Applying for an emergency medicine (EM) residency as an IMG is tough, and much of the standard application advice does not apply. In order to successfully match, IMGs need to know how the process works for them.
General Overview of the IMG Application Process
International medical graduates (IMG) are physicians who have completed their training from a medical school aside from where they intend to practice. While IMG applicants can offer a wealth of cultural, academic, and medical knowledge diversity to a domestic residency program, many face increasing fundamental challenges during their application process, such as limited EM residency positions and additional accreditation processes (ie, USMLE and ECFMG) before they can apply for U.S. residencies.
The simple truth of the matter is that applying for an emergency medicine (EM) residency as an IMG is tough, and much of the standard application advice does not apply. In order to successfully match, IMGs need to know how the process works for them.
So how, exactly, does it work? To assemble the top 5 FAQs, we reviewed data from the National Residency Match Program (NRMP) and from program directors and clerkship directors about optimizing successful enrollment in a U.S. EM residency program.
Before Choosing EM
Prior to applying, it is important to set realistic expectations. Matching into EM is more difficult for IMG students than for U.S. students [Table 1 and Figure 1].
According to the Results and Data from the 2016 Main Residency Match, there were 1,895 emergency medicine PGY-1 positions with 2,476 total applicants. Of those, 783 were “independent applicants” (31.6%), which includes those who went to international medical schools. EM had a 99.99% fill rate with only 1 unfilled position. Approximately 78% of those spots were matched to US allopathic seniors and 12% were filled by osteopathic applicants. This adds up to some sobering news for the international applicant; only 5% of available EM positions were filled by U.S.-IMGs, and 1% by non-U.S. citizen IMGs. This left 30% of independent applicants unmatched among those who listed EM as their only specialty.
Take-Away Points from Away Rotations
One of the most important goals as an EM applicant is to secure a Standardized Letter of Evaluation (SLOE) during an away rotation in the emergency department. According to the 2016 NRMP Program Director Survey results, EM Program Directors ranked “Letters of Recommendation” as the No. 1 factor (97%) in their decision to offer an interview.
Many programs reserve the coveted sub-intern slots (July, August and September) for students from their affiliated medical school. To find viable rotation options, the first step is to look at where students have rotated in the past. The second place to look is the match list for foreign schools to see where IMG's have matched previously. The final option is to call the departments where you are interested in rotating to see if you can secure a rotation.
Rotations at non-academic emergency departments may be easier to obtain. However, the letters of recommendation from these sites may note carry sufficient weight to get interviews. All applicants, not just IMGs, need at least 1 (and preferably 2) SLOEs from emergency departments with residency programs. The SLOE is far more useful to program directors than a regular LOR because it forces the writer to compare and contrast the applicant with his/her peers. Not having a SLOE will severely limit your chances as an applicant.
The Application Process
ERAS opens on Sept. 6, with programs able to view applications on Sept. 15. Therefore, the application needs to be completed as close to Sept. 15 as possible. IMG applicants will not receive interview offers until they have at least one SLOE uploaded. They should also take Step 2 early enough to have their scores back when applications go out. While U.S. students may be able to delay Step 2 and still secure interviews, IMGs really need to have both Step 1 and Step 2 scores to maximize their chances. Choose programs that have matched IMGs over the past few years (do this by looking at the match lists published by the schools and at the residencies websites). Applying to programs with no history of matching IMGs is lower yield.
The realistic IMG applicant will apply broadly for emergency medicine but may also apply for other specialties as well. They should not anticipate being able to scramble into EM. Vanishingly few (if any) international applicants (or anyone else, for that matter) have matched via SOAP (Supplemental Offer and Acceptance Program) into EM in recent years.
The Interview
Obtaining an interview is a big step in the right direction. If you have a unique background, use it to your advantage and highlight the qualities and experiences that make you ideal to train. Most important, be prepared to address your IMG status. Expect the question, “Why didn't you go to medical school in the U.S.?” Have a good, honest answer.
TABLE 1. Annual Emergency Medicine Match Rates from 2009 to 2016
| Annual EM Residency Matches | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 |
| US seniors | 1146 | 1182 | 1268 | 1335 | 1428 | 1388 | 1438 | 1486 |
| US grads | 57 | 66 | 70 | 68 | 44 | 90 | 60 | 73 |
| Osteopathic | 163 | 169 | 177 | 171 | 178 | 177 | 203 | 224 |
| US IMG | 70 | 109 | 71 | 69 | 58 | 87 | 75 | 87 |
| Non-US IMG | 23 | 4 | 16 | 25 | 33 | 30 | 36 | 23 |
| Unfilled | 13 | 16 | 5 | 0 | 3 | 14 | 8 | 1 |
Data collected from NRMP 2009-2016.
Figure 1. Emergency Medicine Match Rates by non-US Senior Application between 2009 and 2016
FAQs: IMG Match in EM – Expert Feedback
1. Why are IMG applicants at a disadvantage?
It is challenging for U.S. EM Program Directors to be familiar with the myriad of international medical schools. As a result, non-U.S. IMG students need to demonstrate objective mastery of the medical arts via top grades, strong letters of recommendation (at least one SLOE), above average USMLE scores, and a robust CV. Any academic difficulty from an IMG applicant is a major red flag and warrants a back-up plan.
2. Are there financial implications to hiring an IMG resident?
Yes. Some medical institutions only sponsor certain types of visas, and for others, the Department has to pick up the tab. It is difficult for a PD to justify spending money to match an IMG applicant when they can match an equally qualified U.S. graduate for free.
3. What is one major pitfall for IMG applicants?
Spelling and grammatical errors. PDs are bombarded with thousands of applications within hours of ERAS opening. Any simple grammatical mistakes or typos may reflect (possibly inaccurately) your level of English proficiency and lead to rejection. Advice: Have someone read your application, and
then have someone read it again.
4. HIGH YIELD! What can IMG applicants do to tip the scale to their favor?
- Find a mentor and advisor to guide you through this challenging, but exciting process.
- Apply (although not exclusively) to programs that have a history of accepting IMG applicants.
- Rotate at an academic program and get an outstanding SLOE.
- Build an overall strong ERAS application:
- Demonstrate to the PDs that you are not afraid of a challenge.
- Include your unique services, leadership, and research.
- Don't forget to mention your unique academic and cultural experiences.
5. What is our single most important advice to an IMG applicant?
Before you apply to any EM programs, make sure you are the best possible candidate, having crossed all of your T's and dotted your I's before clicking the submit button.
Data collected from NRMP 2009-2016.
The Rank List
IMG applicants with a longer contiguous rank list (the number of programs ranked in the first-choice specialty before a program in another specialty appears on the applicant rank order list) have a better chance of matching into EM residency than applicants with shorter contiguous rank lists. The more interviews you do (and the more programs you rank), the more likely you are to match.
Although no number of interviews guarantees a 100% match rate, the standard recommendation is to rank at least 12 programs (the matched U.S. allopathic seniors had an average rank list consisting of 12.3 programs). In ordering programs on your rank list, do not try to outsmart the algorithm; the match is applicant-weighted. IMG applicants should rank just like everyone else, based on where they want to go.
While this list may not instantly transform an IMG applicant into an EM-All-Star, it should provide additional subjective and objective guidance to navigate the international waters of the EM residency application process.