Applying - Advice for the IMG

*Update - July 2022:

The information provided below still provides a useful perspective but is becoming out of date. With the recent decline in U.S. Allopathic Senior Medical Students applying to EM, these circumstances may have changed. It is too early to know, but in 2023 matching into EM may be more attainable for an International Graduate than in the past.

- Adam Kellogg

Before you choose EM

Over the past few years, emergency medicine has become increasingly competitive.  As you get started as an International Medical Graduate (IMG) applicant you need to know what you are getting into.  According to the Results and Data from the 2015 Main Residency Match there were 1821 emergency medicine PGY-1 positions with 2352 total applicants.  Of those, 739 were “independent applicants” (31.4%), which includes those who went to med school internationally.  EM had a 99.6% fill rate with almost 80% of those spots going to US allopathic seniors and 11% filled by osteopaths. This adds up to some sobering news for the international applicant.  Just 4% of spots were filled by IMG’s who were US citizens and just 2% by non-US citizen IMG’s. And that left 30% of independent applicants unmatched among those who listed EM as their only specialty (did not hedge with also applying to another specialty).  

Why is this?  

IMG’s are still considered (by some) to be second-rate applicants.  In addition, residency program directors (PD's) get many, many applications, and they need a way to screen them.  When the NRMP conducted a program director survey in 2014 83% of PD’s ranked being a graduate of an American medical school at a high level of importance. And less than half (47%) of PD’s will interview and rank IMG’s.  

About rotations

One of the most difficult things about IMG’s matching into emergency medicine is their ability to get their foot in the door because clerkships are hard to schedule.  The holy-grail clerkship is one where you can get a departmental Standardized Letter of Evaluation (SLOE) from an emergency medicine residency.   Because international schools are not affiliated with academic EM programs, we have to find places that not only allow rotators, but foreign rotators.  There’s no registry of places that allow IMG rotators because hospitals change their policies so quickly.  Your first step should be to ask your school where students that have successfully matched into EM have rotated.  The second place you can look is your schools’ (and other foreign schools) match list – see where IMG’s have matched and call those departments to see if you can schedule a rotation there.  The last, and unfortunately the most common way, is to call the departments where you’re interested in rotating (and potentially applying to) to see if they’ll let you rotate.  This takes time: you are busy and the clerkship coordinators are definitely busy – it can be a tough job.    

An added wrinkle...

Certain states have requirements to be eligible for licensure which have to do with the rotations (clerkships) that you did during third/fourth years.  There are two terms you’ll being hearing a lot on this topic: Green-book and Blue-book.  Green-book rotations mean that the rotation has an associated residency while Blue-book rotations means there is no associated residency with an established rotation.  States that are stricter about licensure requirements (for example, Texas) require that all of your rotations be Green-book to be granted licensure after doing residency in that state.  This does not mean that you can’t do residency in one of the more selective states – it just means that you can’t get licensed after residency until you pass your boards if you did Blue-book rotations when you were a student.  

Your application

ERAS opens September 15th – your application needs to be complete (with the exception of possibly one SLOE) by then.  This means you need to have your last SLOE in ERAS by October 1st at the latest.  This means the optimal time to do your rotations is before September.  When you’re setting up your core rotations (third year), do them all back-to-back because (most, if not all) EM rotations require that your core rotations be complete prior to the rotation.  

One of the reasons that program directors want to see SLOE’s from ED’s with residency programs is because one of the questions on the SLOE is how that program plans to rank that applicant – it gives the SLOE more context.  Because of the demand to do clerkships at Emergency Departments with affiliated residencies, some non-academic departments offer rotations.  The bottom line is: do a rotation at a non-academic department if you have to in order to get at least two SLOE’s, but know that having a residency affiliated SLOE is preferred to any other letter you could receive.

There’s no statistically favored number of programs that guarantee you a certain number of interviews.  Apply to programs that you know have matched IMG’s over the past few years (do this by looking at the match lists published by the schools) as well as applying to programs you’re generally interested in.  If you haven’t heard from programs that you’re interested in, or are lacking in interviews, don’t be bashful.  Call coordinators, email program directors – be enthusiastic but not overbearing or demanding.  And be ready at a moment’s notice later in the interview season – spots open up during interview days – and you need to jump on them, they’re not easy to come by.  Though they are scheduled in a rush, these interviews carry just as much weight as any other and programs will appreciate your flexibility.  All that said, hedge your bets.  EM is difficult to interview for and match into.  Apply broadly for emergency medicine but also apply for other specialties you see yourself succeeding in.  If you don’t match into EM – do not rely on SOAP.  Vanishingly few (if any) international applicants in recent history have SOAPed into EM.    

The interview

Once you get interviews, you have to knock them out of the park!  Beyond having impeccable interview skills, you need to be prepared to address the awkward flamingo in the room: the IMG thing.  You have to be able to explain why you took the IMG route – and turn it into something that makes you into the applicant that they must have.  For example, if you had problems with standardized testing, you need to be able to show that it was a struggle that you overcame, emerging stronger and better prepared for having persevered.  

And finally, the rank list

From the 2014 Match data, to have an over 90% chance of matching into EM as an IMG, an applicant had to rank over ten programs. And though no number of interviews guaranteed a 100% match rate, having ten programs to rank as your goal should leave you feeling pretty safe.  When it comes time to ranking – don’t try to outsmart the algorithm.  The match is applicant-weighted.  Go with the conventional wisdom: rank based on where you want to go – there’s no trick to ranking as an IMG.  Again, hedge your bets – rank all programs (EM or otherwise) you interviewed with.  Remember, you’d rather your rank list be too long, not too short.

- Max Hockstein, MD

For additional information see the 2021 update of the CORD-EM Advising Students Committee IMG Applying Guide