How to Get Into Residency Programs as an IMG: The Ultimate Guide
/What are the most IMG-friendly residency programs? Learn strategies to maximize your odds of matching into residencies as an international medical graduate
certain specialties, locations, and residency programs are known for being “img-friendly”
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Part 1: Introduction
Applying to residency programs is a challenging process—and if you’re an IMG, the complications and obstacles are even greater. As an IMG, or international medical graduate, the odds of matching into an American residency probably seem stacked against you, making you wonder what you can do to compete with graduates of American medical schools and what chance you actually have of matching.
In this guide, we’ll answer these questions and more. In addition to covering IMG match statistics and application strategies, we’ll go over eligibility requirements and what makes certain specialties and programs excellent choices for IMGs, including a list of IMG-friendly programs. By helping you understand why it’s more difficult for IMGs to match, we’ll provide you with tools and strategies that you can use to overcome these barriers and maximize your chances of gaining acceptance to a residency program in the U.S.
What is an IMG?
First, let’s define IMGs. According to the National Resident Matching Program (NRMP), an IMG is “a physician who received a basic medical degree or qualification from a medical school located outside the United States and Canada.”
Note that nowhere in this definition is nationality mentioned. It’s important to understand that your status as an IMG is determined by the country in which you attended medical school, not your citizenship.
So, if you’re neither a citizen of the United States or Canada, and you’ve also attended medical school outside of those countries, you’d be considered an IMG. Similarly, if you attended medical school outside of the U.S. or Canada despite holding American or Canadian citizenship, you’re also an IMG. On the other hand, if you’ve attended an American or Canadian medical school as an international student, you are not an IMG.
In short, whether or not you’re an IMG is determined solely by the location of the medical school from which you’ve graduated.
What makes an IMG eligible for U.S. residency programs?
In order to apply to residencies in the United States, IMGs must meet requirements on three different levels: ECFMG, state, and program.
Step 1: Apply for ECFMG certification.
First, IMGs must receive certification from the Educational Commission for Foreign Medical Graduates (ECFMG) by taking the following actions:
Apply for ECFMG certification. To ensure that graduates of your medical school are eligible for certification, consult the World Directory of Medical Schools.
Take and pass Step 1 and Step 2 CK of the United States Medical Licensing Examination (USMLE). You need to pass Step 1 and Step 2 CK by the Rank Order List deadline in March.
Take and pass the Occupational English Test (OET)* by December 31st in the year prior to the NRMP Match you want to participate in (i.e., a few months before). Ideally, you should take it as early as possible.
Apply to one of six ECFMG Pathways to demonstrate your clinical skills.* The Pathways are as follows:
Pathway 1: Already licensed to practice medicine in another country
Pathway 2: Already passed a standardized clinical skills exam for medical licensure
Pathway 3: Medical school accredited by agency recognized by World Federation for Medical Education (WFME)
Pathway 4: Medical school accredited by agency that has received a determination of comparability by the National Committee on Foreign Medical Education and Accreditation (NCFMEA)
Pathway 5: Medical school issues degree jointly with a U.S. medical school accredited by the Liaison Committee on Medical Education (LCME)
Pathway 6: Evaluation of clinical patient encounters by licensed physicians
Submit your medical school diploma to the ECFMG for verification. This step can only be taken after you have received all of your academic credits, graduated, and received your diploma and final transcripts.
(*Note that if you previously took and passed Step 2 CS of the USMLE before it was discontinued, you do not need to apply to a Pathway or take the OET.)
Step 2: Check state requirements.
Next, you must ensure that you meet the state requirements for residencies to which you want to apply. Each state sets their own requirements for initial medical licensure in terms of the following criteria:
The minimum number of years of postgraduate training you must complete
The number of times you can attempt licensing exams
The period of time during which you must complete the licensing exams sequence
It’s essential to verify that you meet these requirements; otherwise, you risk wasting time and money applying to residencies for which you’re ineligible. State requirements can be found at the Federation of State Medical Boards.
Also relevant to IMGs is the fact that some states, such as California, have lists of specific international medical schools whose graduates are eligible for licensure. Schools that aren’t on these lists won’t be recognized.
