Residency Training in the United States:
What Foreign Medical Graduates Should Know

Adebonojo SA,
Mabogunje OA,
 Pezzella AT,
West African J. Medicine 2003; 22:  79-87

Contact/ Reprints requests

Samuel A. Adebonojo, MD
Chief, Surgical Services
4100 W. Third Street
Dayton, Ohio USA 45428
Tel# (937) 262- 2150/ 5965
Fax# (937) 267- 7695


The 21st century will witness an increase in global interdependence and integration. This is especially true in medical care. There are over 6 billion people in the world in over 200countries and territories. There is clearly a maldistribution of health care access. Yet, as global economics and politics improve more people will have access to both preventive and curative health care measures, as well as a more balanced growth and distribution of health care resources. A major factor in this growth will be medical education. In a review from 1995 – 1996, there were 1642 medical schools worldwide in 157 countries (1). Unfortunately, there are no international standards or guidelines to judge, both subjectively and objectively, the quality and quantity of these medical schools in terms of the basic medical education/curriculum and subsequent postgraduate medical education/programs. The present review gives a general overview of graduate medical education (GME) in the USA in both accredited and non-accredited programs, with guidelines on seeking information regarding certification, programs, and visas. It should be stressed that, at present, there are certain general facts and perceptions to be aware of. Foreign Medical Graduates (FMG) have increased over the past decade in the USA constituting between 18-25% of enrolled residency trainees. Participation in the 2001 USA National Resident Matching Program revealed 12.5% of active matched PGY1 participants were foreign-born medical graduates (2). There are notable differences in FMG medical school training. There are growing perceptions that FMG’s do not want to return home following residency training. Since 9/11, it is unknown as to what direction the attitudes of the USA government and its citizens will be toward FMG’s and foreigners in general. There is a generalized fear that there is an over supply of USA physicians. Despite this, there is both a need and desire for FMG’s to pursue GME in the USA. There is also a two-fold goal for GME programs in the USA regarding FMG’s: (1) A genuine desire to provide quality GME training and education for FMG’s who will return home and enhance as well as expand health care plans and initiatives; (2) FMG’s provide a valuable pool of health care physicians for hospitals and programs.


In both the developed or industrial countries/ regions and the underdeveloped or emerging countries/regions health care is an important and integral part of the social infrastructure. With an annual growth of 70 million people, the present world population of 6 billion will reach 7.5 billion by 2020, and 9.3 billion by 2050 (3). This growth will be concentrated in South Asia and Africa. The global mortality is over 55 million deaths per year with infant mortality ranging from 6 per 1000 live births in WESTERN Europe to 92 per live births in Sub-Saharan Africa (4). Life expectancy ranges from 49 years in Sub-Saharan Africa to 78 years in Western Europe (5). Interestingly, deaths from non-communicable diseases are greater than communicable diseases, even in the face of the rising number of HIV infected patients, particularly in Sub-Saharan Africa. The growth of non-communicable diseases will continue to rise in developing countries, with an attendant increase in cost and allocation of resources.

There is no standard percent of gross domestic product (GDP) that is allocated for preventive and curative health care services. The range is 1-14% of GDP from government supported health care funding and budgets. Controversy continues regarding the best use of this limited health care budget. The Ghana model (Figure 1) clearly shows this dichotomy (6). The evidence from this model shows that a community-based primary health care strategy was found to provide 20 times as much healthy life per dollar allocated. Yet, controversy persists between health care ministries regarding budget allocations for preventive and curative care. However, it is clear that central to health care planning is the proper education and training of health care personal, particularly physicians. This involves; (1) planning to judge the need for the population served; (2) providing appropriate training both at home and abroad; and (3) management or allocation of trained personal to appropriate areas within the given country to obviate the hazard of maldistribution.

The maldistribution problem is both a local and global problem and challenge (Figure 2) (7). As an example, the USA has 51 surgeons per 100,000 population versus 0.5 surgeons per 100,000 population in the West African region. Added to this problem is the local maldistribution between the urban and rural areas.

