “no”. But if they say yes, it could be your ticket into that residency program.
This is only an overview of how you should pick your electives. This isn’t the only way, but I highly recommend you be thorough and to take your time. And remember, the more hard work you put into something, the better the results and always have faith in Allah (SWT).