Pursuing Medical/Surgical Residency in the U.S.: A Brief Overview

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Hi everyone! I am Nurul Itqiyah Hariadi (Nurul), currently a 2nd year Pediatric Infectious Diseases Fellow at the University of Michigan, Ann Arbor, Michigan. Prior to my current fellowship, I finished pediatric residency training at Children’s Hospital of Michigan (1st year) and UCLA Pediatric Residency Program (2nd and 3rd years). Martin kindly asked me to write about medical/surgical residency and fellowship in the U.S., which may be of interest for some of you. I will not discuss about medical school in the U.S., since I did my medical school in Indonesia, hence I have no experience about U.S. medical school system.

Since I don’t expect everybody to be interested in or well acquainted with medicine, I’ll try to be brief and clear. I think Q&A will serve this purpose the best. I’ll provide the link to helpful websites to find further information as we go along this discussion, and feel free to email me with questions.

First I’d like to clarify a few terms. Residency is a training program to be a specialist in a certain area (e.g. Internal Medicine, Surgery, Pediatrics, Ob-Gyn), while fellowship is a training program to be a subspecialist in one particular specialty following residency (e.g. Pediatric Hematology-Oncology, Pediatric Infectious Diseases, Pediatric Endocrinology).

Q: Why should I consider pursuing residency in the U.S.?

A: The answer can be different for each person. For me, I started considering it when I got married to my husband, who at that time was in the first year of his doctoral study in California. Since we knew it would probably take him several years to finish, we decided that I should try to do residency in the U.S. For others, it may be the interest of specializing or subspecializing in a specific field that has not been available in Indonesia.

One thing I can attest to, at least for pediatric residency, is that even though U.S. residency programs are not perfect by any means, I feel blessed that I have been given this opportunity. The learning experience that I’ve had so far in my former residency and current fellowship programs has been wonderful. They really put great emphasis on balancing resident/fellow education and clinical service in a very conducive learning environment.

Q: Can all international medical graduates pursue residency in the U.S.?

A: Yes, as long as the medical school you graduate from is listed in International Medical Education Directory (IMED).

Q: What are the steps of pursuing residency in the U.S.?

A: In a nutshell, the process to get into residency in the U.S. is as follows:

  • Apply to Educational Commission for Foreign Medical Graduates (ECFMG). You will get an eligibility period assigned to complete United States Medical Licensing Examination (USMLE)
  • Apply for USMLE
  • Pass USMLE Step 1, Step 2 CK (Clinical Knowledge), and Step 2 CS (Clinical Skills)
  • Obtain ECFMG certificate (by passing the USMLE tests above)
  • Apply for residency through a centralized system (National Resident Matching Program/NRMP): starting September each year
  • Interview for residency programs: October until February
  • Rank the residency programs you have been interviewed at: deadline in February
  • Match day: third Friday of March each year
  • Start residency: July 1st each year in most programs

Q: Where do I start if I am interested in pursuing residency in the U.S.?

A: The first two websites I’d suggest are Educational Commission for Foreign Medical Graduates (ECFMG) and United States Medical Licensing Examination (USMLE).

Q: Do I need specific immigration/visa status for residency in the U.S.?

A: If you are not a U.S. citizen or permanent resident (green card holder), you will be on J1 or H1B visa when you do your residency. If you prepare for the tests in Indonesia or other country, you will need a visitor visa when you take the Step 2 Clinical Skill exam or come for residency interviews.

However, if you prepare for the tests in the U.S., you can be on any types of visa at that time, as long as you maintain valid status of your visa. For example, I was on F2 visa (dependent of a student) when I was preparing for the tests since I came to the U.S. as my husband’s dependent.

There are advantages and disadvantages for each of these visa types. Considering the complexity of the this topic, it will be better explained in a separate discussion.

Q: How expensive is residency in the U.S.?

A: Residency programs in the U.S. do not charge the residents fee because they are funded programs, mostly by the government through Graduate Medical Education portion of Medicare, and partly by the hospitals/universities where the programs take place. Resident receives monthly or bi-weekly salary, which differs based on specialty, level of training, and geographical area.

Q: How long are residency programs in the U.S.?

A: The answer depends on the specialty. Most of the primary care specialties such as family medicine, pediatrics, internal medicine, general surgery, and obstetrics-gynecology have a 3-year residency program. Once you finish the residency training, you can go into practice or pursue further subspecialty training. To subspecialize, there are fellowship programs that vary in length. In pediatrics, for example, most subspecialties require 2-3 years of additional training.