The central and local governments must provide a strategy for planning and distribution. The appropriate training is a local, regional and global challenge. Seeking education and training abroad is sought by qualified medical students in three situations: (1) no training or inadequate training at home; (2) advanced training in order to update or advance services at home; (3) or no plans to return home (i.e. ultimately seeking to emigrate abroad for personal and professional reasons). Additionally, ministries of health, faced with the expense of medical education and training, continue to explore other options. Just as the USA has developed a cadre of physician assistants (PA’s), nurse practitioners (NP’s), and nurse clinicians (NC’s) to assist in providing both primary and specialty care, so too have emerging countries. One example is the training of medical assistants in Mozambique (8). Selective training of medical assistants to perform caesarean deliveries in rural areas was quite successful. The Canadian Network for International Surgery (CNIS) is also involved with teaching surgical skills to general practitioners in Africa. The CNIS objective is to reduce and prevent death and disability from surgical problems. They use educational and preventive strategies. Through the essential Surgical Skills (ESSTM) project local African surgeons teach lifesaving skills to general practitioners. Hopefully, in the future, USA based programs, like the Advanced Trauma Life Support (ATLS) program sponsored by the American College of Surgery, will develop similar model programs in Africa to enhance and sustain basic trauma education, evaluation, and support during the first few critical hours of traumatic injury.

The American Health Care System

There are over 6,500 acute care hospitals in the USA of which 300 are major teaching hospitals and fewer than 1250 participating in GME (9). Over 5,000 hospitals, health care systems, networks, or providers of care are members of the American Hospital Association (AHA) The USA population is approaching 290 million people. Over 40 million USA citizens have no health insurance and another 40 million or more retired citizens over 65 years of age are covered primarily by federal health insurance (MEDICARE) (10). The total health care bill in the USA is over 1 trillion dollars, or approximately 14% of the GDP with over 45% of this bill financed by federal, state, and local governments. The aging USA population (approximately 290 million) coupled with the increasing medical costs will continue to stress the health care budget and number of health care providers needed with physicians numbering around 200/100,000 USA population.

Medical Education USA

There are 125 approved medical schools in the USA for the education of allopathic physicians These schools are accredited by the Liaison Commission on Medical Education (LCME). Graduates of LCME accredited schools are eligible for state licensure and enrollment in residency programs approved by the Accreditation Council on graduate Medical Education (ACGME). Graduates of USA and foreign medical schools actively practicing in the USA are summarized in Figure 3. Foreign medical graduates (FMG’s) or international medical graduates (ING’s) constitute over 20% of this group (11,12) (Figure 4,5). Unfortunately, as mentioned, foreign medical schools are not standardized or accredited by an international body. The World Health Organization (WHO) only tabulates the world directory of medical schools (1). Additionally, the Foundation for Advancement of International Medical Education and research (FAIMER sm) publishes an international medical education directory (IMED). This provides an accurate and up-to-date list of medical schools recognized by the government agencies. These agencies are usually the Ministries of health of each country represented. Some foreign medical schools have developed relationships with several USA states with regards to those USA citizens studying abroad in foreign medical schools. They allow for limited exchanges of medical student clerkships in American hospitals. This review does not address USA citizens abroad. There are specific pathways regarding medical school clinical rotations in the USA and the fifth pathway program of GME training in the USA. This was designed to obviate the social service obligations of a foreign institution and facilitate the return home to continue with GME.

The American medical educational system consists of 9 years of primary school, 4 years of high school, 4 years of premedical education at a college or university, and 4 years of a LCME approved medical school. Graduate medical education includes residency training, fellowship training, and research fellowships. Subsequently, American Board qualification or certification as well as state licensure are demanded by most USA hospitals for clinical privileges to admit and treat patients. Most American certifying boards now require recertification at 5 or 10 years. Thereafter medical education is provided by Continuing Medical Education (CME). These are approved lectures, courses, workshops, or meetings. These are designed to keep the physician up-to-date on current ideas, knowledge, techniques, or skills. A varying number of CME’s are required for subsequent future hospital credentialing and state licensure renewals.

Graduate Medical Education in the USA

Following the Medical Doctor (MD) degree at an LCME approved USA medical school, an individual is qualified to be a candidate for graduate medical education (GME) in the USA. As mentioned, the more than 6,500 hospitals in the USA only 300 or more non-federal hospitals are major teaching hospitals, with another 1250 participating in GME. More than 16,000 new physicians graduate from USA medical schools and qualify for GME programs (9). There are 24,000active participants for entry level Accreditation Council Graduate for Medical Education (ACGME)- accredited positions in the USA (2). These excess positions are left unfilled or filled by graduates of foreign medical schools, be they US-born, or foreign born. This has constituted 18-25% of all postgraduate trainees in the USA over the past decade (Figure 5). GME in the USA is financed by public and private funds, yet mostly by USA federal and state government supported MEDICARE and MEDICAID funds. In order to assure quality and standardization of foreign medical graduates applying for GME positions in the USA, the Educational Commission for Foreign Medical Graduates (ECFMG) was formulated.


