Dominate the Match Episode 6_ Applying to Residency as an International Medical Graduate

Hello and welcome back to Behind the Knife. My name is John Williams, the general surgery resident at the University of Michigan and one of the Behind the Knife surgery education fellows. And I'm Jessica Millar, a fellow general surgery resident at the University of Michigan and also one of the Behind the Knife surgery education fellows.

We're so excited to continue our Dominate the Match series this year with international medical graduates in mind. The road to obtaining IMGs is fraught with numerous challenges. Which is why we are so lucky to have Dr. Krishnan Raghavendran here to help guide us on how to apply for a U. S. residency position as an IMG.

As a brief background, Dr. Raghavendran has navigated these waters himself as he earned his medical degree from the Jaharlal Institute of Postgraduate Medical Education and Research in India before emigrating to the U. S. to complete his residency in general surgery at Henry Ford Hospital. He is currently a professor of acute care surgery and critical care at the University of Michigan.

Now, for those of you who are able to attend, Dr. Raghavendran was also the moderator for the

International Medical Graduates in Surgery panel at the American College of Surgeons Conference this past fall in Boston. Which, just for some context, was the last session on the last day of the conference, and the room was still absolutely packed.

I learned so much from this session, and so we invited Dr. Raghavendran and some of the invited panelists from this session to sit down with us and share some of their advice with all of our BTK listeners. Let's welcome our first panelist, Dr. David Hughes. Dr. Hughes is no stranger to Behind the Knife or our Dominate the Match episodes, but for those of you who haven't had the chance to listen to these before, Dr.

Hughes is a clinical associate professor, venocrin surgery, and the general surgery residency program director at the University of Michigan. Today he's going to discuss a program director's perspective on international medical graduates in surgery. I'll be focusing on the residency application process in particular.

Thanks for joining us, Dr. Hughes. Thanks for having me. Dr. ACS conference was absolutely wonderful. Why don't you just get us started with some general perspectives of

IMGs as a program director, and then we'll move into your presentation and ask some questions. That's great. Thank you so much. Dr.

Reykjavik invited me to give this talk about a year and a half ago at the Clinical to kind of talk about how a program director might evaluate an application from an international medical graduate. We talked a little bit about the differences between the application when you are looking at them from a U.

S. medical grad versus an international medical graduate. Some of the biggest things we talked about was that there are some definite differences when you look at an application from an international medical graduate. Many international medical graduates have medical schools that look very different than medical schools in the United States.

They may include some courses that typically would be considered undergraduate courses in the U. S. And typically the length of medical school is much longer, typically anywhere from six to seven years. as the student learns more of the medical things later on in those years. So when we get the

applications, when we look through the dean's letter, which is basically a summation of the student's experience in medical school, the dean's letters look very different from U.

S. medical grads. They may include music appreciation along with surgery and pediatric rotations. So the difference can be pretty visible when you're looking at the applications. Grades can also be very differently applied in all kinds of different medical school backgrounds. Typically, the U.

S. medical system has standardized things into either pass fail or honors pass fail or occasionally a high pass. That allows program directors to compare apples to apples when it comes to medical graduates from U. S. medical schools. Whereas international medical schools tend to have a lot different ways they do grading.

Sometimes it's letter grades, occasionally it's numbered grades sometimes there's no grades whatsoever. So trying to have some semblance of the candidate's clinical performance during medical school is the thing that the program directors look at most closely, I think.

Great. That was a really wonderful general perspective.

Now let's move on to some of the great tips you had for our IMGs during the ACS panel. And for anyone who'd like to follow along, there'll also be a link in our show notes where you can watch the examples that we're about to discuss. So I kind of talked about this a little bit, the differences between IMGs and U.

S. medical graduates applications can be a little bit challenging. One of the first things we need to figure out is the work status. Most international medical graduates have to include whether they are approved to work in the United States as a resident. I'll talk a little bit about that in a second.

The standardization of the medical school curriculum, which we discussed just now. Clinical work experience can be really challenging in other when you look at international medical graduates experience in medical school. I think most program directors understand that clinical experience happens during the clerkship and sub I rotations whereas many international medical graduate schools don't necessarily have

that same structure there.

Many international medical graduates do research as an attempt as a gateway into the U. S. medical system. And program directors often wonder does this research actually matter when it comes to clinical performance as a resident? Many international medical graduates have also taken time away from their clinical duties, finished medical school.

