USMLE.EU

In this article, we would like to close the circle and provide guidance on the MATCH. The Match is a selection process managed by the National Resident Matching Program (NRMP). The Match is an answer to the question why the door to a residency, i.e. specialized clinical training for the doctors, is not automatically open to you, in spite of being a qualified U.S. graduate or international graduate holding the ECFMG Certificate (with or without the U.S. clinical electives, and/or research under the belt). The Match and the residency are the only pathway if you intend to directly capitalize on your hard work and pursue an unrestricted, unsupervised U.S. medical career.

The key problem is the mismatch that exists between the number of available training positions and the number of applicants. This problem has been around each year since the 1970s. In 2019, for instance, 6,869 International Medical Graduates (IMGs) submitted program choices, but only 4,028 of them (58.6%) matched to a first-year position.

Match application

The algorithm of the Match has been matching preferred applicants and recruiting programs from all over the USA and the world since 1952 and it is constantly developing by NRMP. Nowadays, the preferences are submitted in the form of rank order list (ROL) via the independent Electronic Residency Application Service, ERAS.

Where do I submit the application?

ERAS is yet another term that you need to become familiar with. ERAS, Electronic Residency Application Service, serves to facilitate communication between the programs and the applicants in a fair and transparent way. When the right time comes (typically in June prior to the Match year), you can pay for an ERAS token (around 130 USD), which will give you access to the ERAS interface, where all the participating programs are listed. Pro-tip: there is no deadline for the programs to get listed on ERAS, and it might be wise to re-check the participating programs throughout the Match until November to December, esp. if your goal is to apply for each and every program in a given specialty.

You should upload the required materials comprising your application in the ERAS website in cooperation with your medical school. ERAS then enables you to provide parts of your application of your choice to the programs of your choice. Each application is for an additional fee; for the submission of 100-200 applications within one specialty (e.g. internal medicine, pediatrics, or neurology, …), ERAS will charge you approximately 3,5000 to 6,000+ dollars.

Application package documents

One last problem before submitting your application to the program(s) of your dreams, lies in compiling the application itself. In its definitive form, it will be a file of about 20 pages. Expected components are the following:

1. ECFMG Certificate (this includes a diploma from Medical School outside of the US, and USMLE step 1 & step 2 scores)
2. Medical School Diploma
3. Transcript of Records
4. CV
5. Personal Statement (ideally, no more than 1 page A4)
6. Medical School Performance Evaluation (MSPE): 7 to 10 pages
7. Letters of recommendation/reference: preferentially from American attending physicians, programs usually require minimum of three letters

Generation of Medical Student Performance Evaluation, or certification of Medical school transcript may take weeks, depending on your medical school, so plan on June to July. Obtaining the letters of recommendation, the contents of which you are not supposed to know, plus polishing your personal statement, may take up to weeks or months. Try not to procrastinate and manage all the materials in advance of the start day of the Match.

The interview season

The Match opens around September 15, this is the first day when you can submit your applications to the programs. If a program leadership likes you, you can expect an invitation for a physical interview, which can take place anywhere between the end of September to early February. What are the most important parts of your application? As an IMG, your position is different from the AMGs, certain programs will likely not open your application at all. But do not worry, this only means that as an IMG you should apply more broadly than AMGs, there are still many places where you will be regarded as equal.

Factors that are most likely to be considered by the programs before granting an interview (without any guarantee and not necessarily in this order) are the following:

1. USMLE Scores + number of attempts (more than 1 attempt per Step is always a red flag)
   • Programs are likely to have an internal cut-off value for considering interview, scores are a potential first filter that can fail your application without any further considerations
   • Step 3 is not required, but it may be necessary if you would like to be sponsored for an H-1B visa
2. Outstanding
   • research publications (scientific paper in Science/Nature > poster on an international conference > research activity with no definitive outcome > lukewarm relationship to the evidence-based medicine > publicly promoting AntiVax + Creationism on you social media)
   • leadership skills (demonstrated by academic or extracurricular activities outside the medical school)
   • volunteering (global-health missions are a hot topic, but voluntary work for a local community also shows you have a warm heart, too)
3. (U.S.) Letters of Recommendation
4. MSPE
5. Personal Statement
6. Transcript of Records (grades + percentile)
7. Visa status

In-person interviews

Once you get the first offer for an interview, you will need to come to the U.S. in person and you will need to consider the expenses related to the accommodation, travelling, food, ... Your performance during the interview day may be the most important part of the selection process, your professionalism, spoken English, personality and fit into the program / team will be observed and evaluated.

Some AMGs recommend to have around 15,000 USD allocated for the whole process. The bright side is that you can use the interview period to explore many corners of the USA, from New York to Hawaii, to the less famous destinations, which nonetheless may have much to offer, whether you enjoy tropical temperatures, cross-country skiing, or have any other special interests. Depending on your fit to a program, places like central Kansas, northern Wisconsin or South Alabama may all very well take the first place on your list.

If you are not permanently situated in the USA during the interview period, going on with your life and taking just 2-3x brief time-offs for managing the interviews can be doable. Interview period ends in February, at which time you will need to rank all programs where you have interviewed and where you would like to pursue your residency training. This ranking does not happen via ERAS but on the NRMP website. Your list will most likely include no more than 10-20 programs, in which case, no additional fees apply. The final result is announced around March 15 and this decision is final and legally binding. If you do not get matched, you are allowed to try your luck and participate in the supplemental process called SOAP, where unfilled programs get matched with previously unmatched applicants, only after the SOAP is finished, are the both parties allowed to communicate about job contracts outside of the Match. “Pre-match” was historically offered, but in the Residency Match, it is currently not allowed (“all-in policy”), even though some exceptions may exist. Differentiate from the Fellowship Match, where pre-match is a common practice.

Visa

Finally, your visa status should be considered. If you are a U.S. citizen or permanent resident, it will make your life a little easier. Among the IMGs, the most common visas are the J-1 visas and H-1B visas. J-1 visas are generally speaking easier to get (sponsored by ECFMG), and among other things, J-1 visa allows your spouse the right to work in US under J-2 visas. On the other side, after the completion of training, J-1 holders are expected to return to their home country for 2 years or meet criteria for waiver of this requirement. To apply for an H-1B visas, you will need to have your Step 3 done at least 2-3 months before the start of the residency (again, the sooner, the better). The main benefit of the H-1B visa is that it enables you to streamline the application for a U.S. green card once you are done with the residency. The main disadvantage of H1b visa is that the H4 visa for dependents (spouse) does not allow them to work. Visas have various other aspects, it is advisable to consider all the details and seek legal advice or at least find a more official resource than this website. However, among other things, you should consider, if your spouse will be eligible for work when following you to the US, or what kinds of waivers exist, eg. the condition to leave the U.S. for your home country for at least 2 years if you were sponsored for J-1 visas by the ECFMG, etc.

All this might sound complicated, like a light at the end of the tunnel which turns into another tunnel. However, in this article, we intended to provide a general overview of what a medical graduate can expect between the Steps and the start of the residency; detailed definitions and legal advice are not included, and should be sought for elsewhere. However, it is good news that once you get the ERAS token, the sequence of the steps is quite straightforward and even though the American system can be quite bureaucratic at times, there is always assistance available and it is almost impossible to fail this process because of some minor slip or oversight. Now that you can give a name to all the steps awaiting you, we hope your anxiety reduced. Best of luck with your application!

Future changes to ECFMG certification

Based on announcement in 2019, beginning in 2023, ECFMG is going to limit ECFMG certification only to graduates of international medical schools that are accredited by World Federation for Medical Education.

Martin Caha, MD
Last edit: February 3, 2020