International Medical Graduate (August 2020)

This past cycle, 9% of the participants in the Ophthalmology Residency SF Match were International Medical Graduates (IMGs), who matched at a rate of 28% (for comparison, the rate was 85% for US Allopathic Seniors).  This is a statistic that I glanced over when the data was released, but admittedly have not given this group much consideration until recently.  I would like to share parts of an email conversation I had with one of those 72% of unmatched IMGs that has really opened my eyes.  I hope it does the same for you.

The italicized excerpts from this conversation are kept anonymous, but published with permission.

I very much enjoyed reading your blog on UK website, especially your article on how applicants are selected for interviews. I found your article very informative, systematic and transparent. At the same time, I found it thought/questions-provoking as a I reflected on my experience participating in the match cycle, for the 3rd time now. I am writing you this email hoping you would share with me your input on the special case of applicants who are international medical graduates (IMGs).

An International Medical Graduate (IMG) is defined as a physician that graduated from a medical school outside of the United States and Canada, including US citizens and permanent residents who complete medical school outside of the US and foreign nationals that enter the US for residency and fellowship training.  As of 2015, IMGs represent ¼ of all trainees and practicing physicians in the US.  The numbers in ophthalmology are noticeably lower:   5% of residents and 7% of practicing ophthalmologists.

Let me first briefly share my background; I earned my MD degree from [International University], moved to the US in 2016 and completed a 2-year master’s in clinical research at [Well Known US Academic Medical Center], followed by a prelim year at [Second Well Known US Academic Medical Center], and most recently, joined the [Third Well Known US Academic Medical Center] as an imaging research fellow. My USMLE step scores are: 256, 237 and Pass for step 1, step 2 CK and step 2 CS, respectively. I have letters of recommendations from mentors in the US who I worked closely with for 2+ years. I have 10+ publications/abstracts. I am on F1 student visa.

Prior to entry to the US, IMGs are carefully evaluated by the Educational Commission on Foreign Medical Graduates (ECFMG).   IMGs who are not either US citizens or permanent residents almost always complete their training on a J-1 visa, sponsored through the ECFMG at no cost to the training institution.  The vetting process sometimes can be delayed for multiple months pending security clearance, which can lead to delays in training and even loss of residency positions. The J1 program requires holders to return to their country of citizenship for at least 2 years after completion of training.  

A notable exception to this requirement is local, state and federal programs that allow IMGs to remain in the US if they work in an underserved community.  For example, the Conrad 30 federal program offers waivers to up to 35 IMGs per state per year, provided they commit to 3 years working in a medically underserved community.  Other programs include the Delta Regional Authority, Appalachian Regional Commission and Department of Veterans Affairs.

For this and other reasons, IMGs disproportionately work in rural and low-income urban communities compared to US medical graduates, serving as the primary source of healthcare access in these areas. Increasing federal immigration restrictions coupled with projected physician workforce shortfalls raise significant concerns about current and future healthcare opportunities in these vulnerable communities.

A final option for IMGs wishing to remain in the US after training is to apply for a hardship and persecution waiver, which requires “evidence that the applicant would be subjected to persecution on account of race, religion, or political opinion, on returning to the home country.”  The estimated processing time of this waiver is currently 11-14 months.

So, why do foreign graduates seek training in the US?  For many of the same reasons as the rest of us, such as financial opportunities, professional development afforded by our training system, and to improve career options.  There are others as well, including personal relationships that necessitate living in the US, or to seek asylum because of war, natural disasters, and persecution.  I’ll address some of the barriers these physicians face after arriving in the US in an upcoming post, but want to emphasize that there are refugee and international physicians currently living among us working as janitors, taxi or rideshare drivers, or in the hospitality industry, for example.  The under or unemployment of IMGs is all the more underscored by the estimated shortage of 52,000 primary care physicians in the US within the next five years, although the accuracy of all physician workforce data is limited.  Unlike other nations such as the United Kingdom, Sweden, and Turkey that have recognized the need for additional healthcare providers and the benefits of assisting IMGs with securing training positions and integrating into the healthcare system, the United States has been very slow to consider changes to its current process.