Established in 1956, the ECFMG has developed a program to evaluate individual graduates of foreign medical schools seeking entrance into GME in the USA. At present, the board consists of representatives from the American Medical Association (AMA), the Association of American Medical Colleges (AAMC), the Federation of State Medical Boards of the United States, Inc. (FSMB), the American Hospital Association (AHA), the American Board of Medical Specialist (ABMF), and the National Medical Association (NMA). The ECFMG processes USMLE and CSA applications, as well as coordinating and proctoring the CSA (clinical skills assessment exam) in Philadelphia, Pennsylvania and Atlanta, Georgia. They also screen and review all documents pertaining to the final foreign medical diploma. ECFMG certification recognizes that the candidate has met the minimum standards of eligibility and competency. Eligibility for ECFMG certification is summarized in Figure 6. Information regarding USMLE Steps I and II is obtained at the ECFMG website or Step I assesses whether you can understand and apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy. There are 350 multiple-choice questions, divided into seven 60-minute intervals. This is an eight-hour session. Step II assess application of medical knowledge and understanding of clinical science as it applies to patient care. The emphasis is on health promotion and preventive medicine. This is a 400multiple choice exam given in eight blocks over nine hours. TOEFL is the test of American English proficiency. (http:// It assesses listening, structure, reading, and writing. Listening involves 30-50 multiple-choice questions based on dialogues and short conversations. It lasts 40-60 minutes. Structure measures recognition of language appropriate for standard written English. There are 20-25 questions over 15-20 minutes. There are two types of question: 1) incomplete sentences, with four words or phrases as options to complete the sentence; 2) underlined words or phrases, from which one needs to be changed for the sentence to be correct. Reading involves the ability to read and understand text. It assesses comprehension, factual information, and vocabulary. There are 44-60 questions lasting 70-90 minutes. Writing involves ability to write n English on an assigned topic. The assessment is in ideas expressed and elaboration of those ideas. The time limit is 30 minutes.

The Clinical Assessment Skill (CSA) requires successful completion of USMLE Steps II and TOEFL as well as TOEFL. CSA was started in 1998 and is administered in Philadelphia, Pennsylvania and Atlanta, Georgia. This assessment involves a practical evaluation of English skills, as well as evaluation and management of patients <http:// www.csa>. It is a one-day test involving evaluation of 11 standardized patients (SP’s) of which only 10 are scored. The eleventh is for research purposes. It is designed to test the performance of the techniques of physical examination and the ability to detect abnormalities. Frequent errors include failure to check the equipment, unfamiliarity with the equipment (e.g. the ophthalmoscope, blood pressure cuff, and deficiencies in communication of the results or abnormalities).

ECFMG sponsorship requires a valid ECFMG certificate and a contract for a position in an ACGME approved residency program. The duration of ECFMG sponsorship is limited to the length of training accredited by the ACGME. This is usually limited to 6-7 years. The physician must then return home – the mandatory 2 years home rule. Following completion of the residency program, permanent validation of the certificate is obtained. It is this ECFMG validation that confirms FMG certification for USA state licensure purposes. The fifth pathway program is not discussed here, since this applies primarily to USA students studying abroad.


