If you completed your medical education outside of Canada or the US but you intend to practice medicine in one of these countries, then this blog is for you. As an International Medical Graduate (IMG) looking to match to residency programs in Canada or the US, it is important to be aware of the challenges you will have to overcome to match successfully. In this blog, you will learn about the eligibility criteria for IMGs in Canada and the United States, how to prepare your residency application, including your personal statement, and how to get ready for that coveted residency interview.
Here's what you're going to learn:
First, you will need to know how residency matching works. The matching process in both Canada and the United States is facilitated through the use of a computer algorithm. Each applicant submits a Rank Order List (ROL) of preferred programs, while each program director submits a ROL of preferred candidates. The algorithm then matches the applicant’s ranked programs with program directors’ ranked candidates. In Canada, these lists are entered into the Canadian Resident Matching Serivce (CaRMS). CaRMS is a national organization that provides an electronic application and computer matching service for entry into residency positions throughout Canada. In the United States, they are entered into the National Residency Match Program (NRMP), which performs The Match. The Electronic Residency Application Service (ERAS) is used by most American programs for residency matching.
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The Match is a system used to match students with US residency programs. Although not every program uses The Match, most do. Programs that choose to participate are required to register each position and attempt to fill them to ensure a fair process. Before IMGs can start applying for residency positions, they must meet a set of requirements.
US medical schools have their own definition of international medical graduates. The location and accreditation of the medical school attended determines whether the graduate is an IMG, not the citizenship of the graduate. This means that American citizens who graduated from medical schools outside the United States and Canada are considered IMGs. Non-US citizens who graduated from medical schools in the United States and Canada are not considered IMGs. The Educational Commission for Foreign Medical Graduates (ECFMG) assesses whether IMGs are ready to enter residency programs in the United States. You must be certified by the ECFMG before you can take the USMLE or start a graduate medical education program. The ECFMG coordinates the ERAS application process for international medical graduates.
Certification with ECFMG
- Submit an application for ECFMG certification before applying for their examination. Consult the World Directory of Medical Schools to confirm that international medical graduates from your school are eligible.
- IMGs must pass the USMLE Step 1 and 2. These are the same examinations taken by US and Canadian graduates.
- Medical Education Credential Requirements include physician’s medical school and graduation year listing in the World Directory of Medical Schools, awarded credit for at least four years of medical school, documentation of completion of all credits and receipt of a final medical diploma and final medical school transcripts.
The certification process starts when you apply to ECFMG for a USMLE/ECFMG identification number. As soon as you get this number, you can use it to complete the application for ECFMG certification. Once you submit your application for certification, you may apply for examination. As one of the requirements of certification is the verification of your medical school diploma, you cannot complete the entire certification process until you have graduated. With this said, you can apply for the required examinations as soon as you meet the examination eligibility requirements. All of the required examinations are offered throughout the year.
The Federation of State Medical Boards publishes state-specific requirements for medical licensure, including:
- Minimum postgraduate training required
- Number of attempts at licensing examination allowed
- Time limits for completion of licensing examination sequence needed for license eligibility
Make sure to check their website in advance as you don't want to waste your time and money applying in states that limit training permits or recognize fewer international medical schools than the full list of World Directory of Medical Schools. It is crucial to verify your eligibility within each US state and each program before you apply.
US graduate medical programs’ directories
You can find the descriptions of most programs on the following online directories. These include:
- The Fellowship and Residency Electronic Interactive Database Access (FREIDA) is the online directory of graduate medical education programs sponsored by the American Medical Association (AMA)
- The Accreditation Council on Graduate Medical Education (ACGME) also offers a residency directory
- The American Academy of Family Physicians (AAFP) offers an online family medicine residency directory
Each medical specialty has specific information about individual programs, as well as any general or special requirements for application including whether they admit IMGs. Application deadlines vary among the programs. Make sure you confirm your program’s deadlines.
Residency program requirements
Program requirements for each residency position are most often listed on their websites. These may include medical school graduation year, types of visas accepted, or how many USMLE attempts are allowed. Make sure that you understand your program’s residency requirements before applying.
