The IMG Journey: How to Strategically Polish Your CV to Succeed in the Match

Countless International Medical Graduates (IMGs) dream of becoming a doctor in the US. Approximately 11,000 submit applications to ERAS, hoping to match in a US medical residency. Roughly one of two applicants successfully matches. Those who experience the crush of failure had challenges they could not surmount. So, what does it take for success?

I am Dr. Roger Washington, MD, FAAFP, and I have been hosting IMGs in my private practice for nearly 20 years. I have been a Fellow of the American Academy of family physicians, and I am the author of the book Lack of Sufficient Sleep Matters.

Over the years, I have proctored family practice residents, medical assistant interns, physician assistant students, and IMGs. Along the way, I have developed unusual teaching methods and tips to promote confidence in the students that work with me.

My experience and observations have helped me mentor dozens of IMGs passionate about their US Residency dream, just like you. What follows are what I advise as best practices.

International Medical Graduates Have a Dream
Externship in a Safe, Collegial Learning Environment
IMGs Externship- Learning Without Judgement
IMGs’ Pivotal Challenge in the Match Process
So, How Important are the Step Exam scores?
Telehealth Externship

International Medical Graduates Have a Dream

Allow me to share with you the story of two friends who were walking in the countryside. At a distance, they saw a tiger moving deliberately in their direction. Promptly, one of them sat down, removed his shoes, and pulled out some running shoes from his backpack. As he hurried to put on the running shoes, his friend said, “What are you doing? Those shoes are not going to help you outrun the tiger.” The friend replied, “I don’t intend to outrun the tiger. I intend to outrun you.”

My advice to IMGs: No matter your circumstances, your goal must be to do all you can to distinguish yourself as superior to the average IMG applicant.

Throughout the many years that I have hosted an Externship for IMGs, mentoring them to actualize their dream, they have asked me about the challenges they face.

  1. Some are concerned about a gap- the time since graduation when they were not involved with clinical activities.
  2. Some describe less than stellar Step Exam scores. Some decry not having a significant amount of US healthcare experience.
  3. Others worry that their statement will not be convincing enough.

Those challenges can be daunting, but despite the fears they engender, some strategies can help you succeed.

Externship in a Safe, Collegial Learning Environment

I am a Family Practice primary care physician in a private, solo practice in San Jose, California. For 20 years, I have hosted an Externship for IMGs to realize their dream of becoming doctors in the US. Because I own the practice and profit has never been the driving force, I have the luxury of devoting an extraordinary amount of time to each patient. It presents a unique, more relaxed opportunity to teach students.

For your information, California statute prohibits unlicensed personnel from practicing medicine. However, IMGs are permitted to engage in activities ordinarily ascribed to a medical assistant. Under my direct supervision, IMGs have been able to have an enriching and rewarding hands-on experience with patients and familiarize themselves thoroughly with the medical record and the attendant activities of rendering primary care.

They have had the opportunity to interview the patients via zoom or in the office and give patient instructions. After my instruction and under my supervision, the IMGs write prescriptions for medications, physical therapy, and special studies such as polysomnograms.

They call the pharmacy, create requisitions for imaging and lab studies, and assist with referrals and prior authorizations.

Another unique aspect of my Externship is the teaching style I employ.

For the most part, medical schools and residency programs use a teaching style of direct lecture or assigned reading with subsequent questions related to the materials.

It is a hierarchical teaching model involving a set of “demands” placed on students to perform. Accolades or shame are the results of their performance. The threat of shame and the fear of not measuring up to expectations creates conflicts and resentment and is not conducive to learning for the joy of learning.

For example, what medical student cannot recall an attending authoritatively asking a question such as, “What is the most important thing to remember when the patient has a cough?”

When I ask students questions, I want them to feel as if I am presenting them with a safe platform to impress me with what they know and to realize how they can implement their book knowledge in the clinical setting.

My premise is that students learn more effectively when they are allowed to observe, make connections, and speak their minds without demands and judgment.

In my Externship, I have tried to create a learning environment wherein students have the opportunity to apply their book knowledge to the real world without the fear of reprisal or judgment with enough supervision that significant missteps that impact patients are unlikely.

My approach has been to refrain from judgment of my students, and just as importantly, students are encouraged to refrain from judging themselves.

Our egos lead us to believe that we are in the best position of anyone to judge us. Unfortunately, we judge ourselves harshly, which promotes a lack of self-esteem and confidence. Therefore, as a teacher, I encourage students not to judge themselves. We have techniques and tips that promote increased confidence. When you’re confident, your memory is more reliable.

