Residency in the US

Winning Hand

As someone currently in a residency in the US I thought it was time I added to this medical board some tips and advice for anyone interested in taking the plunge across the pond for postgraduate training.

For anyone who wishes to practice independently in the US you must be board certified. By and large the only way one can be board certified is by completing a residency in the relevant field (there are a few rare exceptions). A residency is the training period that doctors commence once finishing medical school, unlike our system of doing an internship prior to commencement of a training scheme. Depending on the specialty it varies from 3-7years. After completion of a residency the option is to begin as an attending (consultant) or to continue in a fellowship (further subspecialty training 1-2yrs). One may enter a fellowship without having completed a residency, a path that many doctors take from Ireland after completing their sho/registrar years. Doing so is increasingly the few ways to advance in the irish system. Again it is worth mentioning that without a residency you cannot stay and practice in the US. You can enter a residency at any age or level of training, however your prior experience will count for little from timeframe point of view.

The first step in applying for a residency (or a fellowship for that matter) is to become ECFMG certified. The ECFMG acts as the central office for all international applicants. www.ecfmg.org

Becoming ecfmg certified is actually a pretty straightforward process, albeit one loaded with paperwork and expense. For certification on must first have to submit documents to certify ones attendance, past or present, at a medical school licenced by faimir. All irish schools are so listed. Next one must complete Step 1, Step 2 CK and Step 2 CS of the USMLE within seven years. Once this is completed you are ecfmg certified and may apply for residencies in the US.

The USMLE

The USMLE are a sequence of standardised tests that all US medical students must take prior to graduation from medical school. Step 1 is usually taken by US med students after their second year and is preclinical in its content. Step 2 is broken into two different exams. The CK is a clinical knowledge exam and like step 1 is computer based and can be taken in Ireland. The CS is a clinical skills exam and must be taken at certain testing centers in the US.

Step 1 is a preclinical exam testing anatomy, physiology, pathology, pharmacology, biochemistry, behavioural science. The best time to take this if you are still in med school is immediately after finishing preclinical years. This is because this test can test minutae of preclinical fields which is very difficult to go back over. It is important to iterate the importance of getting a high score in step one as it is the main screening tools that programs use in screening applicants each year for residencies, in particular for international applicants.

Step 2 CK is a clinical knowledge exam which when compared to step one is a far easier exam. The content is stuff that is largely covered by our own med school training and should pose little difficulty to anyone who is well read and prepared for our own exams. In addition it is not used as a screening tool to nearly the same extent as step one by programs as most US med students do not take this exam until after applying and interviewing for residencies.

The CS is a clinical skills assessment (referred in the past as the CSA). In the past only internationals had to take this exam but now everyone has to take it. It is a one day exam set in a ‘clinic’ setting. This is a pain in the ass only because it is expensive, requires travel to the states to take the exam and untoward stress. It really is probably the easiest to pass and is only pass/fail.

Step 3 is taken when you are in a residency and it is to complete your medical licence.

Applying to residency

The first step in applying for a residency is determining what you wish to do. Unlike our system, most residencies are categorical (same institute for length of training) so once you have secured a residency you are set for the length of your training. The fields are varied – Internal Medicine, General Surgery, Pathology, OB/GYN, Dermatology, Radiology, Urology, Plastic Surgery, Anesthesia, Family Medicine, Neurology, Ophthalmology, Orthopedics, Pediatrics, Psychiatry, ENT. Most of these are applied for throught the ERAS http://www.aamc.org/students/eras/

Application season tends to open August/September with interviews running from Nov to Jan. After interview season the programs and the applicants rank their programs by order of preference called ‘the match’. Match day occurs usually in the middle of march at which time you find out if you have matched to a program.

A full application usually consists of 3 Letters of Recommendation; these can be from faculty at home or preferably from rotations in the US which carry more weight, your med school transcript, a ‘deans letter’, your usmle scores and your personal statement. The ecfmg again acts as the liason office for all these documents and transmitting them to desired programs

Tips for Success

1. Take your steps in medical school. Far easier to do it at the time you are studying than afterwards when you are an intern/sho and studing for the memberships etc.
2. Ace the USMLE if you have aspirations of applying to a competitive specialty or wish to go to a top institute
3. Take rotations in the US if you have the opportunity as you would get letters of rec from us attendings.
4. Try to get some research while in med school, publish if you can. Again this applies more to the more competitive specialties.


Visas

Unless you are a US citizen or Green Card holder applicants basically have 2 options for visas. J1 visas are the most common and easiest to get. The catch is when you have finished your training you must return to Ireland for 2 years before you can apply for a permenant residency visa. There are ways around this requirement, involving either working for the VA (Veterns Administration) or working in an underserved area for a period of time 3-5 years. Another option is a H1B visa which allows you to apply for residency at completion of residency, however spots are limited, you must take step 3 prior to application and not many hospitals support them.

In my later posts I will talk about the pros/cons of the US system and answer any other questions people may have.