Navigating the Path: Emergency Medicine Residency for International Medical Graduates in the U.S.

Kiersten Diercks, MS3 
University of Texas Southwestern Medical Center
EMRA MSC Student Advising Coordinator

Edited by:
Olivia Voltaggio, OMS III
Rocky Vista University College of Osteopathic Medicine - Southern Utah
EMRA Medical Student Council Editor, 2025

To grow as a specialty, Emergency Medicine (EM) leaders hope to expand the diversity of those in the specialty, starting at the level of undergraduate medical education. Matching into a medical specialty in the United States is a difficult and convoluted process, but matching as an International Medical Graduate (IMG) in a system that was designed for MD and DO students adds a different level of complexity. Understanding the requirements and navigating the application process are crucial steps to a successful Match.

Credentialing and Documentation Requirements

One of the first and most critical steps for an IMG seeking to enter EM residency is obtaining Educational Commission for Foreign Medical Graduates (ECFMG) certification. This certification ensures that IMGs meet the educational standards required for training in U.S. residency programs. ECFMG certification requires three things. The first requirement is the institution the student graduated from meets ECFMG requirements. In order to check if an institution meets Eligibility Requirements for ECFMG certification, check the World Directory on the ECFMG website. The second requirement is the Medical Science Examination Requirement, met by a passing USMLE Step 1 and Step 2 CK score. The third and final requirement is the Clinical Skills Requirement and Communication Skills Requirement. The former can be met by following an ECFMG Pathway (2), with many different options for showing appropriate clinical skills based on the circumstances of each applicant. The Communication Skills Requirement needs to be met with a satisfactory score on the Occupational English Test. 

U.S. Clinical Experience and Evaluations

Applicants are required to complete at least two Emergency Medicine clerkship rotations at institutions that offer established EM residency programs; these rotations not only help candidates gain valuable clinical exposure but also facilitate the acquisition of Standardized Letters of Evaluation (SLOEs), which are crucial in demonstrating a candidate's competency and readiness for residency. Zhang et.al (4) and the Council of Residency Directors (CORD) (3) recommend that students complete their U.S. clinical experiences at academic institutions with residency programs. To find institutions that have previously been able to support IMG rotators, EMRA Match is a recommended resource where students can filter institutions by their availability to accommodate IMG’s and percent of IMGs at a certain institution. 

Visa Considerations

For non-U.S. graduates, understanding visa requirements is essential. There are many types of visa requirements, and the visa offered varies by state, county, and institution. As visa sponsorship can limit program options, it is vital for applicants to consider institutions that are able to sponsor visas. Two main types of visa options include the J-1 visa, which is sponsored by ECFMG and requires applicants to return to their home country for two years following residency prior to applying for permanent US residency, and the H-1B visa, which does not have a mandatory home residency requirement but is limited by the ability of programs to find funding to sponsor the visa. It is important to start researching different institutions' visa options early in the application to determine if an institution is a viable option for an IMG applicant.

Residency Application Process and Ranking Strategy

To maximize their chances of success, Zhang et al. (4) recommend that IMGs apply to at least 12 residency programs, acknowledging that U.S. graduates typically apply to fewer. For non-U.S. graduates, extending this list further may increase the likelihood of a match. It is also advised that IMGs present strong academic records, with top grades, robust evaluations from clinical rotations, and a well-rounded curriculum vitae (CV) to enhance their application.

Additionally, Zhang et al. (4) highlight that applicants should review the IMG match statistics for specific programs and analyze how their objective scores compare with those of previous matched candidates. This strategy ensures that IMGs are aligning their applications with programs that best fit their qualifications. 

Program-Specific Considerations and Challenges

While the pathway to an EM residency is competitive, IMGs face additional challenges compared to their U.S. counterparts, such as the perception of academic risk. IMGs are sometimes seen as higher-risk candidates due to the lack of standardization of institutions; this can necessitate stronger academic performance and additional documentation to support their equal qualifications. Furthermore, residency programs may use early filters during the application process that exclude IMGs from serious consideration, further reducing the number of programs where IMGs are strongly considered.

Summary of Recommendations

•     Start researching program specific requirements for IMG’s and visas offered as early as possible!
•     Complete two or more EM clerkship rotations at accredited institutions with residency programs.
•     Achieve competitive USMLE Step 1 and Step 2 CK scores.
•     Rank a broad number of programs (at least 12 for U.S. IMGs, more for non-U.S. graduates).

Conclusion

Pursuing an emergency medicine residency as an IMG in the U.S. is a rigorous but attainable goal. By meeting essential requirements such as ECFMG certification, USMLE scores, and clerkship rotations, and by carefully navigating the application and visa processes, IMGs can enhance their chances of securing a residency position. Strategic planning, including selecting and ranking programs appropriately and gathering strong letters of recommendation, will help IMGs stand out in this highly competitive field.

Resources 

1. ECFMG. World Directory of Medical Schools (WDOMS) Resource. Published 2024. Accessed March 12, 2025. https://www.ecfmg.org/certification/wdoms-resource.pdf
2. ECFMG. ECFMG Certification Pathways. Published 2024. Accessed March 12, 2025. https://www.ecfmg.org/certification-pathways/
3.  Council of Residency Directors in Emergency Medicine (CORD). Advising the IMG: ASC-EM Advising Recommendations for International Medical Graduates. Published 2022. Accessed March 12, 2025. https://www.cordem.org/siteassets/files/committees/student-advising/2022-updated/asc-em-advising-the-img-.pdf
4. Zhang XC, Jarou Z, Danovich D, Kellogg A, Lutfy-Clayton L, et al. International medical graduate advising recommendations from the Council of Residency Directors in Emergency Medicine Advising Student Committee. Acad Emerg Med Educ Train. 2020;4(4):500-507.