Please, allow me to share with you an example.

To demonstrate my point, I once asked an Extern, “What are the four most important symptoms of depression?”. The student hesitated for a moment, then several moments. Their faces became dour. They furrowed their brow and stared to one side in deep concentration. I halted the exercise and apologized.

There is no psychiatric concept of the four most important symptoms of depression. But as most students are prone to do, the Extern heard an unfamiliar set of terms couched in the familiar and presumed it was a piece of information they did not know, and then, doubt and fearfulness took over.

Undoubtedly, every recently graduated IMG who has passed the step one and step two exams would know the acronym SIGECAPS to be the symptoms of Major Depression Syndrome. The phrase “four most important symptoms of depression” is a phrase I conjured. However, my authoritative phrasing suggests the student should know this.

Most students would realize they are unaware of the “four most important symptoms of depression.” It would be commonplace for the student to react judgmentally, fearfully, with thoughts that reflect their doubt, such as, “I should know this,” or “Oh, no! What if I get this wrong?”

Too many students to answer truthfully feels like the correct response, “I am not familiar with the four most important symptoms of depression, Sir,” or they might respond with the dreaded, deflating response, “I don’t know, Sir.” Their fear has undermined them. Let’s look at an alternative scenario.

I believe as a teacher, we should teach beyond books. Students are smart & well-read. It is their confidence that needs more attention.

Let us consider the confident student who is asked the same question in a safe and collegial clinical environment. They are more likely to recall in a moment the symptoms of Major Depression Syndrome are abbreviated by the acronym SIGECAPS.

By convention, we agree that at minimum, either anhedonia or sadness must be present, and a total of five symptoms, most of the time, for two weeks. Rather than be confused by the suggestion of what they do not know, the so-called “4 most important symptoms”, they will respond readily with what they do know for sure. They suggest, “Anhedonia and sadness might be considered the two most important symptoms because they are essential to the definition.”

In saying so, they have essentially nailed the answer. They might, however, go on and make an educated guess as to the other two symptoms and pose, “If most important means greatest risk, I would venture to guess suicidal ideation and guilt because ideation is a strong risk factor for suicide which of course is the worse outcome.

I would suggest guilt because it is the most painful and would promote an urge to escape the pain. Sir, that is only my best guess. I am not familiar with the concept of the four most important symptoms. What are they, and how do we apply the concept clinically”? And that gentle IMG reader is the type of response to a question that earns the strongest LORs. I think it is fair to suggest that you, my IMG readers, were capable of that response.

Always choose confidence. Confidence is the superpower of the match process. Anyone, at any time, can choose to have more confidence. In my Externship, I coach IMGs to be confident.

To quote Frank Herbert from his book Dune, “Fear is the mind-killer.” My Externship’s premise is that all IMGs who have passed the Step Exams are qualified.

I provide a collegial, encouraging, nonjudgmental, and safe environment for them to apply their book knowledge to clinical problems in the American clinical setting; they will eventually grow more confident and realize they can match.

Moreover, giving them lessons and experiences that improve their communication skills more quickly increases their confidence and accelerates their growth. What separates the externs that have worked with me from other IMGs is their strong sense of confidence and superior communication skills.

I invite you to join our Externship.

IMGs Externship- Learning Without Judgement

Studies demonstrate that young children learn language skills more effectively when they have the opportunity to observe their older siblings versus other children who their parents teach/coach one-on-one in what is called the direct lecture teaching model.

The implication is that hierarchical, one-on-one teaching involves “demands” placed on the youngster to behave as they are told to behave. For example, holding up the letter a, a parent might say to their child, “this is A. Say A” This direct lecture with questions teaching style creates conflicts and resentment and is not conducive to learning for the joy of learning.

My premise is that students learn more effectively when they are allowed to observe, make connections, and speak their minds without demands and judgment.

In my Externship, I have tried to create a learning environment wherein students have the opportunity to apply their book knowledge to the real world without the fear of reprisal or judgment with enough supervision that significant missteps that impact patients are unlikely.

IMGs’ Pivotal Challenge in the Match Process

Several students ask me about one major challenge in the match process. The crucial challenge during the match process will be nailing the interview process.
Suppose you flub the interview process, have stellar step exam scores, glowing letters of recommendation, multiple publication citations, and even the rarest, most influential asset. In that case, the personal recommendation from a colleague of the medical residency director won’t save you. You must have effective communication skills and display them during the interview process.