Step 3: Research requirements for individual residency programs.
Finally, individual residency programs have their own requirements that determine eligibility for IMGs, such as how recently an applicant has graduated from medical school and what types of visas they accept or can sponsor. You should confirm with each program to which you apply that you meet their criteria.
How do I get a visa as an IMG?
If you’re not a U.S. citizen or permanent resident, you’ll need to obtain a visa to participate in a residency program. The most common visas for IMGs are the H1-B (Temporary Worker) or the J-1 (Exchange Visitor).
As mentioned, some residencies will sponsor IMGs for visas. Another sponsor option lies in the ECFMG, which can sponsor physicians with non-U.S. citizenships for the J-1.
Your first move should be to check with individual residency programs to see what visa help they offer IMGs. Next, consult the U.S. embassy or consulate in your country, or the U.S. Citizenship and Immigration Services, for further information and assistance.
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Part 2: How hard is it to match as an IMG?
To answer this question, we can take a look at data from the 2021 NRMP Main Residency Match.
In 2021, 42,508 applicants ranked residency programs as part of the Match. Of these applicants, IMGs constituted 31 percent, regardless of citizenship.
The NRMP further breaks the data down into IMGs who are U.S. citizens and those who are citizens of other countries. Let’s take a look at the Match data for these two groups, plus the data for the Match’s largest applicant group, seniors from medical schools located in the U.S.
(Note: The figures above include applicants to both PGY-1 and PGY-2 positions. However, because the vast majority of available positions (92 percent) are PGY-1, it’s standard practice to use PGY-1 match rates to assess levels of competitiveness, as we do below.)
U.S. IMGs:
Applicants: 5,295 (12.5% of total pool)
Applicants who matched to a PGY-1 position: 3,152
PGY-1 match rate: 59.5%
Non-U.S. IMGs:
Applicants: 7,943 (18.7% of total pool)
Applicants who matched to a PGY-1 position: 4,356
PGY-1 match rate: 54.8%
U.S. medical school seniors (MD and DO):
Applicants: 26,967 (63.4% of total pool)
Applicants who matched to a PGY-1 position: 24,762
PGY-1 match rate: 91.8%
These figures tell us a couple things. First, they tell us that citizenship has relatively little to do with whether IMGs match, as U.S. citizens and non-U.S. citizens match at fairly similar rates.
Second, they illustrate that IMGs match at much lower rates than U.S. med school seniors, with a difference of over 30 percentage points.
Nevertheless, 7,508 IMGs successfully matched to a PGY-1 position in 2021. This means that, of the more than 33,000 applicants who matched into PGY-1 positions, 22.5 percent were IMGs.
So while IMGs do face greater challenges in residency matching, they ultimately still make up a significant portion of resident doctors in the United States.
Why is it more difficult to match as an IMG?
There are several reasons why IMGs have a harder time matching than graduates of American medical schools.
If you’re a U.S. citizen, earning a medical degree abroad is often seen as a step down. Unfortunately, most program directors will assume you attended medical school in another country because you were unable to gain acceptance to an American med school, regardless of your reasons. This will raise questions about your academic capabilities.
Depending on what country or medical school you’re coming from, your education may be seen in a more or less favorable light. Program directors will be familiar with the varying reputations of different medical schools and educational systems, and they may weigh these reputations accordingly. That said, even if you’ve graduated from an internationally prestigious medical school such as the University of Cambridge, it will still be substantially more difficult to match into an American residency than it will for a U.S.-educated applicant, due to the other reasons on this list.
Many residency programs want to train doctors who they believe will stick around and serve their local area. This is especially true in less-populated areas of the country.
IMGs who are not U.S. citizens need visas. Securing a visa is a time-consuming and costly process for both IMGs and the residencies who sponsor them. That’s why needing a visa may be seen as a disadvantage in the eyes of many program directors.