Q: What tests do I need to pass to be able to apply to residency programs in the U.S.?

A: There are 3 tests that you need to pass to be able to apply to residency programs: USMLE Step 1, Step 2 CK, and Step 2 CS. Step 1 tests your knowledge in pre-clinical science (anatomy, physiology, pathology, etc.), and Step 2 CK (Clinical Knowledge) tests your knowledge in clinical science (internal medicine, pediatrics, surgery, etc.). As the name implies, Step 2 CS (Clinical Skill) tests your clinical skills, which include history taking, physical examination, communication, and most importantly, interpersonal relation using standardized patients. It also serves as an evaluation tool for your English.

Once you are in residency program, you also need to pass Step 3 in your first year, which is similar to Step 2 CK with addition of simulated cases. Some people take Step 3 before starting residency, which in my opinion is a smart decision because it takes a significant burden from your first year of residency, which undoubtedly will be very busy. In addition, passing Step 3 is needed if you want to apply for H1B visa. Information about each specific test can be found on USMLE website.

Q: What study options do I have to prepare for the tests?

A: You have several options, with their own advantages and disadvantages. First, you can always study on your own, although I recommend having USMLE targeted books to guide your studying. It has the advantage of being the least expensive. However, you need to be very consistent with your study schedule. Second, you can take online courses available from various sources, which may result in a considerable cost. Third, you can enroll in a course held by test preparation centers to intensively study for the USMLE, which is usually the most expensive option. However, it has the advantage of a set time limit to study, which will help to focus all your effort for the tests. I chose the third option, which I think was an investment worth every penny. On the other hand, I also have friends who did well by studying on their own, or by studying with someone who was enrolled in a course held by a test preparation center.

Explore your study style and financial resource, and choose the method that will suit you the most! If you decide to enroll in a course held by a test preparation center, Kaplan is one of the most well known for USMLE.

Q: How expensive are the tests?

A: Honestly speaking, USMLE tests are relatively expensive. For international medical graduates, the list of current fees can be seen at http://www.ecfmg.org/fees/index.html.

Q: What will I need to do after I pass the tests?

A: After you pass Step 1, 2 CK, and 2 CS, you will be ECFMG certified, which means that you will be able to apply to residency programs through NRMP (National Resident Matching Program). The residency programs you apply to will decide whether they want to invite you for interview based on your application package. Needless to say that higher USMLE scores open more doors. After the interviews, you will rank the programs you have interviewed at, and the programs will also rank the applicants they have interviewed. NRMP is the organization that “matches” the applicant’s rank order list with the programs’, which will result in a match.

Q: What else do I need for a good application package in addition to excellent USMLE scores?

A: You will need letter of recommendations, preferably with at least one of them from a U.S. physician or a globally renowned physician from Indonesia in the specialty you would like to pursue. To be able to obtain a letter of recommendation from a U.S. physician, you can go through various paths such as being a volunteer, an observer, or a researcher in a medical facility in the U.S. There are also opportunities to do an elective at limited U.S. teaching hospitals. There is a group on Facebook for Indonesian physicians in the U.S. (Indonesian Doctor Club in America) where you can ask for information regarding these opportunities.

You will also need a personal statement, which should be able to tell your story and why you are the perfect candidate for the program you apply to. I’ve noticed that writing a personal statement is difficult for a lot of Asian graduates since we are not taught to “brag” about our story.

These two topics, along with how to excel in residency interview, also deserve a separate in-depth discussion.

Q: Can I work in the U.S. after finishing residency?

A: The answer depends on your type of visa. If you are on J1 visa, you have to fulfill a 2-year home country requirement before you can return to the U.S.. If you are on H1B, you can directly work in the U.S. after finishing your residency. However, when you are on J1 visa, there are limited waiver opportunities that enable you to directly work in the U.S. without having to stay for 2 years in your home country. Again, since this question is related to immigration/visa requirement, this will be better addressed in a separate discussion.

Q: Can I work in Indonesia with the specialty degree I receive from the U.S.?

A: The short answer is yes, but you need to do a special adaptation program (between 6 months to 2 years) available at several universities in Indonesia. I have to admit that I don’t know enough about this issue. I will share the information once I obtain more of it.

Q: I am currently a medical student in Indonesia. When is the earliest time I can start preparing for residency in the U.S.?