They've done a couple of years of research in a U. S. medical institution trying to get their foot into the door for U. S. Surgical training. So this is what the initial page looks like on the U. S. application. And this authorization to work in the United States is something that program directors need to closely look at to make sure that if you accept this applicant into your residency program, they're going to be able to complete the entire clinical training, which is the five year visa status.

This is a complicated thing, and there's so many different types of visas that are available. Program directors have kind of ad hoc figured out a way to interpret these to make sure that if you do hire

the resident, they'll be able to stay the entire five years, but you can see there's multiple different options there.

I'm just trying to figure out which one will allow them to complete their training. So this is a purely made up example of an international medical graduate application that we have reviewed in the past. Remember most residency programs get about 12 to 1400 applications. Typically for anywhere from five to about, you know, 10 residency spots there.

There are a lot of applications that we have to go through. So this international medical graduate did seven years of medical school outside the U. S. They completed their medical school and now are doing two years of research at a large U. S. academic medical center. They've been great. They've been very productive in their research, got 42 published works, 11 of them as first author.

This is many more than many U. S. medical graduates have by the time they've completed three and a half years of medical school, but they've had no clinical experience at all since medical school. They may be working at a big institution

doing research, but they've been away from patient care for several years.

The letters of recommendation they have, three of the four come from research mentors at the U. S. institution that they're doing research. And one was from a surgeon who they worked with three years ago during medical school. They have no other clinical letters in their application. You look at the dean's letter, seven years, they got all kinds of different cases from music appreciation.

They even did an internship in general surgery during medical school. I presume that's probably like a sub I experience, but again, that's really hard to tell based on where they did medical school. Their dean's letter has some letter grades, a few of them have GPAs scored up to five instead of four, and all the evaluation comments in their entire application comes down to one single line in the letter of recommendation from that surgeon they worked with three years ago.

These are some of the course grades they had. Looks like they do the same kind of clerkship rotations that US medical grads do medicine, pediatrics, anesthesia,

surgery. They got some grades, which are seem like they're on a five point scale, but I couldn't really tell from the Dean's letter, but zero comments from any of the rotations about their overall clinical performance in the Dean's letter.

So it's. Based on the Dean letter, it's a completely black box as to whether this medical student is ready really for clinical care as a surgical resident. Here's a letter of recommendation from a chief of vascular surgery I worked with three years ago. Sounds like they had a great op. Great experience.

They did, you know, almost 200 different vascular cases over the month. And the one comment the surgeon makes about this student is that the surgical skills are still in progress of refinement, but that they've shown keen abilities regarding the basics of surgery bedside manner in the care of patients after surgery.

In the entire 50 page ERAS application, there's one line about their clinical performance. And as a program director, that would give me a lot of pause about whether this, this student is actually ready for a

surgical residency. So this kind of highlights just some of the unknowns for IMG applications when program directors are reviewing them.

And the biggest area that I think program directors wonder about is what is the overall clinical training quality that the student has at their international medical school? It varies so widely. I think most program directors understand the U. S. medical system and what that is. Kind of clinical training the student gets during resident or during medical school, but the international medical student exposure is somewhat unknown.

Ultimately, we want to know how they're going to function in a US hospital system. Are they going to be a good resident? Are they going to make good clinical decisions? Are they going to be able to communicate with other members of the team? Are they going to be able to become leaders on the service when they become chief residents?

All these things are the most important things that program directors look at when it comes to matching people into their program. Interpreting the varied medical school curriculum is really hard for program directors. And the other question we had,

is surgical research really meaningful for surgical residency?

Many programs throughout the country have five years of clinical training with maybe an optional one or two years of research. Success in research doesn't always translate to being a successful clinician. Understand the work authorization status is difficult. There are some courses available for new program directors to help figure this out, but it seems like the government changes some of the rules every year and start to keep track of all the new rules.

And what we want to do is make sure that we can provide the complete clinical training for an international medical graduate. And then the visa status is not going to get in their way to be successful for that. Letters of recommendation can be hard to interpret. And ultimately, when you look at the entire U.

S. application, we want to know, is this applicant be, going to be a good resident? And we need information in the U. S. application to help us figure that out. And with international medical graduate applications, there's a lot of empty spots in there in the application to make it hard to kind of

interpret.

