Slaying the Hydra – An IMG’s Guide on How To Apply for Medical Residency in the USA

Slaying the Hydra – An IMG’s Guide on How To Apply for Medical Residency in the USA

Applying for medical residency in the US has traditionally been perceived as an exceedingly complex process for IMGs, sometimes discouraging them from even trying. However, just like facing a monster with apparently infinite heads, the key to ultimate success lies in combining a clearly outlined strategy with a bit of patience and resilience.


How To Apply for Medical Residency in the USA
Rodrigo Garcia Santisteban


August 14, 2023

Applying for ECFMG Certification: Step 1, Step 2 CK, and the Occupational English Test (OET)

The first part of the process is to apply for a series of exams and achieve passing grades on all of them:

You will need to pass the Step 1, Step 2 CK, and the Occupational English Test (OET) exams. The first two are processed on the ECFMG website, and the latter is processed on its own.

  • USMLE® Step 1: The Step 1 is a multiple-choice exam that features mini-clinical case vignettes that test your knowledge of the following basic subjects: Anatomy, Behavioral Sciences, Biochemistry, Biostatistics and Epidemiology, Microbiology, Pathology, Pharmacology, and Physiology. You will find myriad study aids, and you may be tempted to buy all of them to cover all bases. Remember, the key is to use these tools as you would use medications, choose one or two that are the best fit for you, and stick with them. This strategy will yield much better results than trying to juggle six different question banks at a time. Your application for Step 1 for IMGs may be done through ECFMG’s website after creating an account.
  • Step 2 CK: This exam features similar case vignettes to Step 1 and is primarily focused on Internal Medicine, Surgery, Pediatrics, and Obstetrics & Gynecology. Step 2 CK is much more clinically oriented, and it’s designed to test your diagnostic and therapeutic skills. Regarding study aids, the same advice that I gave regarding Step 1 applies to Step 2 CK; choose one or two tools and stick with them. You can apply as an IMG through ECFMG’s website as well.
  • Occupational English Test (OET): There used to be a second part to Step 2 called Step 2 CS, which included traveling and evaluating simulated patients. Due to the COVID-19 pandemic, the Step 2 CS was replaced by the OET, which is performed on a computer and assesses speaking, listening, reading, and writing skills in medical scenarios. The silver lining? Unlike the USMLE Step examinations, the OET has free study guides and simulated exams on its website.
  • Exam scoring: As of 2021, the Step 1 is graded as pass or fail. The Step 2 CK is graded using a three-digit score calculated based on other people’s scores using a proprietary algorithm. Regarding the OET, sections are graded independently, and you must achieve passing grades on each (350 points on each section, except Writing which requires 300 points as of April 1st, 2022).

Once you pass the aforementioned examinations, you may apply for one of six pathways for ECFMG certification. An independent pathways website explains each in detail and which pathway you should pursue.

Keep in mind that although you won’t need it to send your applications, it does take some time to process, and it is a necessary component of your application to be accepted to any program.

Building Your CV

Everybody has a different style of CV; however, to give you a sense of what is most important, this is the information that you will have to fill in when you build your official application: 

  • Demographic data
  • Medical school awards
  • Volunteer experiences
  • Work experiences (clinical rotations in the US are included here)
  • Research experiences
  • Publications
  • Hobbies and interests
  • Languages
  • Other awards or accomplishments

Your second-grade spelling bee championship may be special to you, but try to use what you consider your most relevant information to keep the length under two pages with average spacing.

The Match Season Explained

Every aspect of the Match must be handled through the Electronic Residency Application Service® (ERAS®) portal. It’s essential to research your particular season’s timeline beforehand to be able to meet important deadlines.

The Match season begins when ERAS® releases its tokens. The tokens are electronic alpha-numeric IDs you will need to start the residency application process. 

ERAS® will give you about three months to complete your application after tokens are released, after which you may send applications to programs. It’s critical to send your applications as soon as possible, preferably on the same day ERAS allows. Many programs automatically reject incomplete applications as soon as they start with their first selection round, so you don’t want to be left behind. Most programs will offer you interviews and allow you to schedule them through the ERAS portal once you have your token and account (some will use other applications such as thalamus).

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Structuring your Residency Application

 Your residency application contains the following documents: 

  • Letters of recommendation (LORs): Programs require a minimum of two and a maximum of four LORs from each applicant; some will specify on their website that they accept a maximum of three; however, I recommend gathering extra letters as a backup. These letters should come from physicians you have personally worked with and who are willing to provide strong recommendations. Don’t ask somebody you consider a friend but have never been professionally involved with. They are uploaded by the authors directly to your application portal and can then be assigned to program applications after about a week of processing.
  • Personal statement: Your personal statement is a chance for you to write about who you are, the moments and people who have inspired your journey in medicine, and why you want to apply for residency in the US. Don’t just summarize your CV, and don’t write endless paragraphs about every moment of your career. Instead, try to explain in clear terms what makes you unique as a candidate and why you are interested in that particular specialty. You must assign your statement to each program you apply for, and if you want, you can even write different statements focusing on distinct aspects that can apply to specific programs.
  • Medical School Performance Evaluation (MSPE): Formerly known as the “Dean’s letter,” the MSPE is a document where your dean of medicine details your performance during medical school and your accomplishments. Your Medical School usually uploads the document directly to your ERAS account.

Researching Programs

Just as the USMLE® exams have a lot of available study aids, many tools are dedicated to helping you search for programs that comply with specific criteria.

However, I highly recommend Residency Explorer, the software included with your ERAS account; it does not cost extra and is very helpful, as you can filter programs based on location. It also lets you see how your qualifications compare to each program’s mean acceptance rate. 

I recommend that you list your program preferences, including university vs. community hospitals, urban vs. rural settings, specialized research electives, etc. Remember, although there is no specified number of programs you should apply for, IMGs usually apply to more programs than US graduates because many programs accept a limited amount of IMGs.

Acing Program Interviews

You should always keep one thing in mind: If a program offers you an interview, that means they have filtered your application from thousands of others; they already like you a lot.

Interviews have two main intentions; on the one hand, they want to get to know you as a person and determine if you could be a good coworker; on the other hand, they want to find out if you are interested in them. 

To accomplish this, I highly recommend you come prepared. Programs will generally do their best to help you by sending you information on their educational offer, current residents, and work benefits.

Interviews are usually organized into two parts:

  • Resident hang-out: Generally organized a day or two before the official interview date, this is a very casual encounter with some of the program’s residents that is designed for you to ask about the things that you wouldn’t usually ask a faculty member. This can include asking about the harshness of the work schedule, how supported they feel by faculty, why they chose to rank that program highly, what they like the most about it, and even the quality of cafeteria food. Remember, this is an official part of the interview, and although you can be a lot more relaxed, always be professional and courteous.
  • Official interview(s): Every program handles its interview day differently, but they will let you know about the schedule beforehand. Some will give you introductory lectures before the interviews, and others may want you to interview with three different faculty members. The most important things to remember are to dress formally, come prepared with specific questions about the program, and try your best to act casually. Programs have questions and strategies designed to throw you off, but as long as you remember to stay calm, you’ll be fine.

Final Thoughts

I want to add one final detail. Unbeknownst to most, Hercules was accompanied by his nephew when he faced the hydra, and he could never have slayed it without his help. Reach out to people going through the same process as you; I can’t assure you that they will all be helpful, but you never know when a friend might come in handy.

Further Reading

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