The Federation of State Medical Boards (FSMB) updates state-specific information for residencies. You can use this site to find out if you can get a license in a specific state during residency. Some states, such as California, have a list of recognized international medical schools that are eligible for licensure in the state. Some states have restrictions on the number of USMLE attempts allowed.
In order to participate in American graduate medical programs, international medical graduates who are not citizens or permanent residents must obtain the appropriate visa. The two most common visas are the H1-B (Temporary Worker) or the J-1 (Exchange Visitor). Some institutions will sponsor the visa for residents in the residency program, so it would be wise to check with your program.
The ECFMG is also authorized by the US Department of State to sponsor foreign national physicians for the J-1 visa. Learn more about your visa application process from your residency program, the American embassy or consulate in your country of residence, or the US Citizenship and Immigration Services.
The Medical Council of Canada (MCC) provides requirements for the residency match process. Make sure to check these requirements on their website before you begin your applications. If you are an IMG wishing to apply for residency in Canada, these are the standard eligibility requirements:
You are a current student or graduate from a school listed in the World Directory of Medical Schools, OR your medical school must be accredited by the Committee on Accreditation of Canadian Medical Schools (CACMS) or the Liaison Committee on Medical Education (LCME) (in the U.S.) OR your medical school must be accredited as a U.S. School of Osteopathic Medicine.
Written and passed, or be scheduled to write the National Assessment Collaboration (NAC) examination
Written and passed, or be scheduled to write the Medical Council of Canada Qualifying Exam Part I (MCCQE Part I). This examination assesses the critical medical knowledge and clinical decision-making ability of a candidate at a level expected of a medical student who is completing his or her medical degree in Canada.
Must be a Canadian citizen or a permanent resident of Canada. Visa holders are not eligible.
You can choose to take the NAC exam and the MCCQE Part I in the order that you prefer. You must also remember to write the examinations before the programs’ deadlines. Please check with your program when the examination results must be submitted and schedule your exam accordingly. You can find important timeline information for your application cycle on the MCC website. Please be aware that the United States Medical Licensing Examination (USMLE) cannot substitute any of these exams.
The above-mentioned list includes just the basic requirements that would allow IMGs to participate in the CaRMS matching process. The requirements of MCC is just one set of criteria, but you must research the requirements of each province separately in order to apply for positions in those provinces. As an international medical graduate, you may have to take additional steps to verify your medical degree, complete additional examinations, or enter into a service agreement that commits you to practice in a particular area for a specific amount of time. Take into account that meeting certain provincial eligibility requirements for IMGs can be extremely challenging.
You can find help discerning all the provincial requirements by visiting the CaRMS official website where you will find the provincial criteria section. Requirements listed under each province in this section will apply to all programs within that province. Ensure you have read the information provided under the provincial restrictions to meet all the necessary requirements when applying for the programs of your choice. A list of programs with descriptions is also available on the CaRMS website. Each program will indicate what documents are required, which exams need to be passed, and which provincial assessments are preferred. When studying each program, be sure to check both the program’s list of requirements and the criteria of the province in which the program is located.
Competition is fierce for IMGs. Each year, thousands of applicants compete for few positions. In recent years, IMGs in the US matched at an approximate 56% rate while IMGs in Canada matched at an approximate 50% rate. According to a study by the NRMP, IMGs that matched to their preferred specialty are most likely to:
- Rank more programs within their preferred specialty
- Have higher USMLE Step 1 and 2 scores
- Be US citizens
When considering how many residency applications you should submit, remember that each application demands a high level of research and preparation. The quality of an application is the most important aspect, so it's better to send fewer high-quality applications instead of more low-quality applications. The Association of American Medical Colleges (AAMC) keeps records of the average number of residency applications per student for different specialties. Some of the most competitive fields, including family medicine, psychiatry, internal medicine, anaesthesiology, and pediatrics, see more than 70 applications from one candidate. So, with all those applications, how can your application stand out? Follow our tips below!
Check out our video below to get into a competitive residency program as an international medical graduate:
Gain clinical experience where you want to practice.