ACGME Approved Residency Programs

Once the ECFMG certificate and sponsorship is obtained, application and acceptance at an ACGME approved residency is necessary. There were 7.985 approved programs in the USA for 2000-2001 The total number of residents in approved programs totaled 96,806. Of these 24,707 (25-5%) were IMG’s (i.e. foreign or USA born graduates of foreign medical schools) (13). The application process is summarized in Figure 7. It is important to network with other students regarding prior experiences in a particular program, city, or state. Both the medical and non-medical aspects must be explored and studied. In addition to the electronic application, an application should also be mailed, usually by overnight express, or registered mail. A personal statement is extremely important. This should outline career goals, and your desire to return home and contribute to the overall health care of your country. The complete application is summarized in Figure 8. If an interview is desired or required certain guidelines and information are required (Figure 9, 10). The interview process is usually conducted at set times with many applicants being interviewed at the same session. What the program directors stress and applicants stress and what to know are summarized in Figures 11, 12. The ranking and matching process is very organized and fair. All interviews should be conducted in one USA visit, if possible. The candidate’s ranking considerations should include subjective and objective considerations (Figure 13). One must be both cautious and realistic. The matching process simply computer matches the applicants with the program. This is done at the National Resident Matching Program in Washington, D.C. (Figure 14). If a match does not occur, the applicant may search for an unfilled program. The results of the NRMMP for 2000-2001 are summarized in Figure (15,16)(2). Despite September 11, the number of ECFMG certified FMG’s has risen. In 2001, there were 5,934 ECFMG certified IMG’s (14). Clearly there is over a 2:1 ratio of certified FMG’s to entry-level positions available. Following a successful match the applicant completes the contract process (Figure 17).




Visa Application

The majority of ACGME residency programs in the USA require the J-1 Visa

(Figure 17). As mentioned, ECFMG certification, along with acceptance by an ACGME approved residency program, are pre-requisites for sponsorship for Exchange Visitor (J-1 visa) status. The ECFMG is the sole sponsor of non-citizen FMG’s or IMG’s for the federal Exchange Visitor program. This program is designed to promote international cooperation and understanding. The J-1 visa is a temporary, non-immigrant visa that requires return to the home country for a minimum of 2 years following completion of the residency, be it successful or unsuccessful (Figure 18). Further decisions regarding changes or extension of visa status is the duty and jurisdiction of the USA Department of State and not the ACGME approved residency program director or the ECFMG. It is important to note the restrictions in Visa status with regard to program changes (Figure 19a,b). Detailed or complicated issues related to visa applications, denials, delays, etc., requires legal consultation. In the USA this is done through immigration attorneys or lawyers. They work with the individual solely, or in conjunction with the particular residency program. (e.g. True, Walsh, & Miller, LLP, Attorneys at Law .

Each state in the USA has their own licensing requirements. Following or during the program credentialing process the individual state requirements are coordinated between the applicant and the accepting residency program. Specific state requirements for physician licensure are available at

Non-Accredited- ACGME Programs

In past years, advanced specialty training was readily available for FMG’s in the USA. J-I visa were readily available. In June 1999, new regulations were issued. The new rules were specific in restricting ECMG sponsorship to ACGME approved programs (15). This particular ruling and restriction places additional hardship on applicants with specific areas of needed training (e.g. congenital heart surgery) and those programs who have benefited from dedicated, sophisticated trainees.


Nigerian Medical Students

A number of Nigerian medical students have received further medical training in the USA. The total number is unknown. It is also unknown as to how many have remained in the USA. In recent years, and certainly after 9/11, prolongation of training with visa extensions will become more difficult and complicated. In a country of over 120 million people there are over 15,000 physicians with 90,000 hospital beds in country (Library of Congress/Federal Research Division/ Country studies/ Area handbook) There are 16 medical schools in Nigeria Clearly there is a need for an increase in both the quantity and quality of physicians in Nigeria The quality of medical school education in Nigeria has been quite good despite frequent school closures and strikes, lack of facilities, and lock of modern technology. The students are intelligent, focused, eager to learn, and highly disciplined. In keeping with the British tradition, the examination process throughout the educational system is highly structured, and competitive. Unfortunately, the rotations and clinical medical school training is disjointed and disorganized due to frequent strikes and economic constraints on hospitals and faculty. There is a lack of actual hands on experience and responsibility. Despite this, applicants for the ECFMG certification and sponsorship have done quite well. Preparation to pass and succeed for the USMLE (I/II); TOEFL; and CAS examinations includes basic and clinical experience, practice, individual and group study, as well as taking the formal Kaplan school courses/curriculum, if possible <http://www.>.