Medical students trained in other countries have more “unknowns.” In other words, IMGs are more likely to diverge from the “standard” American medical student in ways that might create challenges. For instance, IMGs may potentially face the following difficulties:
Cultural differences
Language barriers
A lack of familiarity with the American healthcare system
A lack of strong support networks (i.e., no family and friends nearby)
These challenges may be seen by program directors as risks. As such, when comparing an IMG and a U.S.-educated applicant who are otherwise identical, the latter will generally be viewed as a safer bet.
For all of the above reasons, it’s to your benefit to seek out programs that are maximally friendly to IMGs.
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Part 3: What makes a residency program IMG-friendly?
There are a few different factors that can add up to a residency program being more or less friendly to IMGs, such as location, specialty, and the culture of individual programs. Below, we’ll go over how to think about each factor as you decide which residencies to apply to.
The most IMG-friendly states
Certain states have reputations for being more friendly to IMGs than others. As a rule of thumb, the states that boast the highest numbers of IMGs in residency programs tend to correspond with the states with the largest populations.
Why is this? For one, populous states simply tend to have more residency positions available, so it follows that a higher number of these positions go to IMGs. In addition, because these states generally have diverse, frequently shifting populations, particularly in and around major cities, attracting residents from the local area may not be as great of a concern.
Here are the ten states that accepted the most IMGs in the 2021 Match:
New York: 1,512
Texas: 581
Florida: 570
Michigan: 535
Pennsylvania: 519
New Jersey: 468
California: 428
Illinois: 362
Ohio: 342
Massachusetts: 233
The most IMG-friendly specialties
The specialty you choose can play a huge role in determining how likely you are to match as an IMG. The primary care specialties—family medicine, internal medicine, and pediatrics—are generally considered the most IMG-friendly because they are the least competitive specialties to match into. This is due to the facts that the primary care specialties offer the greatest numbers of available positions and that there aren’t enough U.S. med school seniors to fill them.
Here are the specialties into which the greatest numbers of IMGs matched in 2021, according to NRMP data:
Internal medicine (categorical): 3,416 (45.5% of IMGs who successfully matched into any specialty)
Family medicine: 1,224 (16.3%)
Pediatrics: 552 (7.4%)
Psychiatry: 309 (4.1%)
Pathology: 301 (4%)
Internal medicine (preliminary): 230 (3.1%)
General surgery (preliminary): 269 (3.6%)
Neurology: 226 (3%)
Emergency medicine: 178 (2.4%)
General surgery (categorical): 156 (2.1%)
Around 73 percent of all IMGs who successfully matched landed in one of the primary care specialties, with the greatest numbers by far matching into internal medicine.
To contrast this, when it comes to highly competitive specialties like integrated surgeries and dermatology, not only are there few available positions overall, there are also more U.S. medical school seniors applying than spots available. As such, residency positions in these specialties tend to be primarily filled by U.S. med school seniors, leaving just a handful of spots for IMGs.
To be in the running for these specialties as an IMG, you’ll need to be exceptionally well-qualified in terms of your test scores, experiences, and other application materials—and even then, it’s a good idea to also apply to a less competitive specialty as a backup.
Another way of determining which specialties are most IMG-friendly is to look at the specialties in which IMGs make up the highest percentages of residents. In the 2021 Match, the following specialties had the highest percentages of IMGs among their matched applicants:
Pathology: 51.1%
General surgery (preliminary): 44%
Pediatrics–primary care: 43.2%
Internal medicine (categorical): 39.6%
Neurology: 32.2%
Internal medicine–primary care: 31.6%
Family medicine: 27.4%
Pediatrics: 19.3%
Psychiatry: 16.1%
Internal medicine (preliminary): 14%
While the specialties above are largely the same ones that appear on the previous list, sorting by percentages reveals new perspectives on these specialties. For instance, the fact that over half of all new pathology residents are IMGs greatly boosts its stock as an IMG-friendly specialty.
The most IMG-friendly programs
Beyond choosing IMG-friendly locations and specialties, you should also research individual residency programs to determine which have a history of matching large numbers of IMGs.