As an international medical graduate, you should absolutely gain clinical experience in the country to which you're applying. This is important for making your application stand out and for convincing program directors that you’ve taken the necessary steps to transition effectively from a foreign medical graduate to an effective physician in a new country. In addition to gaining first-hand experiences in Canadian or US healthcare systems, this clinical experience will also allow you to secure letters of recommendation from faculty members who supervised you and who are familiar with the expectations of US or Canadian residency programs. It is a good idea to consider setting up a clinical externship or enroll in an elective program that can provide valuable hands-on experience in the American or Canadian medical system. If you are currently a medical student, many medical schools offer opportunities for visiting student and clinical away electives. Some programs are free, but most require a fee.
Participate in observerships.
If you are no longer in medical school, your chances of obtaining clinical experience in the US is limited, but not impossible. Your best option is to participate in observerships. Similar to shadowing, observerships will provide you with an opportunity to learn about the healthcare system in the country you’re applying, make connections, and increase your overall knowledge. In some Canadian provinces, IMGs may apply for a clinical observership permit. For example, Nova Scotia issues clinical observership permits to students who were trained outside of Canada and do not yet meet requirements for a license to practice medicine in Nova Scotia. The permits allows you observe, learn, and gain insight into the practice of medicine in Nova Scotia under the supervision of practicing doctors in hospitals and medical practices. This will be helpful in preparation for your licensing examinations and skill assessment. Keep in mind that the observership permit is not a license to practice medicine, nor is it considered as training or work experience.
Gain research experience.
Another way to improve your residency applications, especially for programs that focus on academic progress and training future researchers, is to gain research experience. Securing a position as a research assistant will help set you apart from other IMGs as most programs highly value US or Canadian research experience. Try to gain a position where you’ll be testing hypotheses, analyzing results, and preparing reports. Make sure that you form a good bond early on with your research mentor in order to secure an excellent letter of recommendation.
Strengthen your extracurriculars.
Extracurricular activities matter for one simple reason: every strong candidate has them. You will not be a program director’s top choice if you have nothing to put in the CaRMS or ERAS experiences section. Clinical experience, volunteering, teaching, and research are great experiences to possess. These activities can make you stand out above other applicants and can be the difference between simply matching and matching with your preferred program. The directors of residency programs will want to see that you are passionate about medicine and your specialty choice and that you’re constantly learning and growing as a person and future physician. It’s important to note that not all extracurriculars have to be related to medicine. Showing dedication and a long term time commitment to activities that are important to you are just as meaningful. For example, commitment to a particular sport, a musical instrument, or even a type of dance. Now, this doesn’t mean that you have to join every single student-run clinic or apply for every leadership program. Make sure that you are only participating in activities that you actually enjoy and are significant to your growth and development.
Demonstrate core competencies.
It is crucial for IMGs to familiarize themselves with Canadian and US guidelines that dictate the expected behavior and abilities of future physicians. The CanMEDs framework is a good reference for any future physician, as it identifies the qualities and abilities physicians require to develop in order to perform their jobs well. These qualities and abilities can be grouped into these seven roles: medical expert (primary role), professional, communicator, collaborator, leader, health advocate, scholar. When preparing your personal statement, CV, or if you are practicing for an interview, try to relate your extracurricular activities and experiences to these seven roles. AAMC competencies is another framework that can help you choose and highlight appropriate extracurricular activities. Fifteen abilities and skills are grouped into three categories: pre-professional competencies, thinking and reasoning competencies, and science competencies. These 15 core competencies can help you organize your developed skills and abilities, and connect them with your program’s expectations.
Craft an eye-catching personal statement.
For most residency programs, the personal statement is a key factor in their choice of candidates. It’s important to demonstrate reflection in your personal statement and write concisely. You’ll have to write a separate residency personal statement for each specialty you apply to, but not for each program, so it's important to adhere to any word or character count stated in the program-specific instructions. Let’s examine some of the things you should keep in mind when preparing your personal statement for each program.
