The USA Dream for IMGs: Coming to an end? Analysing the 2012 Match

My attention was drawn to an article in the JAMA today (1) by one of my friends who is actively pursuing the USMLE route. And after reading this, I guess I have to admit that one now has to make haste in order to prevent waste. Now I have long been wanting to write about this but somehow never came around to do it. Finally, having read this article today, I decided to give it a go. Now this is entirely my perspective on last year’s match and it may be entirely off-base. So do not put too much of thought into this. This year several of my friends are appearing for the match and I wish them the very best of luck. Also, this post is intended to be a wake up call for those who have been sitting on their dates, trying to do that extra bit to eke out an exceptional score. it is time to take the plunge!

ResearchBlogging.orgLet us start with some number crunching first – get the boring stuff out of the way before the real horror movie starts. No, just kidding… The number of students applying for residency in the US programs has increased in leaps and bounds, as the NRMP report shows in this trend-chart dating back to 1952 (2):

image

The Match system changed a bit in 1975 when the internship was retired and PGY-1 positions were offered as residency slots directly. It was also around that time, that the total number of applicants began to rival the number of positions available. Kind of makes me wonder what a paradise it is where one does not have to scramble for the seats… But let us come back to reality. In the 2012 match, a record number of PGY-1 positions were offered: 24,034, but to counter that, a record number of applicants also dropped their names into the hat: 38,377! However, this still looks like a fair competition when compared to the Indian scenario, where the approximately 7,000 residency slots are fought over by as many as 70,000 to 80,000 people – these are just anecdotal numbers generated in retrospect of my experience of “matching” in the Indian system last year but I am sure the numbers will be worse (looking from the student perspective), and not any better. I am not including the DNB or private colleges or the non-MD seats (diploma and other 2-year training courses) in this reckoning.

Coming to the non-US IMGs segment, which most of the Indian applicants belong to, let us take a look at the favored specialties which drew people:

image

A total of 2,775 non-US IMGs were offered residency slots in the PGY-1 programs and an additional 155 for PGY-2, bringing the grand total of the matched IMGs to 2,930. Here’s the whole break up for the PGY-1 slots:

Subjects Non-US IMGs
Anesthesiology 31
Child Neurology 11
Dermatology 1
Emergency Medicine 25
Emergency Med – Family Med 0
Family Medicine 347
Family Med – Preventive Med 2
Internal Medicine (Categorical) 1239
Medicine – Dermatology 0
Medicine – Emergency Med 2
Medicine – Family Med 1
Medicine – Medical Genetics 0
Medicine – Neurology 0
Medicine – Pediatrics 14
Medicine – Prelim PGY1 only 114
Medicine – Preventive Med 0
Medicine – Primary 57
Medicine – Psychiatry 4
Neurodevelopmental Disabilities 0
Neurological Surgery 13
Neurology 67
Obstetrics-Gynecology 72
Orthoepedics 6
ENT 0
Pathology 96
Pediatrics  categorical 242
Pediatrics – Anesthesiology 0
Pediatrics – Emergency Med 0
Pediatrics  – Medical Genetics 2
Pediatrics – PMR 0
Pediatrics – Prelims 3
Pediatrics – primary 21
Peds/Psych/Child Psych 0
PMR 4
Plastic Surgery Integrated 0
Preventive Medicine 0
Psychiatry Categorical 137
Psychiatry – Family Med 0
Psychiatry – Neurology 0
Radiation Oncology 0
Radiology Diagnostic 11
Surgery Categorical 57
Surgery Prelim PGY1 only 143
Thoracic Surgery 0
Transitional PGY1 only 51
Vascular Surgery 2
Total 2775

Now let us take a look at the past few years for the IMGs and how they have fared:

image

image

and this is in sharp contrast with the seniors of the US allopathic schools:

image

Or even the overall picture which is much rosier than it is for the average Indian graduate:image

The same sentiment is shown in the trends of the match rates as well:

image

What I find interesting in this graph is the fact that while the success rates for the US Seniors has remained monotonously high (as it should be), the rates for the Non-US IMGs is dropping. With the proposed expansion of uptake of more graduate students to combat the predicted shortfall of doctors, this will get even worse, but more on that later. The other trends, namely, the US IMGs and Osteopathic and non-traditional applicants, has remained steady and shows minute upstroke of late.

Taking a look at the raw numbers confirms my fear that as more and more IMGs apply, the lesser and lesser likelier they are to match:


2003 55.7%
2004 52.4%
2005 55.6%
2006 48.9%
2007 45.5%
2008 42.4%
2009 41.6%
2010 39.8%
2011 40.9%
2012 40.6%

With these in mind let us look at what it means for people coming up ahead.

The prediction is that in 2015, the number of US-trained medical graduates will outstrip the number of residency slots up for grabs. Now that means 2015 becomes the watershed year for the IMGs, especially the non-US ones. Although some amount of the American Graduates are not going to be able to match for different reasons, that shall be the only slots available for the iMGs, since it is reasonable to believe that the system shall favor the AMGs who have come through it. And to be honest, that is exactly how it should work.