Specific Guidelines for Nigerians in ACGME approved residencies in the USA

It is extremely important to develop a focused plan and goal for study in the USA. Personal considerations include financial support, family, and present/future obligations in Nigeria. The major goal must include returning home. This can be difficult once exposed to the USA. The lifestyle and advanced medical system may become obstacles to returning home. This is quite understandable. An increasing number of Nigerians try to stay in the USA. Look for programs with an affinity for FMG’s. Try to network with other Nigerians in the USA. Most programs with a high FMG population are in rural areas and the inner city areas. The most popular specialties that FMG’s match with includes internal medicine, family practice/primary care, pediatrics, preliminary (transitional), psychiatry, and emergency medicine. The most difficult specialties include ophthalmology, orthopedics, general surgery, obstetrics/gynecology, plastic surgery, ENT, and cardiothoracic surgery. Again, the application process is extremely important. Sometimes, a notary public authorization is asked for (unusual for FMG’s). Some states require limited state medical licensure. This may require strict translation of non-English medical school diplomas and letters of recommendation by approved translators.

Once approved and accepted for an interview, the program will seek further insight into the character and personality of the applicant, and may pose clinical medical questions to assess logic and clarity, rather than knowledge content. The applicant , in turn, must assess the medical and non-medical aspects of the program being applied to. Non-medical concerns and problems include housing, insurance, transportation, security, social support for accompanying family members (school system, job opportunities for wife or husband).

Once matched, a contract or an official letter of employment from the Program director is required. This is essential to complete the Visa application. The accepting program usually provides further information and guidelines for the JI visa. Following the JI visa approval, planning and arrangements for travel to the USA is conducted. It is best to arrive 2-4 weeks prior to the July starting date (Figure 20). Many programs have an orientation program prior to the official starting date. This may also include obtaining BLS, ACLS, and ATLS certification. Rotations and call schedules are usually given early to allow subsequent vacation planning during the academic year. Benefits are summarized in Figure 21.

The ultimate success for residency training is multifactorial. A focused career plan is followed by adequate preparation to complete the application process. The visa issue is extremely important. Yearly checking and validation is important. Failure to complete the residency program involves both subjective and objective elements. The objective elements include the language barrier, success or failure on yearly in-service exams, and poor performance ratings on clinical rotations (Figure 22). The personal subjective elements are summarized in Figure 23 (a, b). Specific problems for the African FMG are summarized in Figure 24.





The present review is by no means exhaustive. It should serve as a guideline to more detailed and focused information. It is extremely important to network with friends, family, and professional colleagues regarding the subjective and objective aspects of pursuing GME in the USA. Though, at times, frustrating and depressing, the ultimate goal of achieving a superb training and experience is experienced by the majority. Useful internet addresses are listed in Appendix One.


  1. World directory of medical schools. World Health Organization-Seventh Edition. 2000 Geneva, Switzerland
  2. Lostumbo EM, Beran RL. (2001): Results of the National resident Matching Program for 2001. Acad. Med. 76: 665-668

(3 ) Atlas of the World, Ann Harbor, Michigan, Harper Collins, 1999 p.6

(4) International Brief: World Population at a Glance: 1998 and Beyond. U.S. Department of Commerce Economics and Statistics Administration Bureau of the Census 1B/98-4 Issued January 1999.

(5) Murray CJL, Lopez AD. (1997): Mortality by cause for eight regions of the world: Global Burden of disease Study Lancet. 349: 1269-1276

(6) Hyder AA, Morrow RH. Disease Burden Measurement and Trends. In: Merson MH, Black, RE, Mills, A.J ed. (2001): International Public Health, 2-4

(7) MacGowan WAL. (1997): Surgical manpower worldwide. American College of Surgeons Bulletin 72: 5-19

(8) Garrido PI. (1997): Training of medical assistants in Mozambique for surgery in a rural setting. South African J. Surgery 35: 144-145

(9) Epstein AM. (1995): US Teaching Hospitals in the Evolving Health Care System. JAMA 273: 1203-1208

(10) Iglehart JK. (1999): The American Health care System- Expenditures. N Eng. J of Med. 340: 70-76

(11) Iglehart JK. (1996): Health Policy Report, The Quandary over graduates of Foreign Medical Schools in the United States. N Eng. J of Med. 334: 1679-1684

(12) Mullan F. (1997): The National Health Service Corps and Inner-City Hospitals. N Eng J of Med. 336: 1601-1604

(13) Brotherton SE, Simon FA, Etzel SI. (2001): US Graduate Medical Education, 2000-2001. JAMA 286: 1056-1060


(14) Hallock JA. (2002): ECFMG and the Challenges Facing International Medical Graduates. Association of American Medical Colleges May, 2002 p 2-3

  1. Jonas RA. (2001): New Visa limits for Foreign Medical Graduates: Crisis in Subspecialty Care in USA. Asian Cardiovascular & Thoracic Annals 9: 250-252



Figure One



Population to be served Health expenditures*








$17, 000,000 (15%)


* Approximations based on 1975-1976 annual estimates




The health care dilemma in Ghana. The distribution of funds and personnel for primary health care compared to costly hospital-based care is in inverse proportion to the numbers of people that need to be reached. The health care pyramid for Ghana is upside down!