IMGs looking to match in Canada and the United States can find helpful information in program directories. First, be sure to study the description of the program you’re applying to as it will give you some clues as to what you should emphasize in your personal statement. Read between the lines – the description may give direct or indirect indications as to what this program likes to see in their residency candidates. Does the program stress public service or research? Does it seem to highlight specific qualities like interpersonal skills, or academic prowess? Perhaps the description questions candidates’ level of commitment, ability to handle pressure, and communication skills? Decide accordingly what the main message of this description is and what kind of impression you want to make. Create a strong connection between your candidacy and the program.
Next, your statement needs to answer why you want to pursue a particular specialty. Remember, your personal statement is not a recitation of your CV, instead, it's an opportunity to discuss who you are as a person, how your experiences have led you to apply, and why you are a suitable candidate for the position. You'll need a strong, unique introduction, evidence filled body paragraphs, and a conclusion that ties everything together and leaves program directors wanting to learn more about you.
Finally, your personal statement should be free from grammatical errors and spelling mistakes and should be reviewed, ideally by a professional, multiple times, in order to get it just right. Have a look at successful residency personal statement examples to help you craft your own effective essay.
The interview is your chance to assess your chosen programs personally. Even though you’re the interviewee, what’s great about residency interviews is that you also have the opportunity to play interviewer to decide whether or not you want to become a resident in a particular program. During your interview, keep tabs on how compatible you are with the program, how comfortable you feel, and how well the program meets your desired goals. You’ll want to assess the program’s strengths and weaknesses so that you will be able to structure a well-founded ranked list of your chosen programs. At the same time, your interviewers will be trying to assess your compatibility with their program. During your interview, faculty and residents will try to understand whether you would be a welcome addition to their program. In short, the residency interview is a delicate and complicated interaction that tests both the candidate and the program.
The only way to ace your residency interview is to prepare effectively in advance. Follow these tips below to help get you there:
Determine your interview format: Review the information you’ve received from the program to determine your interview format. You could have a panel interview, traditional one-on-one interview, video interview or MMI.
Research: It’s essential to do your research before the interview so you know as much about the program as possible. Go into the program’s website to review their mission statement, core values, accomplishments and history. You will almost certainly be asked the “why our program” question, so you need to develop your own suitable answer to this question. Find out what is important to them, and then highlight your relevant experiences and values that make you a suitable applicant.
Reflect: Know yourself. Be confident and aware of what you have to offer. You have acquired a wide range of skills and experiences throughout your education and your training. Be sure that you can articulate experiences you've had, answer why they were important, and what you've learned from them. It is essential to be able to connect your skills to the programs’ expectations.
Highlight key qualities and desirable personality traits: Highlight traits sought by interviewers such as drive, motivation, communication skills, determination, confidence, reliability, honesty/integrity, dedication, analytical skills, listening skills. You should be highlighting some of these qualities in your personal statement but you should also discuss them in your interview.
Practice: You need to be prepared to answer common residency interview questions such as "tell me about yourself” and "why our program" effectively and these are not easy questions to answer on the spot. For this reason, it's essential that you practice with questions that you're likely to encounter so that you can formulate a strong response early on. In addition to preparing with practice questions, the next step is to prepare by taking full-length mock interviews in the format of your interview. For example, if you have a MMI, it’s a good idea to participate in a realistic MMI interview in order to understand different types of MMI questions, practice your pace, and receive personalized feedback to strengthen your answers and eliminate any weaknesses or red flag responses. Have a look at our 100 MMI questions to get you started and if you're applying to CaRMS, check out our CaRMS interview questions and CaRMS interview prep blogs.
Gather a list of questions to ask your interviewers: It’s a good idea to have some interesting questions prepared ahead of time to let your interviewers know that you’ve really given some thought to the qualities of their particular program. Prepare specific questions about the program, location, residents, and school and ask them at the end of your interview. Try to stand out with your questions. Your interviewers are most likely tired of answering the same questions (just like you). You will make a more lasting impression if you come up with memorable inquiries, in addition to those that will help you rank the program effectively.
Rehearse: Once you have your main talking points for answering residency interview questions, you need to rehearse. Practice by saying your answers out loud in front of a mirror, or if you can, record yourself. This will help you look for any nervous or unfavorable behaviors you may be exhibiting such as playing with your hair or pacing. You don't want to memorize your answers, but you want to ensure you’re hitting the most important points during your responses and that you feel comfortable and confident.