Now it would mean several things for the students overseas. It shall obviously lessen the issue of brain drain. Anecdotes go that entire batches of a certain medical college have relocated to the US post-USMLE. While that does add to the sheen of the prospects for the students of that particular institute, I believe, and bite me for saying so, it does the nation no good. Now I am not about to propose laws and rules to hold people back, nay, if anything I oppose such acts of delusional grandiosity, for people shall do what they want to, but at the same time, I believe it is a gross waste of national resources when the bulk of students from one of the best training institutes shift to the US. And take with them their expertise which could have otherwise served the nation. But that is another issue. Clearly, once the AMGs outstrip the residency slots available, the contest for seats will be vicious.

What I am wondering is that whether it shall spawn the evil of MD-love that is rampant in India. Here, at least after your MBBS, you are licensed to practice Medicine. But in the US, where the ticket to Residency is essential to make a living as a doctor, this might be a bit of a problem. A certain segment of the graduates may, after their training, move into the non-traditional routes – the pharmaceutical industry, pure research or some other forms – an option that is rapidly gaining popularity in India where MBBS graduates who are toiling for an MD-ticket get disillusioned by the unfairness of the system and jump the ship on a clinical career. It shall be interesting to see what transpires for the AMGs when the graduating students are more than the PGY1 slots offered.

The other concern is that with graduate education spending cuts coming in, the residency seats may actually shrink in the years to come. If that happens, the already decreasing number of seats shall be even more inaccessible for the IMGs. The European Union and Australasia has largely become inaccessible (the EU more so than down under, probably) to the average Indian graduate, but even with the US being cut out, the pressure on the already over-burdened PG-entrance system will become worse.

The US boasts of a rare balance of professionals of different nationalities representing its medical force. The cultural, ethnic and national diversity of the US physician corpus is probably wider than that of any other country. While that is a good thing in an age of globalization, it does not essentially mean great future for the AMGs themselves. Hence, when the AMGs outstrip the available slots, I am sure there shall be some sort of an unwritten rule to favor an AMG when one is available for a particular program, ahead of IMGs. And that is the logical thing to do as well. I mean it is senseless to burden them with $200,000 worth of student loans, decimate their social lives, often break up families, and then leave them high and dry. This would essentially mean that poorer AMGs would be selected ahead of more competent IMGs just because they were there and they applied. While the quality control and training in the US is supposed to be fool proof, yet, a compromise on quality is never good in the long run. Attend some of the peripheral government hospitals in India, and you shall know what I am talking about.

Another thing remains: the choice of specialties. The AMGs, who have an AMG:PGY1 slot ratio of 1.45 (an all time high considering the numbers from the recent past, by the way) this year, have the luxury of looking down on Primary care or Family Medicine or Pediatrics and the like – basically the specialties with the least pay, the most work and the worst of administrative handling. They are also loathe to work in the difficult areas, poorer areas, places with lesser medical services (where workload is thus higher) and the rural counties.(3) The IMGs also represent a healthy amount of the physicians in the primary care/public sector, as they twice as likely as the AMGs to take up these jobs, where they have to work longer hours, in areas which are medically underserved and hence bring them lesser money.(4) When the ratio falls below 1, and the scramble for PGY1 slots gets worse, it shall be interesting to see whether AMGs still maintain this haughty attitude towards the specialties with lesser pay and instead of waiting for a big fish settle for the smaller ones. This trend has already emerged in India where the seat crunch is severe and where the MBBS is more or less a vestigial degree. This could lead to quicker professional burn out and higher dissatisfaction, leading to poorer dissemination of services.

Rounding it off:

So what does all of this mean for you, the Indian/ International Medical Graduate? This is what I reckon, is the distilled wisdom from all this chattering:

1. Get started on those steps quickly and try for a match before 2015. Preferably for 2014, just in case something goes wrong!

2. The scores shall become important. Though they are not meant to be a screening factor, what does a Program Director do when he is faced with a deluge of international graduates with similar levels of training from a non-accredited system?

3. Being in a medical school that has premier visibility in the International community might be of help (if it is not already). We all know which Delhi and Chandigarh based medical institutes I am talking of!

4. Having a killer CV. This has always been important, but probably never more so than now.

5. Doing the rounds – the clerkships and observerships are time to build the rapport. Make the connections. Ensure that at least the Institute where you have clerked at least gives you a call up.

6. Have a plan B. Buy Mudit Khanna-Amit/Ashish or whoever is most popular in the business of giving the keys that open the doors to the Bipolar system of Indian PG selection.

References:

ResearchBlogging.org1. Traverso G, & McMahon GT (2012). Residency training and international medical graduates: coming to America no more. JAMA : the journal of the American Medical Association, 308 (21), 2193-4 PMID: 23212494

2. Results and Data: 2012 Main residency match. NRMP

3. Mick SS, Lee SY, Wodchis WP. Variations in geographical distribution of foreign and domestically trained physicians in the United States: “safety nets” or “surplus exacerbation?” Soc Sci Med. 2000;50(2):185-202.

4. AMA-IMG Section Governing Council. International Medical Graduates in American Medicine: Contemporary Challenges and Opportunities. 2010. http://www.ama-assn.org/resources/doc/img/img-workforce-paper.pdf.

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80 thoughts on “The USA Dream for IMGs: Coming to an end? Analysing the 2012 Match

  1. Very Interesting post and pretty accurate as well…However another trend the figures don’t reflect is the steady rise of Carrib IMGs…who are US citizens going to Carrib schools. They basically do their rotations in some US hospital but are affiliated to Carrib schools…Now they are considered IMGs but being US IMGs and having no visa issues are preferred over the conventional non US IMG. So though the overall match % of IMGs may remain consistent, the demographics are steadily changing… Also there’s been an increase in number of .O.s and also the preference of programs to opt for more and more D.O.s (some govt. directive or sort am not sure)… So it’s not merely a rise of AMGs that’s making it more and more difficult for the non US IMGs.