Figure Two (7)

Number of Surgeons per 100,000

Population Worldwide


United States 51

Japan 31

Sweden 29

Canada 26

The Netherlands 18

Australia 16

Germany 13

New Zealand 12

Poland 11

China 10

Qatar 9

Ireland 7

Latin America (Colombia) 7

United Kingdom 6

South Africa 6

Egypt 6

Bahrain 5

Kuwait 4

Philippines 1.45

Sudan 0.6

Kenya 0.6

West African States 0.5

Tanzania 0.3

Figure Three


Graduates of US & Foreign Medical Schools

Practicing Physicians in the United States *









All Graduates 511,090 559,988 632,121 683,201
Graduates from

US Med Schools

398,430 437,165 483,039 501,236
Graduates from Foreign Medical Schools 112,660 122,823 149,082 158,710
A. U.S.- Born 16,344 18,905 19,275 20,060
B. Foreign- Born 96,316 103,918 129,809 138,642






*Data from American Medical Association Physicians’ Master File





Figure Four


Graduates of US & Foreign Medical Schools

Entering US Residency Programs, 1988-1994 (11)*






Graduates of US

Medical School

Graduates of FMS

US Born Foreign

































*Data from Association of American Medical Colleges



Figure Five



Residents in Training in U.S. Allopathic Hospitals (12) *

Graduates of Graduates of

Total U.S. Foreign

Academic Year Residents Medical Schools Medical Schools

1988-1989 82, 795 71,239 11,556

1989-1990 87, 001 73,680 13,321

1990-1991 91, 781 75,764 16,017 1991-1992 95, 162 77,020 18,142

1992-1993 98, 622 77,721 20,901

1993-1994 102,341 78,581 23,760

1994-1995 103,754 78,074 25,680

1995-1996 104,612 77,849 26,763

Increase from 21,817 6,610 15,207

1988-1989 to




* Data are from the Association of American Medical Colleges.

Figure Six

Requirements for ECFMG Certification *





USMLE: United States Medical Licensure Examination

ECFMG: Educational Commission for Foreign Medical Graduates




* http://www/


Figure Seven


How to Apply for Residency Training Program



  • Application forms filled electronically via the Electronic resident Application System (ERAS)
  • Application must be fully completed



Figure Eight


Important Documents Required With Applications

  • Completed application form
  • Recent photographs
  • Superior scores in USMLE steps I & II
  • Passing grade in the Clinical Skill Assessment
  • Permanent Certification of Standard ECFMG (Form 246)
  • Positive Provost/Dean letter
  • Good letters of recommendation
  • Impressive Personal Statement

Figure Nine

How Residency Interviews Are Conducted

  • All applications are screened & vetted
  • Many are rejected due to:
  • Lasts from ˝ to 1 ˝ days
  • Interview may focus on questions to determine breath of knowledge, compassion, personality, ability to organize & communication skill
  • The Interview Panel ranks applicants by averaging the objective & subjective scores



Figure Ten

Preparing For the Interview

    • Interviews are normally conducted from early November till late February
    • Ask for early interview date
    • Preferably November or December
    • Research the internet about the program and type of hospital
    • Be familiar with what the Hospital is famous for:

- Trauma

- Oncology

- Transplant surgery etc



Figure Eleven



What Program Directors Look For In Applicants


  • Interview performance
  • USMLE scores & CSA pass
  • Good command of English language
  • Good communication skill
  • Provost/Dean’s letter
  • Letters of recommendation
  • Strong Personal statement
  • Reputation of your Medical School
  • Ability to fit into the program


Figure Twelve


What the Applicants Should Know About The Program

  • Future changes in direction of the program
  • Change in Program Director and/or staff
  • Strong points of the program
  • Weak points of the program
  • Past results of In-Service Exam (ABSITE)
  • Past results of Qualifying & Certifying exams
  • Do all Categorical residents finish the program? If not, why?
  • Do Senior Residents have trouble finding jobs or Fellowship positions?