Send thank-you letters: Remember to send thank-you letters to program directors within 48 hours after your interview. Include your name, interview date, and ideally, the names of your interviewers.
According to the most recent NRMP Main Residency Match, the following are the most IMG friendly residency programs in the top 12 IMG friendly states:
Total IMGs: 897
US IMGs: 36
Success rate: 4%
Non-US IMGs: 53
Success rate: 5.9%
Total IMGs: 1658
US IMGs: 97
Success rate: 5.8%
Non-US IMGs: 28
Success rate: 1.6%
Total IMGs: 2278
US IMGs: 450
Success rate: 19%
Non-US IMGs: 229
Success rate: 10%
Total IMGs: 6979
US IMGs: 939
Success rate: 13.5%
Non-US IMGs: 1811
Success rate: 26%
Total IMGs: 524
US IMGs: 51
Success rate: 9.7%
Non-US IMGs: 130
Success rate: 24.8%
Total IMGs: 942
US IMGs: 49
Success rate: 5.2%
Non-US IMGs: 36
Success rate: 3.8%
Total IMGs: 360
US IMGs: 34
Success rate: 9.4%
Non-US IMGs: 154
Success rate: 42.7%
Total IMGs: 1839
US IMGs: 182
Success rate: 9.8%
Non-US IMGs: 290
Success rate: 15.7%
Total IMGs: 1094
US IMGs: 108
Success rate: 9.8%
Non-US IMGs: 81
Success rate: 7.4%
Total IMGs: 605
US IMGs: 51
Success rate: 8.4%
Non-US IMGs: 60
Success rate: 9.9%
Total IMGs: 1335
US IMGs: 135
Success rate: 10%
Non-US IMGs: 169
Success rate: 12.6%
1. Is there anything else I can do to increase my chances of getting noticed by the program of my choice?
There are some things you can do that could give you a competitive edge. It is a great idea to participate in opportunities that are offered near the place where you would like to practice. For example, during your medical school studies, you can plan to take an elective over the summer in the city where your desired program is located. By getting to know some of the local professionals, you can later ask them for a letter of reference when applying to your desired position. Familiarity with local professionals can increase your chances of getting a desired position. Forming relationships and having a recognizable name with doctors and residents who are related to your desired program could become a great advantage during the application process – you will be more than just a name on a piece of paper. Another tip is to try and reach out to program directors and current residents. This can also help in becoming a candidate who stands out more, plus it will allow you to learn more about the program, and potentially help in getting observerships.
2. What if I get asked about my rank order list during the interview?
For CaRMS, programs and applicants are not obliged to discuss where they are going to be ranking each other. So, generally, for Canadian programs, this is not a question you need to worry about. For US programs, while it is not likely to come up during the interview, let them know that you really enjoyed learning about the program and it's educational components, as well as meeting the faculty and residents, and then state that you will be making decisions about your rank order list once all your interviews are finished. This way, you'll be respectful but honest, and you don't have to state exactly where you'll rank each program.
3. What should I put in my letter of intent?
Review our medical school letter of intent blog for details and a full-length example.
4. Is there a limit to how many times I can take the Medical Council of Canada Qualifying Exam Part I (MCCQE Part I)?
You may take the MCCQE Part I a maximum of four times. However, you cannot retake the exam if you have a pass result. A one-year waiting period will be required between the third and fourth attempts. After four attempts, in exceptional personal circumstances, you can request to the Central Examination Committee for special permission to make a fifth attempt.
5. What should I include in my CV when applying to residency programs?
Your residency CV should highlight your skills and experiences and should be constructed in reverse chronological order. In general, it should include the following:
- Personal data
- Clinical experience
- Research experience
- Volunteer experience
- Awards and scholarships
- Professional associations and memberships
- Interests and skills
- Extracurricular activities
6. Are there questions my interviewers are not allowed to ask me during the residency interview?
Yes, there are certain questions that you do not have to answer. It is illegal to make employment decisions based on race, color, sex, age, religion, national origin, or disability. A frequent area of concern during the interview process is questions related to parental leave, pregnancy, and child-rearing plans. The prohibition against discrimination on the basis of sex includes discrimination on the basis of pregnancy and child-rearing plans. You do not have to answer questions related to marital status, number of children, or plans to have children, but you may want to prompt a discussion of the provisions for maternity/paternity leave and/or childcare responsibilities in the residency program.