    • Thanks for dropping by to read this and leaving your comment on it. As someone who is actively going through the process of USMLE, I guess you shall be better equipped to speak of such issues as the Carib grads, which do not find any place in the official records.

  2. Yikes! This information is very ominous since I will be graduating in 2017. In 2015, the ACGME, in addition to other changes, will absorb D.O. residencies. There may thus be a small increase in ACGME residencies available, which may push the residency funding issue back a couple of years (I hope) and make more slots available for everyone.

    You hit a lot of good points. Personally, I can tell you that student debt is crushing, especially for students like myself who had to fund their own undergraduate degree on top of medical school. Total cost of education is closer to $300,000-$350,000. If more residencies aren’t made, med students will begin defaulting on loans. Who will want to go into medicine then? Only the rich. Folks who can afford education these days.

    • Anton, thanks so much for giving some further insight into the matter. As I have admitted at the very outset, this is more of a personal opinion than anything else. I also think that if Obamacare was to take off well and truly, then there would be a lot more focus on primary care, which has traditionally not been a specialty of choice for AMGs. So, it would be interesting to see how AMGs respond to that. But what I am wondering is, what with inflation and all, if the USA cannot bring down the costs of studying medicine, how many people are going to keep at it. $350,000 is way too much debt to take up while starting your life and career (which anyways starts later than any other profession). The costs of education needs to be reduced if the real problem of shortage of physicians is to be addressed. No one will be going into Primary Care of Pediatrics with a load of $300,000 on their shoulders. They will always prefer the higher paying branches,

      Anyways, I await the 2013 match reports with much interest.

    • Exactly! The debt is still manageable, and the career is still profitable from a financial standpoint. Like everything else in the US these days, this issue with student debt will get solved right when we reach the tipping point (at the very last minute) before complete and utter disaster.

      I’ve always said this, and I will continue to. If medical student debt was eliminated, there wouldn’t be a shortage of primary care docs. Maybe this is too simplistic of a solution, but debt has a LOT to do with what field people choose to pursue.

      If it’s your year to match, good luck!

    • Well, I am not even in line for the USMLE race. Some of my best friends are, though, which is my primary concern in tracking the progress of the fates of the IMGs in the system. :-)

  3. Wonderful take on the current system in the US. No denial that the worst days are yet to come. I am sure in a country where every guy is entrusted with the dreams of becoming a doctor right when he is a neonate,by his parents….India should resort to better career options too. There is a very famous idiom in Hindu ‘ Door ke dhol suhawne ‘ Which means (it looks good from faraway) Our medical profession is like that to. People think becoming a doctor is like having a cruise ticket,who will tell them that how far they actually are from reality..

    • AH, aren’t you being a little too negative now? Yes there are difficult days, and sometimes we want to quit and just be like those tech guys who branched out after our +2 days… but honestly, would you rather be doing anything else? Dunno about you, but I would not! :-)

  4. Wonderful take on the current system in the US. No denial that the worst days are yet to come. I am sure in a country where every guy is entrusted with the dreams of becoming a doctor right when he is a neonate,by his parents….India should resort to better career options too. There is a very famous idiom in Hindu ‘ Door ke dhol suhawne ‘ Which means (it looks good from faraway) Our medical profession is like that to. People think becoming a doctor is like having a cruise ticket,who will tell them that how far they actually are from reality.

  5. Stupid Indian strikes again….
    I have always found hilarious about how people who are not working with us in US as doctors comment on US medical system which is undoubtedly the best.

    • Are you a doctor??? I seriously doubt it coz I haven’t seen such a pathetic one before!! Never have I seen a person attached with a medical profession be so rude, arrogant,opinionated and the one who jumps to hasty conclusion! I think you are more of a racist coz and you are here just for the sake of interfering with good. If you still know how to read,then I suggest you should probably READ the Post before publicly showing off how much of a dolt you actually are. Racists like you are the ones who bring bad name for your country. We all know US has a great medical system but I never has Racists like you too….shame on you -Racist!!!

  6. Are you a doctor??? I seriously doubt it coz I haven’t seen such a pathetic one before!! Never have I seen a person attached with a medical profession be so rude, arrogant,opinionated and the one who jumps to hasty conclusions! I think you are more of a racist and you are here just for the sake of interfering with good work. If you still know how to read,then I suggest you should probably READ the Post before publicly showing off how much of a dolt you actually are. Racists like you are the ones who bring bad name for your country. We all know US has a great medical system but I never knew,it has Racists like you too….shame on you -Racist

  7. Pingback: USMLE 2013 and IMGs: All That Glitters is NOT Gold | Scepticemia

  8. As am IMG graduate of St. Matthews and US citizen who cannot get into any residency anywhere, thank you for writing this article. I am $250,000 in debt with no chance ever of being able to pay that off. My life is financially over before it ever begun. If you are reading this and think you’ll be able to land a residency after attending one of these schools, you are delusional. Stop now, get out, do something else.