Having a communication skill set that allows you to connect personally with Americans effectively is akin to having a superpower. Anyone can improve their communication skills. I coach IMGs to develop, practice, and hone their communication skills.

You can read through this to know what my students are saying about my Externship Program & teaching style.

So, How Important are the Step Exam scores?

In 2022, the Step 1 score was changed to a pass / fail grading score to reduce the adverse effects the stressors related to taking the test had on students.

Research has shown that the most effective predictor of a new hire’s future success is their standardized test scores. Furthermore, research suggests that, for the most part, an individual tends to score similarly throughout their academic career. Occasionally, someone who scores in the 70th percentile, for example, will increase their score to the 90th percentile.

Residency program directors, therefore, favor IMGs with higher Step Scores. More so in internal medicine.

Many IMGs with lesser Step Scores have a doubt as to the possibility of their ultimately being successful at matching. To quote Frank Herbert, “Fear is the mind-killer.” An IMG absolutely can be successful with “lesser Step Exam scores.” I know that because there are IMGs with the “lesser Step Exam scores” who have matched. Those IMGs maximized their other opportunities with their letters of recommendation and their CVs, crafting a convincing personal statement, networking with others who could intercede on their behalf, and ultimately, they nailed the interview process.

Excelling on the Step Exam is a function of the total hours of preparation and one’s excellent test-taking skills. Rather than engaging in other activities and opportunities that could prepare them for a career as a physician, students devote inordinate amounts of time to the Step Exam. Other activities such as contributing to a research team or working in the community became missed opportunities to develop superior communication skills and increase their confidence.

My experience has been that anyone can learn better communication skills. As always, confidence is the key to effective verbal and, perhaps, more importantly, to one’s non-verbal communication skills. Let me offer you an example.

Usually, when I hear an IMG tell me what they believe to be a lesser Step Exam score, they straightaway offer a reason, an excuse. They behave as if they expect to be judged and rebuked. Even over the phone, when there was no opportunity for them to read my nonverbal cues, they offered an excuse for the poor showing. Alternatively, a more confident student could report the same score and, rather than offer a reason, might readily offer other more laudable achievements that support their candidacy.

They could launch into a report of their research accomplishments, their volunteer work in the community, and how much they have grown from the experiences, offering interesting, humorous anecdotes that engender a human connection.

And if pressed about the low score, they might describe having reviewed the materials and acquired a solid and reliable knowledge base. They might add that if retaken, they anticipate scoring much higher. Also, if it were pertinent, they could offer their Step 2 CK score as evidence of their readiness for residency training.

An IMG can view every challenge as an opportunity. A confident attitude toward your challenges may help you visualize those opportunities.

In my Externship, I strive to teach communication skills. My experience is that confidence is a critical factor. And oddly enough, being well rested contributes significantly to one’s self-confidence.

Telehealth Externship

As a mentor of IMGs, I aim to coach as many young doctors as possible. The coronavirus pandemic has demonstrated to everyone that telehealth and remote learning are possible. I host a Telehealth Externship providing IMGs an opportunity to participate remotely to observe and learn what my years of experience have demonstrated is the skills set they may acquire to make their dream of becoming a US doctor a reality.

Medical residency program directors prefer at minimum two letters of recommendation.

An outstanding, personalized letter of recommendation that you receive as a result of an on-site Externship with a well-qualified US physician could very well outweigh any perceived challenges to your ERAS application.

The Telehealth Externship I host could be your primer, allowing you to outshine other IMGs during your on-site Externship.

You can learn to be confident and express yourself as a successful, US-trained residency candidate does. Moreover, you will be exposed to the clinical activities of our family practice sessions. You will hear the didactic lessons about the US healthcare system, such as topics as the insurance system, including the commercial and government types, managed care, tiered medical formularies, health maintenance organizations, formulary, copayments, deductibles, and disability.

The telehealth participants will be observers. They will receive a thorough education in four weeks, preparing them to earn a superior personalized LOR in a future on-site Externship. The ERAS application process begins in late August, but letters of recommendation can be uploaded into November 2022.

The Externship is being offered at a reduced price to be available to more applicants. We anticipate offering a discount code when more than one joins at least one other from their study group.
I have successfully mentored dozens of IMGs to overcome their challenges. My Externship is unique, and my teaching techniques are unusual. I coach IMGs to distinguish themselves, and I teach them to emphasize the assets they already possess. Our results are desirable.
So, as you are on my website, do check out this link for upcoming Externship updates.