Pursuing Medical/Surgical Residency in the U.S.: A Brief Overview
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 firstname.lastname@example.org. I hope this small discussion is useful!
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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.