Complete Guide to Medical Residency in the USA for International Students

Looking to pursue Medical Residency in the USA? You’re not alone! According to the American medical association (AMA), about 22.7% of licensed physicians in the United States are International Medical Graduates (IMGs). 

Many medical doctors and students worldwide choose to pursue Medical Residency in the USA due to its numerous benefits. 

  • Quality of training.
  • Research opportunities. 
  • Excellent career prospects post-training.
  • Flexible employment system.
  • High income and good lifestyle. 

But you don’t get something for anything. 

Or, in other words: No pain, no gain. 

The truth is, the US residency match is a highly competitive, challenging, and lengthy process, and to be honest, I had a panic attack the first time I heard of all the requirements. 

Is it hard? The answer is yes. 

Is it worth it? The answer is still yes. 

Is it doable? The answer is definitely yes.

Therefore, If you’re willing to take on the challenge, we’ll review together in this article all you need to know about the US residency match journey. 

But, before we proceed, note that some of the information provided here may change.

Therefore, you should regularly monitor the official website for any updates. 

ECFMG Certification: A Key Requirement for Pursuing Medical Residency in the USA 

Before taking action, you must first ensure that your medical school is listed in the World Directory of Medical Schools (World Directory) and, thus, that you’re eligible for the ECFMG certification. 

If it’s not the case, you cannot start the ECFMG certification process and take any USMLE exams. 

The ECFMG certification process starts by doing the following: 

  • Obtain a USMLE/ECFMG Identification Number through ECGMG online services.
  • Submit the notarized Certification of Identification Form (Form 186) to ECFMG.

This part is quick and easy; you just have to follow the instructions. 

Now that you’re registered, things will become more fun, as the next step involves much studying. 

And I really mean a lot of studying.

You’ll have to take the USMLE Step 1 and the USMLE Step 2 CK exams to participate in the residency match. 

The exams are computer-based and shouldn’t be taken lightly, as they literally represent your application’s backbone. 

Luckily you can find on this blog many articles related to USMLE Step preparation that will help you nail the exams.  

Before the Covid 19 pandemic, candidates had to clear the USMLE Step 2 CS exam to complete the ECFMG certification processes.

This exam has been cancelled since and replaced for IMGs by Pathways to meet the clinical and communication skills requirements.

There are a total of 6 pathways, and the official website gives all the information to identify your pathway. 

Regardless of the pathway, you’ll have to take one final exam: The Occupational English Test.  

Once you’re done with the USMLE exams and have cleared the pathway, to complete the ECFMG certification process, you must send your diploma and medical school credentials to ECFMG. 

Processing these documents can take weeks to months, so you may have to be patient. 

Application to programs

Okay, once you’re ECFMG certified, what’s next? 

Well, the residency match season usually starts in June every year. 

At that time, you must purchase a token that will give you access to your ERAS account., and start getting ready for the match by doing the following:

  • Work on a list of programs you want to apply to.  
  • Start writing your personal statement. 
  • Collect the Letters Of Recommendation from the doctors you’ve worked with.
  • Work on your resume.
  • Gather all the necessary documents ( MSPE or Deans Letter provided by your medical school, medical school Transcripts, and a professional photo) 

The sooner you start, the better it is. 

 What I have described so far in this article is only “the tip of the iceberg.” 

The requirements we’ve detailed are what is “officially” requested to participate in the match process and be considered by most programs. 

But participating doesn’t necessarily mean matching. 

To match, you must be considered a “strong candidate,” which takes much more than we’ve just seen. 

So, let’s dive into what’s behind the scene to understand all the elements that can make a difference in the match process and help you achieve your goal. 

Match into Residency in the US: requirements and Process

Now, let’s dive deeper into what lies beneath the surface and explore the additional requirements for International Medical Graduates (IMGs) pursuing Medical Residency in the USA.


Scores are critical in the residency match journey. 

Since USMLE Step 1 changed from a graded to a pass/fail exam, programs now place more emphasis on Step 2CK scores.

Although some residency programs specify a minimum passing score as a prerequisite for consideration, others do not. This does not necessarily imply that they place less importance on exam scores.

Usually, a score above 240 on Step 2CK is considered good. Of course, the greater your score is, the better it is for your application. 

However, if you score below 240, you may still have further chances to match, as the minimum match score can vary depending on the specialty you are applying to. More details for each specialty are outlined in the NRMP charts.  

For example, the average Step 2CK score to match into anesthesiology as an IMG in 2022 was 240, while it was 235 for internal medicine.

Research experience and publications

When I was creating my program list for internal medicine, I noticed that research or publications were rarely indicated as a requirement by the programs. However, having research or publications on your application is like adding sprinkles to your ice cream – it’s not necessary, but it makes it more enjoyable!