    • Marie, do not give up hope so easily. Becoming a doctor is a dream, a passion. Stay on the track and I am sure success shall follow. All the best. I hope things work out…

  9. I graduated from King Edward Medical University, which is considered the best in Punjab (Pakistani Punjab). Believe me getting in is NOT easy. After my house job, I was offered a job at the Punjab Institute of Cardiology. I left all that to come to US but could not match. With the exponential increase in the number of IMGs, the rapid rise in the number of MD and DO seats in the US, it is getting next to impossible. I spent close to US $18000, wasted 2 years but to no good. I am returning this year and am sure will be ridiculed by my relatives who will simply blame me for not being ‘intelligent’ enough to make it into US. But the saddest truth? Try telling all this to a medical student in Pakistan and he/she will paint you as a complete moron!
    I know I thought my seniors were not good enough when they returned after 3-4 years to start a house job. I love this profession and do not regret choosing medicine but the expectations from relatives (in my case) is simply devastating!
    I will return only to face shame. I lost the job offer. I lost money. I lost time. My fiance of 5 years almost left me and it was very hard convincing her to stay. Sad! Sad! Sad! :-(

    • One of my most favorite sayings is by a Physicist, and not a Physician. Richard Feynman. He (rather his wife) used to say: What do you care what other people think? Your life is YOUR life, man. The US dream is hard to achieve and is getting harder with every passing year. You have been through a hell of an ordeal and I feel for you. All I can say is that keep the faith in your abilities and surely something or the other shall work out. Life finds a way.

  10. What if you are an international graduate but you are an American citizen and you intend to take USMLE in USA?

    • Well, then you have a marginally better chance, since you shall be able to apply to a lot of places which have stringent or stingy visa policies (or none at all). However, for all practical purposes, you shall be regarded as an IMG, though you do have the theoretical advantage of being a citizen. So, all said and done, you’re probably not as well placed as the American grads, but not so damned as the other IMGs.

  11. hey hi

    ill b finishing my internship from mumbai in jan 2015..
    so if i apply for match in 2016
    will it b more difficult as compared to 2015
    i mean is it dt ONLY the year 2015 is gna be difficult or every year following 2015 also
    waiting ur reply
    thnx

  12. Have just scanned the thread.
    For me it raises the fundamental concern of medical education, subsequent training and opportunities in India. Despite this degree of brain drain and perceived anxiety as the competition abroad is getting tougher, we have singularly failed not only to adapt our training systems to “Fit for Purpose” but also to give young doctors the much needed motivation, incentives and environment to practice in India.
    ‘When there is a will there is a way.’
    Some questions remain: Do we have a will? If yes, let us work together. If not, How can we create collective will?

    • You raise a more fundamental, a more philosophical, and for the policy makers, a very uncomfortable question. Brilliant students enter medical schools all over the nation, not with their eyes on lucre but primarily with a naive desire to be of help, to be a productive member of society, to join a professional fraternity that has enjoyed a social privilege through the ages because of their ability to heal, to take away the pain. However, as med school wears on, these very people transform into calculating, cynical skeptics who want to ensure that their own careers and lives are managed. The problem is much more deep rooted than just the medical school curricula. It is social pathology, a cultural illness that we need to address; and right now, through denial, we’re just making it worse.

  13. Pingback: FY 2014 Budget: Did the US Govt Make USMLE Tougher for IMGs? | Scepticemia

  14. Hi Pranab,

    Great article. I wanted to touch on your ’rounding it off’ #2 regarding scores.. The scores are in fact meant to be a cut-off factor for programs, and are becoming increasingly important, as you mentioned, in gaining residency interviews. A good portion of residency programs will not even consider someone with scores below a certain cut-off, all of whom have different criteria based on a variety of factors. For example, highly sought after University programs will usually not even consider a candidate with scores below 200 (for Family medicine), or 220 (For Internal medicine), and often much higher for tougher specialty programs, while Rural Primary Care programs often have lower score criteria.

    It is unfortunate that this is the case, because there are many very strong candidates who for some reason or another, didn’t score well on the Step 1. But this is just how it goes with the increasing number of applicants on a yearly basis.

    Thank you for such an informative article, definitely loaded with lots of important information that will hopefully help future students consider whether the IMG route is the right choice for them. And although it is becoming increasingly difficult, I hope that anybody who has the dream of becoming a practicing physician in the US will not let the negatives deter them from trying.

    All the best.

    • Paul,
      Thanks for reading the article and taking out time to respond. I went through your USMLE website and it looks great… I downloaded your ebooks as well. :)

      As for the cut-offs, the theoretical cut-off maybe 220 or 200, but practically, they are much higher, and even higher for the IMGs. I maybe wrong when I say this, but from what I understand of the philosophy of the USMLE, the USMLE step scores are not supposed to be used for comparison of the applicants with one another. It is a measure of each individual’s ability to write the exam. With that in mind, programs set a basic quality control sort of screen, like 200/220 as you mentioned.

      However, that is not the sole criteria. Or even the main one. I have seen applicants with scores of 250+ being not even called to interview in Internal Medicine and Paediatrics programs. The scores are a double edged sword, especially for the IMGs. You get a poor score, and you’re out of reckoning… but a good score (sometimes even a GREAT score) does not ensure even being called up for an interview.

      Cheers!

