IMG Info: Applying to Specialist Training in the U.S.

By Sarah Wesley

The decision to move to a different country and work in a different medical system can be daunting.  When one trains in a certain system, one is prepared for working within that system, often having mentors and a sophisticated understanding of what is expected of them.  However, specialist training in the U.S. provides a multitude of benefits that help to reconcile the complications of moving out of one’s comfort zone.

The U.S. system offers physicians a chance to enter into a legal contract to complete concise training in a predictable number of years, culminating in qualification as an attending/consultant-level physician.  In addition to one’s duties as house officer, one is exposed to extensive and scheduled educational time in a hospital. The U.S. offers a variety of hospital settings – community, rural, urban, academic – within which to complete training, an aspect which is exceedingly important as one considers significant others, children, and lifestyle preferences.

Moreover, as a part of the contract for training, U.S.-based programs include many employment benefits, from free health insurance to free meals in the hospital to gym passes and subsidized housing with childcare, perks which are not ubiquitous in many other alternative training schemes.

In future posts, I will go into specifics and provide tips on each component of the preparation process for applying to the United States through a system called the “Match.” For now, as you look ahead and plan, you should focus on completing the main components of your résumé, a must to submit the application:

1)    EXAMS:

The U.S. Medical Licensing Exams (USMLE) Steps 1 and 2 must be completed before actually starting a job in residency.  In order to submit the first stage of the application, you must have passed Step 1. However, you must also provide evidence that you have scheduled your Step 2 before the second stage of the application.

I would advise that anyone applying from abroad should have a good Step 2 Clinical Knowledge (CK) score completed in time for the application submission in order to optimize the number of offered interviews.  The Step 2 is divided into two components, a written CK exam and a clinical skills (CS) exam.  The latter CS exam is the only Step that must be taken in the U.S. in-person at a designated center. The Step 1 and Step 2 CK can be taken at multiple sites in most countries all over the world.

The Step 3 is the last of the USMLEs and can be completed any time after graduation from medical school. The Step 3 is not required until you are in residency, but, for non-U.S. citizens, it can be beneficial for obtaining a better work visa if taken before starting in a program.

The TOEFL is an English language exam that assesses your fluency in reading, speaking, listening, and writing.  Anyone who is not a native English speaker must pass the TOEFL. Like the Step 1 and 2 CK, the TOEFL can be taken at many centers around the world.


Most institutions will require that applicants complete a minimum of two clerkships (sub-internships) in the U.S.  Some applicants will have the finances and time to complete many more, with questionably added benefit dependent largely on where you apply and to which specialty.  Observerships are useful for the personal benefit of experiencing an institution or certain subspecialty, but they will not be regarded as work experience in an American hospital on your application.


At least one to two letters of recommendation from physicians working in the United States are necessary for success in the Match process. Many international graduates can obtain these while doing clerkships in the U.S.   Moreover, it is important to have at least one letter from a physician, professor, or research mentor who has worked with you at your home institution or medical school.


Applying to U.S. will require some financing, as the USMLE Step exams will cost somewhere in the range of $3000.00-$4000.00 depending on which country you take them in.  The Match application itself has a processing fee and additional charges if you apply to more than a certain number of programs.  Most sub-internships will also charge a fee, but I will write later on ways to get around paying for expensive electives without sacrificing quality.  Finally, you will have to fly to the U.S. for interviews, but again, there are ways to consolidate interviews and cut costs.

These tasks may seem intimidating, but if you make a realistic schedule for completing them, everything will come together as it has for so many international graduates coming to the U.S.  The benefits of your efforts are well worth it as you consider that U.S. programs offer specialist training over a much shorter and perhaps more intense period of time, while also being very mindful of the personal needs of trainees.


2 thoughts on “IMG Info: Applying to Specialist Training in the U.S.”

  1. What’s missing here is that as a graduate of medicine, weather you studied in Cuba, China, India, Iran, or The Moon, you need someone to vouch for you. One needs that “phone call” or direct recommendation. U.S Graduates have the their established schools to designate a voice for their residency applicants. Foreign graduates however have the ECFMG which in reality do nothing with respect to vouching directly. Yes, they help with the ERAS process, and are a verification stone, but in reality their voice is non-existant with respect to recommending applicants — in essence, everyone is just a number.

  2. Sarah G. Wesley, MD MPH

    You’re spot on with this comment. Who you know is very important, particularly for certain institutions and for certain specialities. But this is true for American and international grads alike. A physician speaking on you behalf might be your ticket into a program, but I do not think it is necessarily requisite for matching, as with the other things mentioned above.
    Having seen multiple grads from my European med school match to competitive programs at which they had never even stepped foot, I do think that your interviewing skills and the strength of your application – Step scores, research, and letters of recommendation – will get you the job over others, no matter where they are from. The U.S. has become increasingly welcome to international grads, for as the population becomes more diverse, it is pivotal for the smooth running of a hospital to have physicians with different language and cultural skills.
    To reiterate though, it is necessary to have AT THE VERY LEAST 1-2 letters of recommendation from physicians who have worked with you in the U.S. system, regardless of their affiliation with your institution of interest.

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