7. I didn’t match! What do I do?
Don’t panic if you do not get a match. Often, even if an IMG candidate completes all the examinations and other requirements, many IMGs are not successful in their first participation in the matching process. This is mainly due to the limited number of spots assigned to IMGs. Every year there are applicants who don’t match. Many students who don’t get placed through the main matching systems try to obtain positions through alternative avenues, like Supplemental Offer and Acceptance Program (SOAP) but do keep in mind that these are also usually very competitive. If you find yourself with a year off, use that time wisely to gain experiences that may give you a competitive edge in your next cycle of applications and reach out for professional help in reviewing your application to ensure it puts forth the best version of yourself. Do not beat yourself up – this is a long and complicated journey. If you’ve come this far, you can overcome this challenge.
8. Does my IMG status hurt my chances of matching?
IMG status does make the matching process more difficult. These difficulties come from the laborious process to merely qualify for the residency match and the steep level of competition. In truth, the matching process is challenging for all applicants, not just IMGs. Many US programs prefer to accept skilled American graduates over skilled international graduates, but there are IMG friendly residency programs that have a steady number of international students admitted every year. If you are an American citizen and an IMG, US programs may ask why you didn't go to an American medical school. Be prepared to answer this question. Remember, being an IMG does not put a ceiling on your ability to match with your desired program.
9. What kind of US clinical experiences should IMGs have?
There are two types of US clinical experiences. The best type of clinical experience is to take electives at US medical schools as a student. They can be clerkships, externships, sub-internships, etc. Students can enroll in US medical schools' elective clinical rotations during their final year at medical school. Try to find out if your medical school has affiliations or agreements with US medical schools. If your school does not collaborate with any US medical schools, it will be more difficult, so be sure to plan ahead. Student elective clinical rotations last about four weeks, then you move onto the next elective course. These electives will provide you with hands-on experiences. You will first observe a technique or procedure, and then you will perform the task under the guidance of your faculty instructor. One of the great benefits of such electives is that you get to "try on" different departments and programs to help you determine which specialty you'd like to pursue.
The second type of clinical experience is observerships. As previously mentioned, observerships are not hands-on experiences, but they can lead to great opportunities. A good relationship with a faculty member in your observership may flourish into a mentorship. Because observerships generally last longer than electives, they have the benefit of showcasing your growth and productivity over time. If you form strong relationships with your mentors, you'll be able to secure strong letters of recommendation that can help your application stand out. Lastly, observerships will help you transition into US practice.
10. Are observerships paid?
Observerships are meant to benefit the observer and prepare them to enter US clinical practice, unfortunately, they are not paid.
11. As an IMG, who should I ask to write my letters of recommendation?
As an IMG applying to residencies in Canada and the United States, it would be ideal to have references from faculty and physicians from these two countries. This would mean long-term planning on your part. Try taking some electives in the program or state where you’d like to match. Get to know the faculty and physicians. Be sure to keep in touch with them after the elective is over. If you form a good relationship with your US colleagues, they would be the optimal referees for your IMG applications.
Another option is to find observerships in your field in the US and Canada and ask your mentor to provide you with a letter of recommendation. A letter from a specialist from another country who did their residency or fellowship in the US or Canada would also be a good addition. If you don't have letters of recommendation from North American physicians, it does not eradicate your chances of matching. The most important aspect is that your letters are strong and your referees can demonstrate why you would be a good fit in your specialty of choice.
12. Should I pursue an additional degree in the US or Canada to increase my chances of matching?
Additional qualifications do not necessarily increase your chances of getting into residency programs. For this reason, you should only pursue an additional degree in the US or Canada if it is in line with your professional goals, not because you think it will improve your chances of matching to residency programs.
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