    • I wish I could tell you! There are many factors at play when people are asking you to an interview. Your CV, your scores, the statement of purpose and whether your views about your career is in sync with the philosophy of the place you’ve applied to, human judgment (or misjudgment, depending on your point of view)… Only the people in the ivory tower can tell you what exactly is the reason! But one thing that we can say with certainty is that the score is not the ONLY criterion for picking people. The algorithm is unknown and since I have not been in the system, for me, unpredictable. One can only cover the bases and hope for the best!

    • I believe I can probably answer Akshay’s question, I am very familiar with the system. Having a really good score is essential to meet a program’s minimum requirements and get the rest of their application looked at by the people who make the decisions. Without a score that meets the programs ‘minimum requirement’, your application is going in the trash, plain and simple. For the person with a 250 on Step 1, their applications are being looked at by every program they apply to, that is almost certain. There are many factors beyond that which may not get them interviews. These days, having zero US clinical experience is a big turn off for programs, and is often a very big reason why students aren’t invited for interviews. Having a poorly written personal statement as well, because although great scores are required, if a person’s motivation for applying aren’t in line with the program or their English is poor, etc, etc, they likely won’t be invited, simply because there are so many people who have good scores and are genuinely interested in the program – and programs can often decipher between the two. Another killer is less-than-stellar clinical grades, which indicates a variety of potential flaws with the candidate, from irresponsibility to laziness, to many others. There are so many students with top scores, that it is necessary to also have a well-rounded application, and anything that raises a red flag is likely to disqualify a student from being invited for an interview.

      Just to keep in mind, I do not know the person whom we are talking about here, but from my experience in dealing with students over the years, these are likely reasons why someone with outstanding board scores would not even be invited for an interview.

      Hope that helps.

    • I believe that sounds about right. Also, I would wager that no American grad who’s cracked 250 on the steps will be ever rejected a residency position of their choice. This problem afflicts the IMGs solely.

  15. hi pranab. Awesome article. I graduated in 2012 and residency in the U.S has always been the dream.But i somehow managed to convince myself, due to the enormous time and money spent on it(given my economical condition)that i’m not cut out for it right away,and i’d planned to give steps after joining in PG in India. But when i care to stop and listen to myself,my insides are screaming at me saying this is not what i want to do. And moreover i recently came to know that getting a fellowship over there after graduation is like 20 times tougher!So here i am once again over the internet searching for more info about the USMLE for IMGs. As your posts say,is it really depressingly competitive to get into a residency program of IM or Psych? Would it be easier for girls,like you know,we could marry a guy from there(ofcourse as we’d be settling there) Will that kinda thicken my chances of getting into residency? I’ve a decision to make,that too in a short time,will you kindly help?

    • Thanks for the kind words Shruthi. All I can say is that if you have a dream, chase it. You may end up wasting some time and money, yet it is better having tried and failed (mainly for reasons beyond your control), than not having tried at all. And the “what if?” question will not come back to haunt you!

  16. Hello Pranab!!! Great work with the blog! Really!! I wished, I had found it earlier. !!! At present M preparing for the steps also applying for the electives too …To better explain my situation I mention that I have been dreaming of residency in US since long ,, but recently I have been criticized by my seniors and friends for pursuing this as a career, saying that efforts which I’ll put won’t be worth for me ,,as due some reasons, i plan to RETURN back to India soon after getting residency &/ fellowships ( or will work there for some years after being board certified). I was told that on returning back, when it’s time to earn handsome there in US, I would be earing just marginally more compared to the efforts and money I put for the match Vs. my INDIAN PG COUNTERPARTS … !! M confused, and feel demotivated with my plans due to all this. Please help as I don’t wish to spend some more time thinking about all this as I have already done before. Is it that the difference between the US returned fellow’s won’t be that significant compared to indian counterparts (Apart from the getting a World Class qualifications). I wished to know somewhat the exact figures to get this elucidated soon, so that I get VALUE TO THE EFFORTS that I put into this. Can u please throw light on the job scenario for those doctors who wish to return to India??! Awaiting reply soon!! ? Help!! :(

    • If you are looking for money-making career-advice, I am the WORST guy to ask. I write articles on a blog that I pay to maintain and give away stuff for free. I cannot be counted upon for money-related advice. But in any case, I think if you chose Medicine for the money, you are in the wrong profession; you should try and win (or rig) an election. Way better prospects there.

      If it is the USMLE that you have dreamed of pursuing, then, on no account, back down. At least give it your best shot. If it works out, well and good, if not, then at least you shall not have to live with the regret of “what if I had tried”? :-)

      I know this decision can be such a killer. Do not spend too much time making the right decision. Make the decision, Then stick to it.

      All the best!

  17. hi,pranab,
    i persuing ms surgery here in mumbai,in third year now,will complete it in 2014.i want to prepare for mle,want residency there ,in surgery,but i know its quite difficult thing,but still i want to be there for residency,if not surgery then IM,is it additional factor that having completed ms or md here in india,or how it is helpful for me to get residency there ,and other question do age matters there in interview,//?

    • Age is but a number. I know a lot of older grads (albeit American ones) who have got into Medicine after a career in some other subject. One thing I would like to say is that, I think, with Affordable Care Act coming in, more and more AMGs will now opt for Internal Medicine as it will become more financially rewarding if the system gets rewired. I would say that you would have a fair chance of hitting Surgery residency there as well!

      I hear that having an MD helps, but how much, I cannot say, Increasing age is perceived to be a negative factor, but, I must say that it should not be an insurmountable one.