Figure Thirteen

How to Rank The Programs After your Interviews

  • Depends on your Gut feelings
  • Don’t base your ranking on personal reasons
  • Avoid big name teaching hospitals
  • Factors to be taken into consideration:



Figure Fourteen


The Ranking & Matching Process


  • The Interview panel ranks all applicants by averaging the objective and subjective scores
  • The applicants rank the programs in order of their preferences
  • The rankings are sent to the NRMP in DC.
  • The computer matches the applicants with the programs, if a match is possible
  • If a match does not occur, the applicant scrambles after the match with available unfilled programs


Figure Fifteen

Results of National Residents Matching

Program For 2000 & 2001 (2)

Year 2000 Year 2001

# % # %

US Senior Medical Students 13,485 94% 13,542 94%

US Foreign Medical

Graduates 1,114 57% 1,048 52%

Non-US Foreign

Medical Graduates 2,418 39% 2,294 45%

All Applicants 18,391 73% 18,354 77%



Figure Sixteen

Residents Positions Filled by Specialist in NRMP

In 2000 & 2001 (2)

Year 2000

Year 2001

  US Foreign US Foreign
Family Practice 57% 8.3% 49% 9.0%
Int. Medicine 63% 17% 13% 16.0%
Pediatrics 75% 8.80% 12% 8.1%
O & G 75% 3.92% 15% 4.6%
Surgery 63% 7.28% 10% 8.2%
Orthopedic 88% 1.8% 6.0% 0.7%
Anesthesiology 50% 20.6% 15% 12.4%
Emerg Medicine 82% 1.1% 17% 0.9%
Pathology 38% 26.3% 18% 22.5%
Transitional 82% 6.2% 6.5% 3.6%


Figure Seventeen


What Next If You Are Matched?

  • Obtain a contract or an official letter of employment from the Program Director
  • Obtain a statement of need from the Ministry of Health of your home country or last legal country of residence
  • The statement must indicate the assurance of the country that it is in need of the specialty of training and confirm that the applicant would return home at the completion of training
  • Complete the ECFMG form
  • Upon establishing applicant’s eligibility, ECFMG will issue Form IAP-66 which is the Certificate of Eligibility for J-1 VISA
  • Take your application form for Visa and other documents to the Embassy in your home country or home of last residence
  • The Embassy issues the J-1 Visa
  • Submit Form 246 signed by the Program Director or designee to ECFMG
  • ECFMG issues the ‘Valid Indefinitely" sticker on the holder’s certificate


Figure Eighteen


Recent Changes in ECFMG Regulations

Relating to Foreign Medical Graduates


  • "The alien physician may once and not later than 2 years after the date the Alien enters the US as an Exchange Visitor change his/her designated program or training…"
  • "The Alien Physician may be allowed, with approval of ECFMG, enter into additional Fellowship Training Program."
  • The full length of time required to complete training required for certification must not exceed 5-7 years depending on the program
  • Each year of training is contingent upon satisfactory completing the requirement for promotion throughout the length of the program
  • Preliminary of Non-Categorical status guarantees only one year of training


Figure Nineteen (a)

Changing From Preliminary to Categorical Program

  • Residency training program is a progressive educational process
  • J-1 Visa holder may NOT change from preliminary year 1 to Categorical year 2 in the same specialty
  • However, he/she may progress from preliminary year 1 to categorical year 2 in the same specialty or in another specialty
  • When ECFMG issue Form IAP-66, a preliminary position is only for one year; however, the J-1 Visa is for 5 years for surgical residency. But the Exchange Visitor must understand that a second preliminary or categorical year is NOT guaranteed since training in the same specialty must be progressive
  • Also note that you can only change your specialty once


Figure Nineteen (b)

Preliminary Program Conversion Regulations


Changing From

Changing To


Preliminary PGY-1

In Surgery

Other Specialties


Preliminary PGY-1

In Surgery

Categorical PGY-2

In Surgery


Preliminary PGY-1

In Surgery

Categorical PGY-1

In Surgery



Figure Twenty



The Orientation

  • Usually 1-2 weeks starting from June 15-30
  • Purpose:
    • General information & meeting key personnel
    • Getting to know other residents
    • Filling several forms for:
      • Temporary medical license
      • DEA Number
      • Hospital identification badge
      • Parking permit
      • Application for loan
      • Food Voucher
      • BLS, ACLS +/- ATLS Courses are taken during the orientation period