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Immigration is a polarizing and popular topic (always has been), and likely to play an even more prominent role in upcoming elections.  It is intimately tied to political and personal conversations and I cannot ignore it is in the background of this one.  I will mostly side-step this issue, but do want to end this blog post with a powerful poem and perspective written by the British, Somali poet Warsan Shire:

I hope by having this conversation with you I can share a unique perspective and, ultimately, contribute to improving the match process including for IMGs who can be strong applicants but face a different set of barriers.

The last post, opened up the topic of International Medical Graduates (IMGs) and a personal conversation I had with one that had yet to successfully match into ophthalmology.  I’d like to continue that thread today, highlighting some of the obstacles IMGs face in securing a training position.

As before, the italicized excerpts from this conversation are kept anonymous, but published with permission.

Reflecting on my last match experience; out of the 112 programs I applied to last year, I was offered only two interviews. Both from programs where I had connections. I find this surprising, especially after reading other applicants experiences online and comparing my application to theirs, and know how many invites they were offered.

According to NRMP data, only 5.6% of IMGs successfully matched in 2018 (versus 94.3% for US graduates). The odds are deflating, and the process costly – both in terms of time and finances.  It takes a IMG an average of three years to enter an ACGME residency program, with the following steps required to becoming an active physician: “confirm eligibility with ECFMG, obtain ECFMG certification (dependent on passing USMLE Step 1 and Step 2 examinations), obtain experience in the US health care system, apply for residency, complete residency, pass USMLE Step 3 examination, apply to state medical board for licensure, and finally receive license to practice medicine.”

Of course, each of these steps have fees.  As mentioned previously, it currently costs a IMG $4,500 just to sit for the USMLEs.  Additionally, like – and even more than – most other applicants, IMGs feel the need to apply broadly for residency positions: 

As I shopped for programs this match cycle, I ended up applying to almost all programs again. I applied broadly for three main reasons. First, the system incentives you to apply to more. Second, having had only two invites last year, I thought it would be unwise of me to apply for less. Third, I justified this to myself as a long-term investment and I am only losing money (me consoling myself for paying >$3,000 for the third time now just to apply to programs).”

Here are some of the other hurdles IMGs face:

 The visa sponsorship barrier – A few programs explicitly state that they don’t sponsor visas. Although I find it surprising that all of these programs have a “Non-discrimination Statement and Policy”, I totally respect the transparency regarding their visa policy.

According to the same 2018 NRMP data, the average USMLE Step 1 and 2 CK scores for matched US IMGs was 222 and 232, while it was 234 and 240 non-US IMGs, respectively.  This also suggests a bias over visa status.

Programs prestige and the IMG stigma – I was once told by a program director, who I approached after a panel discussion at the AAO, that he would love to have me for an interview, but went on to say he couldn’t, and this is because they have a unspoken policy against IMGs, as matching an IMG would make them look weak to other applicants. 

Internationals are a minority within the applicant pool for Ophthalmology – Unlike other specialties, like medicine for example, ophthalmology programs are not exposed to a large number of applications by IMGs, and therefore may not be used to reviewing it. I once got a rejection from an ophthalmology program I am interested in, and when I reached out, the feedback was they thought I consistently scored below average during my med school, which didn’t make sense. Turned out they read the passing scores on my med school transcript as my actual scores. Also, a GPA of 3.3/4 is not the same across every medical school across the world, and the concept of AOA or Gold Humanism award is not known to my med school, for example. So, comparing all applicants as apples to apples can be tricky.

The total number of IMGs participating in the ophthalmology match last year was 61, representing 9% of the applicant pool.  Within the NRMP, the Electronic Residency Application Service (ERAS) provides the option for programs to skip the Medical Student Performance Evaluations (MSPEs) of IMGs.

Flexibility is a double edge sword – Having my immediate family in [a foreign country] makes every state/city in the US equally attractive, and this gives me flexibility that not everyone has. At the same time, it makes it hard for me to make the case that I have strong ties to a specific city or location – which I feel programs value a lot and factor in the selection process. I try to be honest about this when I write a letter of interest to a program, but not sure how well that is perceived.