      And at the end of the day, remember that ALL I say might be wrong; for all you know I am a sheep herder pretending to be a medical blogger to while my time away as my flocks graze.

      Cheerios!

  18. dude do you mean that it is near impossible for immigrants to practice medicine in the US after 2015??
    I will be completing MBBS by December 2015… what are my chances??
    I’m only an above average student , with around 65-70 % in 1st and 2nd MBBS…
    What are the chances of getting residencies of other countries like Australia, UK etc??
    are those bleak too??
    am waiting for your reply dude… pls reply…

    • Max,
      It is just going to get more difficult to crack the USMLE and match through to residency programs as the pressure of the AMGs increases. And 65-70% is very good as MBBS Exam scores, man! And it really does not matter how good/bad you are at the Indian exam system as the USMLE is a different ball game altogether! As for the other countries, well, UK is a bit saturated; more and more graduates are looking at Australia and NZ. But they come with their own retinue of issues!

      All the best!

  19. Notice that the news came in the same time with obamacare. Why is that? US will need cheap doctors and who is it? The desperate ones! If the number of graduates will outnumber residency positions desperate-to-work-anywhere will appear. Doctors who will work for little money hoping to match the following year. Its called the primary care in european union and is exactly what obamacare is heading to. So dont worry, america will need imgs. Will it still be that american dream we allve heard about?

    • Considering that doctors do get paid decently, that would not be as bad a proposition. But yeah, I can see why American grads would not want to pursue it again. And the problem that you speak of has already taken place in India. People will go anywhere to get to do a residency in a discipline of their choice. If not, then they will beg, borrow or steal to buy a seat in one of the private universities… believe me, everyone wants those two letters to suffix their names!

  20. Hello pranab,
    that’s a hell lot of information I received within an hour, and it’s really gotten me going again and again in my head as to what should I really do.
    I have just completed my second MBBS and have hopes of pursuing my career abroad either in the US or Australia.
    (you may think its quite early for me to ask, but still i would like to know)
    But all this discussion has put me in a fix as to what I should decide for myself.
    My family hopes to see me abroad and I also wish for the same, but somewhere in my mind I am afraid as to what may happen if I end up losing my time and money.
    Cut throat competition here has made getting a PG seat just a matter of luck.
    I would like to have your views about it.

    • Muna,
      Sorry for the late reply! It is never too early to start dreaming, believing! So kudos to you on having a dream. You are on the way to the future! Cut-throat competition in India is still acceptable seeing how you can “match” to any of the seats provided you manage a good rank in an extremely skewed exam system. However, if the US increases med school seats to such an extent that there are not enough residencies to go around, then, for obvious reasons, they will be taking the AMGs first, then concentrating on the IMGs for seats that might be left over. So, it is a difficult call.

      However, if you have a dream, go chase it. Don’t listen to neurotic bloggers. For all you know they might be yak herders whiling their time away in the lonely pastures of Tibet.

      Cheers!

  21. Hi Pranab,

    With USMLE aspirations, I wrote my step 1 examinations, but the scores were not convincing enough. Now, I’m not ready to waste 1 more year in taking up the Step1 again, and the step2 and 3 and then wait for the matching. I planned to look for alternate options available in USA for MBBS graduates.

    Thought you might help me on this. Please let me know the alternate options available for MBBS graduates in US. As of I searched, I was able to find the non-clinical courses like MS-Bio Tech, MS- Micro Biology, MS – Pharmacology etc. Which of the non-clinical departments got good job opportunities in USA? Please suggest. Also, please provide the list of top universities offering the non-clinnical masters in USA.

    • If “not convincing enough” is an euphemism for “not passing grade” then you can write the Step 1 once more. If not, then sorry, you cannot take the Step 1 again just so that you can improve your score. And as for the advice you’ve asked me, I would love to pretend that I am a learned person who knows it all (most people think that I do anyways), I am not, so I will not be the best person to advise you about that. However, if you have dreamed of chasing a clinical residency, then don’t let it slide. A couple of years this way or that in life is not a big deal compared to the ever-hated question of “what if” gnawing away at your insides for the rest of your life! But yeah, it is not gonna be a walk in the park, not by any extent of imagination!

  22. Pingback: USMLE Match 2013: Part 1: Positions per Applicant – Revealing the IMG Story | Scepticemia

  23. Hi Pranab,
    Great work man, yr blog is very informative. I have done my MD in radiology from India and am in the process of taking USMLE step1. My goal is to get fellowship over there not residency, I would be grateful if you shed some light on following questions-
    1.Will I be eligible for match in ACGME accredited radiology fellowship?
    2. Suppose I do not get matched in any radio fellowship can I spend one yr as transitional year / preliminary year, and then apply for the match next year, whats the difference between the two?
    3. You mentioned variations in licencing policies and visa polices among different states, which state do you think is best for Indian IMGs?

    Thanks in advance.

    • 1. Yes you are eligible for an accredited fellowship but they are very difficult to land.
      2. Where do you want to spend the transitional year at? Residency wise?
      3. You have to look at the visa sponsorship policies. It is not state-wise. It is usually a university-based decision you have to make.