Figure Twenty-One




  • 2 weeks vacation
  • One week educational meeting
  • Moving allowance
  • Personal loan with low interest
  • Malpractice Insurance
  • Health & Dental Insurance
  • Life & Long-term disability Insurance option
  • Short-term disability (maternity, family, sick leave)



Figure Twenty-Two


Resident’s Continuous Evaluation

  • Staff evaluation of residents after @ rotation
  • Continuous & bilateral feedback after @ rotation
  • Biannual review & discussion of residents’ performance by the Residency Committee including 2 chief residents as members
  • Residents are also given the opportunity to evaluate:

- Value of each rotation to their training & education

    • The attending staff they served under
    • Program as whole
    • Affiliated Institutions
  • All constructive recommendations are taken seriously and acted upon

Figure Twenty-Three (a)


Reasons For Failure

  • Wrong choice of career
  • Change to another specialty
  • Unhappy with matched program
  • Dissatisfaction with clinical & educational experience
  • Loss of interest (Burnt out)
  • Rigors of the specialty: long days & nights
  • Domestic problems
  • Illness or death



Figure Twenty-Three (b)

Factors Responsible For Poor Performance

  • Higher incidence among:
    • FMGs (specific percent is unavailable)
    • Underrepresented minorities
    • Older residents >35 years
    • Single parents
  • Situational, personal & professional stress
  • Perceived poor academic performance
  • Depression
  • Cognitive dysfunction
  • Psychiatric illness
  • Substance abuse and alcoholism

Figure Twenty-Four


Problems Specific to African FMGs

    • Difference in medical curriculum
    • Medical technology divide
    • Attitude & cultural differences in approach to authority
    • Interpersonal relationship
    • Behavioral problem
    • Language or accent problems
    • Different life stage, stress & strain
    • Lack of family support & financial strain
    • Length of time since graduation from Med School
    • Traumatic experience from discrimination



Useful internet sites for detailed information


American Association of Colleges of Osteopathic Medicine (AACOM)

American Association of International Medical Graduates (AAIMG)

American Medical Student Association (AMSA)

Association of American Medical Colleges (AAMC)

Educational Commission for Foreign Medical Graduates (ECFMG)

International Federation of Medical Students’ Associations (IFMSA)

International Medical Graduates website

Legal information regarding visas

The Princeton Review Guide for Students and Graduates of International Medical Schools





Figure One Ghana Health Care Model

Figure Two Number of Surgeons per 100,000 Population Worldwide

Figure Three Graduates of US & Foreign Medical Schools Practicing Physicians in the Unites States

Figure Four Graduates of US & Foreign Medical Schools Entering US

Residency Programs, 1988-1994

Figure Five Residents in training in U.S. Allopathic Hospitals

Figure Six Requirements for ECFMG Certification

Figure Seven How to Apply for Residency Training Program

Figure Eight Important Documents Required With Applications

Figure Nine How Residency Interviews Are Conducted

Figure Ten Preparing For the Interview

Figure Eleven What Program Directors Look For In Applicants

Figure Twelve What the Applicants Should Know About The Program

Figure Thirteen How to Rank The Programs After your Interviews

Figure Fourteen The Ranking & Matching Process

Figure Fifteen Results of National Residents Matching Program For 2000

& 2001

Figure Sixteen Residents Positions Filled by Specialist in NRMP in 2000

& 2001

Figure Seventeen What Next FI You Are Matched?

Figure Eighteen Recent Changes in ECFMG Regulations Relating to Foreign

Medical Graduates

Figure Nineteen (a) Changing From Preliminary to Categorical Program

Figure Nineteen (b) Preliminary Conversion Regulations

Figure Twenty The Orientation

Figure Twenty-One Benefits

Figure Twenty-Two Resident’s Continuous Evaluation

Figure Twenty-Three (a) Reasons For Failure

Figure Twenty-Three (b) Factors Responsible For Poor Performance

Figure Twenty-Four Problems Specific to African FMG’s

Appendix One Useful internet sites for detailed information