A: You can start as soon as you finish the 2nd year of medical school to apply to ECFMG as you can see at http://www.ecfmg.org/2012ib/students.html. Although you may apply for and take the examinations after completing the basic medical science component of your medical school curriculum, it is recommended that you complete your core clinical clerkships, including actual patient contact, before taking Step 2 CK and Step 2 CS.

I am sure that you still have tons of questions. The links I mentioned above are useful to get started, but also feel free to email me at nurul.hariadi@gmail.com. I hope this small discussion is useful!

Photo by Mercy Health via flickr

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Nurul Hariadi
Nurul Itqiyah Hariadi is currently a fellow in Pediatric Infectious Diseases University of Michigan. She received her M.D. degree from Universitas Indonesia in 2004. Prior to her current training, she completed her residency at Children's Hospital of Michigan (2007-2008) and UCLA Pediatric Residency Program (2008-2010). She lives in Ann Arbor, Michigan, with her husband, a 6-year old daughter, and a baby son.
  • ms nurul hariadi may i know your email ?? please reply ms nurul.

  • Rahmadika Nofri

    mba…minta emailnya boleh?

    • Nurul

      Maaf benar2 terlewat. Email saya ada di paragraf terakhir artikel ini.

  • Pingback: The Anatomy of Residency in the U.S.()

  • Shubha

    Hi Ms.Dr.Nurul..ur post is very helpful.I Am Shubha.I hav completed my medical school in India (M.B.B.S) .I am now in USA on a F2 visa since Aug 2012…I am planning to take up step1 here in USA itself in October 2013. The order in which I appear to take up USMLE exam is as follows: step1, Step2 CK, CS 1.Can I take the step1 in USA on a f2 visa?
    2. Can I take Step 2 CK in US on F2 visa?
    3. Will Taking Step 1 and Step 2 CK on F2 visa in US, create problems when I apply for CS visa and J visa for Residency in US from India?
    How did u go about?where did u write ur step1 and step2?
    Kindly clarify these doubts as clearly as possible. Happy new yr 2013. Shubha

    • Nurul

      Hi Shubha, nice to know that this post can be a little helpful. As for your questions, I’ll try to answer them:

      1&2. Yes, you can. I was on F2.

      3. I didn’t have any problems, but I applied for CS from within the US. I believe it should be fine, but you can always email ECMFG to clarify.

      I took all my USMLE steps in the US while on F2 visa. If you can complete Step 1, 2CK, & 2CS while you are in the US on F2, I strongly recommend that. You may not need 10 months to prepare for Step 1, most people I know took 4-6 months each to prepare for Step 1 & Step 2 CK. Step 2 CS usually requires significantly less time to prepare, especially if you’re already very familiar with English.

      Hope this helps. & happy new year to you too!

    • Abhishek

      Hi Shubha, I was wondering if you get any information from ECMFG about “Will Taking Step 1 and Step 2 CK on F2 visa in US, create problems when I apply for CS visa and J visa for Residency in US from India? ” Thanks!

  • Ms.Nurul.. thanks before for your these useful articles, I have emailed you yesterday about some questions. Hope that you reply it. thank you..

    • Nurul

      Hi Adiraja, just sent you the reply, so sorry for the delay

  • francesmn@hotmail.com

    Hello Ms Nurul, Your site is very
    informative. Could you please answer my questions.

    My daughter has completed her medical school in India a month ago and is doing
    her 1 yr internship in India. She is a USA Green Card holder. But we don’t live
    in USA.

    She is planning to write all the USMLE exams in USA after her internship is
    done. You have mentioned that a Letter of Recommendation is required for
    applying to a Residency Program.

    Please clariy,

    – if she definitely needs to do the “Electives” in USA or any other
    place for that matter, to get a LOR?

    – Is doing “Electives” in USA compulsory?

    – Does she has to do the ‘Electives’ for a LOR ? Do all med students who apply
    for Residency programs in USA do “Electives”?

    I am wondering if she can skip doing Electives. Write the USMLE exams and apply
    for Residency. Will her Green card status help in any way compared to
    international student applying for the same.

    Please advise.

    Thank you. Frances MN

    • Nurul

      Hello,

      If the question is “definitely”, the answer is no. However, an LoR from a US physician usually carries more weight compared to those from non-US physicians, except if your daughter gets an LoR from an internationally/regionally well-known expert in particular field, even if he/she is not a US physician. Hope this helps!