A program’s track record on this matter is important because there are many programs that claim on paper to accept IMGs and sponsor visas but, in actuality, rarely do. Alternatively, some programs may only accept IMGs who are U.S. citizens in order to avoid the hassle of visa sponsorship, even if they don’t explicitly advertise this practice.
To illustrate this, we can look at the NRMP’s 2020 Program Director Survey. 17 percent of program directors responded that they never interview U.S.-citizen IMGs, and 32 percent indicated the same for non-U.S.-citizen IMGs. Over 50 percent indicated that they “seldom” interview either.
Though these statistics may be discouraging, they make clear why it’s crucial to do your homework on individual programs before sending out residency applications. By focusing on the many programs that do regularly interview IMGs, you can increase your odds of matching, not to mention save valuable time and money.
To research programs, you can use the AMA’s Residency & Fellowship Database, known as FREIDA, to filter programs according to a number of criteria, including specialty, location, percentage of IMGs, accepted visas, and more.
Another useful strategy is to research where graduates of your medical school have matched in the past. Your medical school may even be able to provide you with a list of programs where alumni have successfully matched.
At the end of this guide, we’ll also go over a list of specific IMG-friendly programs to assist you in your program search.
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Part 4: Strategies for applying to residencies as an IMG
As we’ve just learned, you can increase your chances of matching by strategically choosing individual programs, specialties, and states that are known to be friendly to IMGs. In addition, here’s what else you can do to stand out from the crowd and further improve your odds of matching as an IMG.
1. Apply broadly.
It’s not unheard of for IMGs to apply to hundreds of programs. While this may sound extreme, our general recommendation is to apply to at least 100 programs in each specialty you’re interested in.
You may be able to get away with applying to fewer programs if you are a truly exceptional candidate—think a Step 1 score of 240 or higher—but this will also depend on the competitiveness of the specialty into which you hope to enter.
Submitting such a large volume of applications is expensive and will put you back thousands of dollars. That’s why you should carefully consider whether the specialties and programs you’re applying to are truly realistic for you. You can use NRMP data on IMGs who successfully matched to determine whether your stats make you a viable candidate for different specialties.
2. Take any interview that you’re offered.
Unfortunately, you can’t afford to be picky about program or location when going on residency interviews.
3. Gain clinical experience where you want to match.
An excellent way to enhance your application profile is to demonstrate clinical experience in the United States (or Canada), particularly within the specialty that you want to go into. Some programs may even list U.S.-based clinical experience as a requirement.
Clinical experience in the U.S. is important for a few reasons. It will help allay program directors’ fears that you’re unfamiliar with the American healthcare system, and it will demonstrate that you have the language skills and cultural fluency necessary to work effectively in the U.S. It will also allow you to network and obtain valuable letters of recommendation from U.S.-trained faculty who can attest to the above. This can help mitigate some of the risk that program directors associate with accepting IMGs.
The best way to gain clinical experience is to enroll in elective clinical rotations in the U.S. if you’re still in medical school. Your med school may have affiliation agreements with American medical schools, which will make the process much easier. Or, if you’ve already graduated, you can pursue observorship opportunities at an American hospital.
4. Gain research experience.
Research experience, particularly done in the U.S., can improve your medical student CV and help you stand out. You may be able to find a research position by networking while doing your clinical rotations or observorship, or via your personal networks.
5. Demonstrate strong test scores.
In the survey of program directors we discussed earlier, USMLE Step 1 scores were cited as the most important factor in selecting which applicants to interview. Step 2 scores were cited as third-most important. That’s why demonstrating strong Step scores is one of the best ways to stand out as an IMG.
Here are the mean Step scores among IMGs who matched in 2020 across all specialties:
U.S. citizen Step 1: 222.9
U.S. citizen Step 2: 233.5
Non-U.S. citizen Step 1: 233.9
Non-U.S. citizen Step 2: 240
As illustrated above, on average, non-U.S. citizen IMGs needed to score higher on their board exams than U.S. citizen IMGs in order to successfully gain a match.
The more competitive the specialty, the better your scores will need to be. For example, IMGs who matched into orthopedic surgery in 2020 had mean Step 1 scores of 241 for U.S. citizens and 249 for non-U.S. citizens.