  24. Pranab,

    Had I read your blog a couple of years back, I’d have been scared, and angry. Scared, because back then, I had just taken my USMLE Step 1, and had passed it with a rather good score, and was moving forth with my head held high. Your blog would’ve shown me beforehand what lay ahead of me. Angry, because you’ve been shoving the truth in the faces of many an aspirant of graduate medical education in the United States, and you’ve been doing it very bluntly. And often, it’s hard to discern the difference between bluntness and impertinence.
    I went through ‘hell’ to get past the Steps, get myself ECFMG certified, apply for the match, and go through the interviewing process. And, I- a non-US, visa-requiring IMG- consider myself very lucky to have finally tasted success in the form of a residency position in an internal medicine residency program in the United States.
    Looking back, I can barely smile at those anxiety-filled, sleepless months that I spent, hoping to someday live my dream. And, I can very well understand the anxiety in the words of all those who’ve commented on your post here, and I must say, that you’re doing a great job of allaying their nervousness, and boosting their morale, while at the same time, showing them the facts as they are.
    I see that you’ve done your homework, and are quite well-versed with the scheme of things. But, having had a first-hand experience of the entire process, I’d be more than happy to share my thoughts, and answer some of the more difficult questions that many have posed/will pose to you here.

    • congrats on your success… can you tell how much you scored in each step and , are high scores given preference ??

    • Sam,
      Thanks a ton. I would appreciate your responses to the queries. It is great to have helpful people around to help with such difficult issues, which keep shifting shapes with every passing year.

  25. Max,

    Thank you.

    Yes, high scores are definitely given preference. Scores are often the first filter criteria that most programs consider. And, as the mean scores on the Steps rise, so do the passing scores. For instance, when I took Step 1, the passing score on the three-digit score scale was 188. Earlier, it was 175. Presently, it is 192. When I took Step 2 CK, the passing score had gone up to 196. Presently, it is 203.
    Most internal medicine programs would want an IMG applicant to score well over the mean score on each step. The scores are very important. If you haven’t scored well, your application is going down a trash can.

  26. I am a St. Matthew’s University School of Medicine graduate from 2013 who cannot get a residency. I passed my Step tests with good scores (over 200 on Step 1). I applied to everything from rural medicine, to internal, and family this year and last and received no interviews. Zero. Nada. I’m a US citizen with an excellent personal statement who got good grades throughout medical school. But none of that matters. All they see is that I’m FMG, and I don’t have a chance.

  27. I am a Canadian citizen that was just accepted into St. James School of Medicine in the Caribbean. I should be starting in May, and I am glad that I got in (although I know these schools are for-profit organizations so they don’t really like to turn anyone down). I’ve always been skeptical of being able to practice after graduating from an offshore school, but this article has made me Extremely skeptical. I know I might need to supplement their curriculum with Kaplan or something in order to do well on my steps… but I fear that passing my steps (or even doing well) may not be good enough. I’ve already given them a deposit and have spread the word to my friends and family… I’m under so much pressure and I really don’t want to make the biggest mistake of my life and regret it. I’m a hard worker so I’m motivated to work night and day for this, but facts and facts, and stats are stats. Should I just propel myself into this and hope for the best?

    • Hi,
      Medicine is an insanely rewarding career and you are going to love every moment of it. It changes your life. It makes you look at life differently. It is a calling, not a profession, as Sir Osler would have said. Also, do not worry too much about the exams. Keep studying the basics. Keep doing the resources outlined at the back of First Aid and come the time for USMLE you are going to ace them. One of the editors of FA is an alumnus from a Caribbean medical school! So do not be depressed. Enjoy life. Enjoy curriculum. Enjoy studies. You shall do great!

  28. Hi Pranab,

    Honestly, I am a little scared after reading the article which is great and truly informative though. I am a permanent resident of US who went back to India (as I belong to US middle class who cannot finance the medical education in here) to pursue my dream of becoming a doctor. I finished MBBS and also did MD (Anesthesia) in India on a merit seat. I finished my step 1 with 221 and am due to give my CS and CK. I am looking to apply in September 2015 and am interested only in Anesthesia or IM positions. I have no US clinical experience till now but will make sure that I get it and obtain 2 or 3 Lor’s before I apply. I cannot apply before 2015 September due to different responsibilities which share my time along with studying. But whatever you said in the article made good sense. I cannot settle in US without doing a residency or fellowship in US and I never want to switch careers. Not that I don’t like India where I am born. But to settle in US, work hard to get good money and donate a lot of my earning to poor people in India has developed into a dream off late. I can’t wait to realize my dream and any information or talk that USMLE is gonna close doors worries me a lot. So does it mean it becomes impossible for me to get into a residency program. Will the fact that I don’t need a visa and that I have a post graduate degree in Anesthesia help? Please answer me at your convenience.

    • All the best for your application Ganesh. There is nothing to be scared of. You have a dream, you pursue it. Having a US citizenship is indeed a major plus point. I also hope you have obtained the requisite amount of US clinical experience. All the best for the application. Let us know how it goes?

  29. now I’m really worried! I have always dreamed of the American Board of Pediatrics! i failed the step 2 CK before. I left that dream for a while but it keeps chasing me!! I’m also an older medical graduate! so I have alot of facts against me!
    should I start over and start with step 1 this time? or should i do something like MRCPCH?
    please help as I find it sooo difficult taking a decision!!!

    • Failing a step is a major setback, I must say, but if you have a dream, pursue it. Otherwise the regret and the “what if” will keep chasing you. Sure it will cost you some money and a lot of time and effort but you shall at least have the satisfaction of knowing you threw your name in the hat and then hope for the best. Also, doing the MRCPCH might be a good idea. Do not let detractors hold you back. Have a plan, work it out.