  • Edwardus Setiawan

    halo dr.Nurul .
    sangat senang membaca post dari anda ini.
    Nama saya Edu, saya sedang koas semester akhir di RSHS bandung. Saya sangat berniat untuk sekolah di luar negeri untuk program residensi saya, yang mana saya tertarik untuk belajar Jantung (penyakit dalam)
    untuk saat ini, langkah apa yang sebaiknya saya persiapkan? bolehkah saya bertukar email dengan dr.Nurul ? terima kasih

    • Nurul

      Hai Edu, email saya ada di paragraf terakhir artikel ini. Silahkan kirim pertanyaan2-nya.

  • Leo

    halo dr.Nurul. maaf saya sebut
    nama saya dengan inisial saja. saya L, lulusan fkui juga.saat ini saya sedang belajar usmle utk mengincar residency di US.saya ingin menanyakan beberapa hal yang cukup spesifik via email.sy akan sangat berterimakasih bila dr.Nurul bisa membantu saya..trmksh byk sblmnya

  • pamamjit

    hello Dr my son is green card holder in us,he passed his U S M LE step 1in 2006 july. but due some problem he delay his step 2 till june 2011.he cleared step 2 and appeared ck in us three time oct 2011, april z012 again April 2013 always clear ed two parts and in one failed.,dr I am worried about him. Can he appear in next attempt? other option for mbbs indian student in us. thank you .

  • Fatima Baloch

    Hello Dr. Nurul

    I am a final year medical student who recently got her F-4 visa. There was no such circumstances to get the visa since last month and I had all the intention to take USMLE after I was done with my House Job in my home country.(Pakistan)

    Now that I have the Visa/Green Card I want to ask you the following two questions and I hope that you will reply to them.

    1. Should I do the House Job in my home country? Considering that it would help me in Clinical Skills step. I will get good exposure to the patients and get a little experience too.

    2. My relatives and friends in Pakistan think that I should take the exam in USA as it would benefit me. Whereas, my relatives in America think that I should take the exam in Pakistan since it would be lighter to my pocket. I am confused! Do I need to have my citizenship to get the benefits of an American in the USMLE, or, will the Green Card suffice? I am worried because citizenship would take 5 years.

    Please reply to my queries. I will be obliged.

    Thanks in advance.
    – Fatima

    • Nurul

      Hi Fatima,

      The answer to question number 1 depends on 2 things: 1. Whether the House Job is needed to officially obtain your medical degree. 2. Whether ECFMG requisites for all clerkship can be met without doing House Job.

      My personal preference for question number 2 is to save money as much as possible, so if you don’t need to be in the US for other reasons, you can just take the exams (with the exception of Step 2CS) in your home country. There is no benefit pertaining to citizenship/PR in USMLE, it will be beneficial for applying to residency programs as some programs will only take citizens/PRs. I’m not 100% sure, but I think just being a PR, and not necessarily a citizen, is already an advantage in applying to residency programs.

      Hope these help!

  • Sowmya

    hi Dr.nurul, i completed my mbbs from india…..but my question is …i failed twice in my medical school in my first & third years….. will it affect my residency ? will i be denied interviews ?? pllzzz let meknow…im already devastated…..

  • Jaismene Randhawa

    Hello Dr.Nurul
    Im presently doing my internship in India and planning to give my exam somewhere in march april next year. I just wanted to know, that irrespective of the usmle scores, do they prefer the students who have done electives over observship-or electives and observership has the same weightage?

  • Himadri Vakharia

    hi.. dr. nurul … my query is regarding the visa status.. i already have a b1/b2 visa. but can i do observership and or research on f2 (student visa dependent ) visa ? f2 visa can let me stay there as long as my spouse is on students visa n i dont have to come back to india n go back to usa again n again till i get matched… so till i get matched, is it better to stay on b1/b2 or as an f2?? pls reply.. major decisions rely on this answer.. thanks..

  • Ranganath Wijesinghe

    Hi Dr Nurul,

    Im a MBBS Dr from Sri Lanka.Your article is so helpful.Just like you,i’m planning to go to USA as a dependent of my wife. So I have to resign my job in Sri Lanka,because i’m not allowed to get no-pay leave yet. The problem is they are reluctant to give visa when i’m resigning. Did u have the similar problem? If so what did you do?

  • Hein Htut

    Hi your site is very helpful I want to match in a surgical residency program. I would like to ask what else I need to do to match . Please . Sice matching in a Surgical program as a IMG is too hard .