To contrast this, in family medicine the mean Step 1 scores for IMGs who matched were 211 for U.S. citizens and 219 for non-U.S. citizens.
However, high scores are still no guarantee that you’ll match into your dream residency. Among IMGs who applied to orthopedic surgery residencies and who had Step 1 scores in the 240–249 range, only 9 percent actually matched. In family medicine, the match rate for IMGs with similar scores was a more reassuring 70 percent. That’s why strategically choosing specialties and programs is a must, even for high-scoring applicants.
Some programs employ cutoffs for Step 1 scores, so you’ll also want to make sure your scores are in the ballpark of consideration for both the programs and specialties you’re applying to.
6. Obtain a strong Medical Student Performance Evaluation (MSPE) and letters of recommendation.
Letters of recommendation and MSPEs are nearly as important as Step scores in evaluating residency applicants. According to the NRMP program directors’ survey, program directors rated them as the second- and fifth-most important factors, respectively, when determining which candidates to interview.
For IMGs, these materials take on an even greater importance because glowing, specific evaluations are one of the best ways to counter the perception of risk that’s typically attached to IMGs. That’s why testimony to the following will go a long way:
That you’re an excellent doctor and student
That you understand the American healthcare system
That you will thrive and fit into American culture
That you speak English fluently
That you’re personable and easy to work with
That you have interest and experience in the specialty you’re applying to
Unfortunately, it’s not uncommon for IMGs to suffer from generic MSPEs and letters of recommendation, particularly if the people writing the evaluations are not familiar with the American residency system themselves. While you can’t control what’s in your MSPE, you can seek out recommenders who know you well and, ideally, who work or were trained in the United States.
7. Write a standout personal statement.
For comprehensive advice on crafting a top-notch personal statement, head over to our guide to residency personal statements.
Beyond the information that any personal statement should include—such as what draws you to a particular specialty or what your professional goals are—as an IMG you’ll also want to convey the story of your path through medicine and how it’s led you to your current aspiration of attending residency in the United States.
If you’re a U.S. citizen, this means addressing why you attended medical school abroad. And if you’re not a U.S. citizen, you should discuss why you need to complete your residency in the U.S., away from your home country.
The key is to show how your personal path as an IMG is an asset rather than a hindrance or a mark of failure. Consider the following: What perspectives has your education given you that you wouldn’t have gained in the United States? What about your background makes you a unique, interesting candidate?
If English isn’t your native language, you’ll also want to make sure that your grammar, spelling, and syntax are flawless. The same goes for any written communication you send during the application process, including emails. It’s a good idea to have friends, classmates, mentors, or admissions consultants who are fluent in English proofread your writing so it doesn’t inadvertently detract from your application.
8. Take advantage of networking opportunities.
Creating a network of professional contacts in the U.S. will help you with many of the strategies above, such as gaining clinical and research experience and obtaining letters of recommendation. Plus, the stronger your network in the U.S., the better the odds are that someone you know will have a connection to a program to which you’ve applied. For IMGs, this can add valuable familiarity to your application.
To grow your network, reach out to and maintain connections with teachers or mentors who have studied or worked in the U.S. Researchers, faculty, or doctors who you’ve met through away rotations or research experiences are also valuable contacts. Graduates from your medical school who have successfully matched as IMGs may help open doors as well. Finally, make a point to attend meetings and conferences within your specialty.
Final thoughts
While never easy for anyone, matching into residencies in the U.S. is especially difficult for IMGs. Not only will you face systemic obstacles such as ECFMG certification, state licensing requirements, and, for non-U.S. citizens, the need for a visa, you’ll most likely also encounter biases against you due to the perception that IMGs are inherently riskier candidates than U.S.-educated applicants.
To counter these biases, you’ll need to do everything you can to mitigate the perception of risk by presenting yourself as a standout candidate. This includes earning excellent USMLE Step scores, gaining valuable clinical and research experience in the U.S., and obtaining enthusiastic evaluations and letters of recommendation.