  30. Mana——
    Hi Pranab
    I have done step1 and step2 CS once without success. Five years have flown by since the first attempt. Very busy with family. I am a FMG, very much aware of the limitations like you mentioned. Problem is, cannot take my mind off clinical practice. Any suggestion on other areas of fulfilment

  31. Interesting to note that most ppl who comment on American health system have never worked in USA. As the author spoke about number crunch first let me also talk about numbers. As of 2012 MCI information the total MD Clinical seats in India are 2612. The Surgical seats including ortho, ENT, Ophthal and general surgery are 1639. These number are for a country whose population is 1.2 billion. Now in USA a country where the population is barely 315 million they have more than 16,000 clinical residency positions (including medical and surgical fields). I have excluded pre and para clinical fields in both the countries. Details can be looked up here:- http://www.startmedicine.com/app/residencyconsiderations.asp
    Firstly, the sheer number of IM residency positions which the USA offers to International grads (around 1200) is much more than the total number of seats in whole of India (960).. So the chances of you securing a PG seat in USA is much higher than in India.
    And furthermore those 960 seats are the total number of seats which are MCI recognised. If u factor in ST reservation, SC reservation, BC (a/b/c/d) reservation, Physically handicapped and service candidates the seats which are left for open competition is a mere 657 !!!
    So Mr Pranab what do you say now?? IMG match rate is not decreasing in USA. Its pretty much stable. Nobody knows what is going to happen if Obama care kicks off in full swing. It could be a good thing or a bad thing. Many economy pundits here are scratching their head to rectify the huge costs of medical care. Its unwise for us sitting in India and giving a loose comment–” Oh docs will be ruined if Obama care kicks in”. Hundreds of intellectuals are working at that crisis. And rest assured medicine is a recession proof profession. The salaries will not be affected.
    Secondly, the salary which the residents draw in their first year is much much higher than the salary which the assistant professor in bangalore/hyderabad is drawing. Dont just rub it off saying “Money is not everything”.. Money is something and u better have some with you before speaking loosely.
    To be exact in numbers the starting salary for a PCP here is in the range of 130,000 to 150,000. thats roughly equivalent to 78Lakhs if we consider the current $ rate. Can you tell me how many doctors earn such kind of money?? Hardly anybody…
    Rounding it off;
    1.If ur interest lies in Internal medicine then USA is much better option than India. Hands down.
    2.Sadly for ppl interested in surgical specialities USA is not open
    3.improve ur CV..get good scores and get good exposure
    4.We know hundreds of students who buy seats in India from anything ranging from 25lakhs (physiology) to 2 crore (radio and ortho)..investing 10-12 lakhs is all that is needed for usmle..ull have a bright future. and all the money which u spent will be back with u in less than a year.
    5. Ull be learning the actual medicine which is evidence based rather than mugging harrisions and davidson..

    • 1. Ok your argument is fallacious because it is based on the presumption that IMGs have equal claim on the 1200 seats as AMGs. They do not; and they should not either! An AMG spends an insane amount of time and money to get to that stage and it is their right to have the first claim on the seat. In India, you have an equal claim on the 657 seats. So, if you look at it logically, you shall see that the problem lies in the number of IMGs applying, because the corpus of seats available will then get into an adverse ratio.
      2. That is NOT true. Lots of people are matching into Surgery every year. Do look at the numbers before passing judgment like this. It is tough, but not impossible.
      3. Yup. True.
      4. Let us keep people buying seats out of the equation. That is an entirely different story altogether.
      5. Once again, an unfair generalisation. Learning Medicine is up to you. You can make it mugging based or evidence based. Depends on you. It does help to have infrastructure and support but how you learn is up to you. One can lead the horse to the water but one cannot make it drink.

  32. Dear Pranab
    just a simple question
    what are your chances of getting residency after clearing m.b.b.s( from India ) and usmle VERSUS doing medical school in good carribean school .

    • OK. It is a simple question with no simple answers. Officially Caribbean students should be treated as IMGs. However, a lot of US students go to the Caribbean medical schools because of financial or other considerations. Because of that, some people are of the opinion that they hold an edge over other IMGs. The issue of the so-called FMG vs IMG crops up. Anyway, there aren’t any separate match stats (at least that I know of) for Caribbean students, so it would not be possible for me to answer one way or another with evidentiary support.

      Sorry for such a vague answer.

      Any US-IMGs or Carib grads care to help out? Cheers!

  33. Hi, Pranab!
    I’m a 2nd year MBBS student. So, by the time if finish my internship, it will be 2018 and USMLE won’t be a cakewalk. That sounds daunting. I’m bent on getting a surgical residency and I guess that doesn’t make things any easier. What I wanted to know is – What exactly is expected of a good applicant for a surgical residency? Apart from stellar USMLE scores? Like research work?
    Loved the article, by the way.

    • Hi Pranab,

      I would like to know what are other options for Indian Medical graduates other than residency.

    • One could try for an MPH, or go for a PhD. There are alternate routes such as management and MBA as well. One could try for a research associateship as well.

  34. hi all,
    I am pg in pathology with 4-5year work experience after PG, planing to take USMLE .graduated in 2004. have got a few publications, what rae the chances of getting residency match, please advise. i am too late to start, what shall be the next move. Thanks

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