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The residency application process is time consuming, costly and nerve wracking for every applicant.  There are very valid reasons for certain groups to feel disenfranchised or particularly vulnerable in the process, such as those with borderline board scores, are from DO programs or lower tier institutions, ethnic and gender related disparities, and many others. These two posts are not an attempt to minimize those issues, but to highlight another group that is often (at least in my limited, personal experience) even further marginalized.  I don’t have an immediate remedy for any of this, but I hope that discussing it and providing the perspective of one applicant can raise awareness. 

I’ll finish with an update. This conversation and blog post started in the fall of 2019, well before the match cycle ended. I was so thrilled in January to receive an email from this individual stating they had matched into an ophthalmology residency position. Below are some of their parting thoughts:

I am happy, I am elated and I am excited for this new chapter, and the longer the wait the greater the reward. When the chair of the department congratulated me on the match day he said “It took a while but it was worth the wait”. I couldn’t agree more. I think anyone who matched would say the same, so I am not sure how much more I can add to that. I do, however, have something to say about my experience not matching in the previous cycles that is maybe worth sharing with others.

Everyone applying to ophthalmology match or any match in general has challenges to overcome, and in my case being an IMG was one challenge. The challenge may vary but I believe it’s the attitude toward a challenge rather than the challenge itself is what really matters. Working on developing mental toughness and adopting a growth mindset is what helped me shape my attitude not when I matched, but when I didn’t, and kept me motivated to purse my goals. These are a few of the strategies that helped me:

–        There is no one-size-fits-all:

I am fortunate to have many friends and mentors who I met along the way and were very generous to support me and share their experiences with me. For them, I am eternally grateful. But what has worked for them isn’t necessarily what has worked for me. For example, the year I matched I wore a blue suit (it looked darker before buying it in the store!) which was against the “match guide” rule of wearing a dark navy or a dark gray suit. However, I still matched. This is not to say that blue suits are a significant factor to match (maybe it was for me!), but this is to say that everyone has a unique story.

–        Breaking out of the victim mentality

My father, who is a lawyer in [international country], told me once “I don’t know much about the medical training in the US, or what it takes to match into ophthalmology, but one thing I know is that it’s a country influenced by capitalism. You should bring more to the table than what you expect to take”. His advice opened my eyes and helped me break out of the victim mentality of saying that the system is biased against IMGs (which is at least partially true), and find excitement in adopting an entrepreneurial approach.

–        The very basic rule: take care of your body.

Eat healthy, exercise and sleep well. The simplest, yet most effective strategy (whenever I could afford it).

–        Surround yourself with those who believe in you.

I can’t stress this enough. Supporters of success are not very common encounters so keep them close. This is not to say that people who constantly remind you how extremely hard matching into ophthalmology is are bad people, in fact they are realist who rely on facts. But it’s important not to let these constant reminders put you down.

–        Good things take time

This is not a sprint, but a marathon. After speaking to other inspiring IMGs who matched into ophthalmology before me, one common theme stands out; time. They all spent a couple of years working hard before matching, and that’s the plan I had in mind. Being patient and planning my short- and intermediate-term goals accordingly helped me a lot.

–        Time is a luxury

Being able to continue to pursue ophthalmology after not matching is a privilege not everyone can afford. Some people have loans or other circumstances that would make it impossible to pursue something for a long time. That said, I had to make sacrifices myself to be able to afford such luxury. So make sure to know what you want, and rearrange you priorities accordingly. Nonetheless, I acknowledge and feel grateful for the privilege of time. 

–        It’s about the journey not the destination. 

As cheesy as this may sound, it’s very true. Numbers don’t lie; some applicants won’t match. I could have been one myself. What helped me live with this possibility is changing the definition of success by instead of saying I am successful only if I match, I tried to say I am successful as long as I am continuing to improve, learn and have an impact. Roosevelt said it better: “Do what you can, with what you havewhere you are”. At the end of the day, life is larger than a residency position. Although this is maybe obvious to others, I found myself too involved and had to remind myself of this from time to time.

–        At the end, it’s all about the people.

As my program director told me after the match; beyond the USMLE scores, the letters, the publications and what not, it goes down to connecting as a human. The reason why I chose ophthalmology in the first place, and the reason why I ranked my matched program as my top choice is the people. These are people I look up to and people I enjoy working along with.