On top of this, by applying widely to residencies and specialties known to be friendly to IMGs, you can strategically set yourself up for the greatest chances of matching and, thus, a successful medical career in the United States.
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Appendix: List of IMG-friendly residency programs
Using FREIDA, we’ve compiled a list of the most IMG-friendly residency programs in the U.S. as defined by the following criteria: at least 90 percent of residents are IMGs and both H-1B and J-1 visas are accepted.
We highly recommend that you do your own research based on the parameters that are meaningful to you. For instance, as a U.S. citizen, accepted visas won’t be an effective criterion. In addition, 90 percent IMGs is a high cutoff. Nevertheless, this list can serve as a useful jumping-off point in your search for potential residencies.
Anesthesiology
Cook County Health and Hospitals System, Chicago, IL
Family Medicine
University of Alabama Medical Center, Selma, AL
Mount Sinai Hospital Medical Center of Chicago, Chicago, IL
BronxCare Health System, Bronx, NY
Mercy St. Vincent Medical Center/Mercy Health Partners, Toledo, OH
Internal Medicine
Bridgeport Hospital/Yale University, Bridgeport, CT
Danbury Hospital, Danbury, CT
AdventHealth Florida, Orlando, FL
Piedmont Athens Regional, Athens, GA
AMITA Health/Saint Joseph’s Hospital, Chicago, IL
St. Agnes HealthCare, Baltimore, MD
Rutgers Health/Trinitas Regional Medical Center, Elizabeth, NJ
BronxCare Health System, Bronx, NY
Montefiore Medical Center/Albert Einstein College of Medicine (Wakefield Campus), Bronx, NY
St. Barnabas Hospital, Bronx, NY
Icahn School of Medicine at Mount Sinai, Bronx, NY
Brookdale University Hospital and Medical Center, Brooklyn, NY
Interface Medical Center, Brooklyn, NY
Bassett Medical Center Program, Cooperstown, NY
United Health Services Hospitals, Johnson City, NY
New York Medical College (Metropolitan), New York, NY
Rochester General Hospital, Rochester, NY
Rochester Regional Health/Unity Hospital, Rochester, NY
TriHealth (Good Samaritan Hospital), Cincinnati, OH
Cleveland Clinic Foundation/Fairview Hospital, Cleveland, OH
Mercy St. Vincent Medical Center/Mercy Health Partners, Toledo, OH
St. Elizabeth Youngstown Hospital/NEOMED, Youngstown, OH
Robert Packer Hospital/Guthrie, Sayre, PA
Nuclear Medicine
Rush University Medical Center, Chicago, IL
Johns Hopkins University, Baltimore, MD
Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
Obstetrics and Gynecology
BronxCare Health System, Bronx, NY
Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals/Queens), Jamaica, NY
Zucker School of Medicine at Hofstra/Northwell at Staten Island University Hospital, Staten Island, NY
Pathology
Danbury Hospital, Danbury, CT
Boston University Medical Center, Boston, MA
Westchester Medical Center, Valhalla, NY
Temple University Hospital, Philadelphia, PA
Pediatrics
Saint Peter’s University Hospital, New Brunswick, NJ
St. Joseph’s University Medical Center, Paterson, NJ
BronxCare Health System, Bronx, NY
St. Barnabas Hospital, Bronx, NY
Brookdale University Hospital, Brooklyn, NY
Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals/Elmhurst), Elmhurst, NY
New York Medical College (Metropolitan), New York, NY
Mercy St. Vincent Medical Center, Toledo, OH
Psychiatry
Berkshire Medical Center, Pittsfield, MA
BronxCare Health System, Bronx, NY
Brookdale University Hospital, Brooklyn, NY
Icahn School of Medicine at Mount Sinai (NYC Health and Hospitals/Elmhurst), Elmhurst, NY
Radiology (Diagnostic)
Quinnipiac University Frank H. Netter MD School of Medicine/St. Vincent's Medical Center, Bridgeport, CT
Bridgeport Hospital/Yale University, Bridgeport, CT
Mercy Catholic Medical Center, Darby, PA
Surgery (General)
BronxCare Health System, Bronx, NY