That being said, the importance of research and publications can vary depending on the specialty you’re applying to, just like with Step 2CK scores. Competitive specialties like dermatology or neurosurgery tend to place a higher emphasis on research experience and publications, while less competitive specialties like family medicine or internal medicine may not stress them as much.

If you want to learn more about getting publications, you can refer to my article that gives IMGs some clues on navigating the mysterious world of how to get published.  

US Clinical Experience

US Clinical Experience (USCE) is the clinical experience International Medical Graduates (IMGs) acquire in the US healthcare system.

Gaining clinical experience in the US is key for IMGs, as these experiences will allow you to: 

  • Gain a better understanding of the US healthcare system and medical practices
  • Enhance your clinical skills and build your confidence in patient care
  • Demonstrate your ability to work in a US healthcare setting, which can improve your chances of matching into a US residency program.
  • Make connexions that may boost your chances to match in a residency program. 
  • Get the Letters of recommendation you need to apply to programs. 

As with the scores, some residency programs detail how many and which type of USCE they require on their website, while others don’t.

But, again, this doesn’t mean that they don’t care, nor that those programs wouldn’t consider it.

Many IMGs wonder whether USCEs are mandatory because some programs mention in their requirement that IMGs can apply without USCEs. 

But again, applying doesn’t mean matching

Therefore, can you apply to a program without any USCE? Yes. 

However, is it a good idea to apply without any USCE? Definitively No. 

If you’re an IMG with limited USCE, there are still ways to strengthen your application. Consider applying to clinical externships, observerships, or research positions in a US healthcare setting. 

If you want more information about USCE, you can refer to my article about all you need to know about US Clinical Experience as an IMG.

Year of Graduation

Okay, folks, now we’ll have to discuss a sensitive topic. 

First, what do we mean by the Year Of Graduation (YOG), and how do we calculate it? 

Your year of graduation refers to the year you graduated from medical school and the time that has elapsed since then.  

For example, if you graduated in March 2019 and plan on participating in the Match of September 2023, your YOG is four years and six months. 

Well, now, why does it matter? 

Being an “old grad” is considered a red flag and may compromise your chances of matching in a US residency program. The definition of an old graduate can vary from program to program and can be anywhere from 2 to 5 years after graduation.

For the best chances of matching, it’s recommended to start the application process while still a student or within two years following graduation. 

However, even if you graduated 5 or 10 years ago, don’t lose hope. 

Some programs do accept IMGs who graduated more than five years ago.

The more recently you’ve graduated, the better your chances are to match, so staying up to date with the requirements and timelines for each program is essential. 

By keeping your options open and being proactive in your application process, you can increase your chances of success and find the best program to fit your needs

Visa Status

Well, if you’re like me, meaning that you aren’t a US citizen nor have a green card, then you need a visa to pursue residency training in the US. 

The most popular visas for IMGs are the J1 and H1B visas. 

Because this article aims to give you an overview of the process of pursuing a residency in the US, we won’t discuss these visas in depth. 

Instead, I’ll briefly summarize what you need to know about these two visas, their advantages, and their inconvenience.

The J1 visa

The J1 visa is by far the most popular visa for IMGs. 

Most IMG-friendly programs accept it, and ECFMG usually sponsors it. 

If you are considering pursuing a fellowship, the J1 visa is the best option. 

However, note that when on a J1 visa, you are a non-immigrant and must return to your home country for two years after completing your training. 

There are J1 visa waivers that may allow you to stay in the US, but those are challenging to get. 

For more information, you can refer to the American Medical Association website. 

The H1B visa

The H1B visa is less common than the J1 visa, and only some programs sponsor it. 

The main advantage of the H1B visa is that you aren’t subjected to the two-year home-country physical presence requirement. 

However, this type of visa is only suited if you want to pursue a fellowship. 

It’s important to note that candidates who want to apply for an H1B visa must take the USMLE Step 3 exam, as this visa is typically used for physicians who have completed their residency training and are pursuing a fellowship or a job in the US.

Understanding the differences between the J1 and H1B visas and their respective advantages and disadvantages is essential when pursuing residency in the US. By staying informed and prepared, you can make the best choice for your situation and achieve your goals in the US healthcare system.”


Pursuing residency training in the US is a goal shared by many IMGs worldwide. 

The journey’s first step is understanding the process and requirements to reach this objective. 

In addition, as an IMG, it’s crucial to take the time to comprehend the following:  

  • The importance of scores in your application.
  • The weight of research and publications
  • The number and quality of USCE 
  • The Year of Graduation,
  • The choice of visa. 

Ideally, applicants should score as high as possible, get enough USCE, be ECFMG certified by the time of application, and apply early after graduation. 

However, keep in mind that each application is unique. 

Being an ideal candidate doesn’t guarantee a match, and having red flags doesn’t mean either that you have zero chance of achieving your goals. 

Simply do your best, give it your best shot, and good luck, everybody! 

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