So when we think about what IMGs might be able to do to improve their overall ERS application, is really try to demonstrate the quality of your clinical training. How did your medical school, how did the experience either in a U. S. medical system or an international medical system prepare you to be a surgical resident clinically.

Make sure that comes through in your personal statement, at least two of your letters of recommendation where they can talk about your clinical care and really try to get the dean's letter to populate with some comments about your overall clinical performance. If it's possible to get experience in a U.

S. medical system, actually working as some sort of clinician, either volunteer basis. Or a paid basis that would be very helpful. That would prove that you've developed the skills in medical school to make a successful surgery resident explain how your experience in the U. S. system has helped prepare you for residence above and beyond just the research that you've done in the U.

S. institution talked about the

Dean's letter that M. S. P. E. Make sure there's some evaluation comments about your clinical performance. Many international medical grads have had a long distance traveled. They are very resilient. They have been able to come a lot, overcome a lot of barriers to get into medical school in the first place, to graduate medical school, and to be ready for residency.

Make sure that distance traveled and that resilience and grit comes out in your personal statement. And maybe even some of your largest recommendation you have from some surgeons you've worked with. And if you can at all portray how you're going to be an excellent surgical resident in the US system, that's, that's what the program directors really want to know.

So, the take on points program directors, I think we're kind of risk averse. We want as much information about a candidate as possible. And if the US application doesn't include that information, it makes us kind of pause about inviting that particular applicant for an interview, because there's just too many unknowns.

And

most U. S. medical graduates are easily comparable because the U. S. applications look really similar between U. S. medical grads. If internal, international medical grads can make your application look just like a U. S. medical grad, it allows us to compare those a little bit more easily. And we all know that there's tons of superstar international medical graduates out there.

Program directors want to find these, we want to bring you into our program but the question is how do we really go about finding them? So these are just kind of my thoughts based on some experience looking at international medical student applications. I'd be happy to discuss more and if you have any questions.

So before we move into any questions, Dr. Raghavendran, do you have any initial thoughts on some of the information that we just discussed with Dr. Hughes? So, what I really liked about Dave's presentation was this was a very honest presentation. So I think the take home message is we do understand it is hard for international graduates to get into the system, but we still

see a lot of international graduates in the system and there are no easy, clean solutions.

There are solutions which David has highlighted, and I think a good idea would be for us to work with international systems. For instance, I have I've been working with a person in India who is in charge of accreditation of their residencies and how they can make their system comparable to what we have in the U.

S. But it's still a long way to go. And David, thank you so much for highlighting this in your presentation. I really, really liked your presentation. So Dr. Raghavendran, what do you see as some of the biggest challenges related to the information that Dr. Hughes just presented? From a perspective of a international graduate, I've lived in this country now for more than 30 years.

So, but I did get a chance to go to India recently. So

the first thing that hit me when they were showing the slides were when I graduated, there is no, there was no concept of a Dean's letter. The general idea that you get a transcript at the end of your experience is a entirely US based system. So we didn't have Then the second thing that hit me was during our rotation, there was no formal evaluation.

So we would be rotating through the different rotations. So when I was doing my general surgery, I was rotating through urology, neurosurgery, cardiac surgery, plastic surgery, but there was no formal evaluation. And things are changing a little bit in India right now. They have adopted some of the U. S.

based competencies, but it's generally not seen throughout it hasn't penetrated, so to speak. Then the third thing that came to me, the way we are assessed in a foreign system, at least

the Indian system is whether you pass or fail your exams. So there is a written exam and there is an oral exam and a clinical exam.

If you pass your Master of Surgery or MS, the equivalent of your residency. It's not based on your competencies throughout the year. It's not based on whether somebody really thinks that you are a good surgeon or you have these surgical capabilities. It's how you take the exams. So that's the first thing.

The system is so, and I can only imagine how different it is for different countries. So what I'm talking about is what is going on sort of in the Indian system. The second thing I would like to point out, it is really hard for an international graduate to come and do a clinical rotation in the U. S.

First of all, as an example, the University of Michigan does not allow any sort of externships. Because they are seen as some

sort of a barrier for our own resident training. Second of all, the international graduates who haven't graduated from our system here are not allowed to touch a patient or directly inquire about the welfare of a patient or do a physical exam of a patient related to the legal system that we have in our country here.

So it gets really hard for them to get some sort of an experience in the U. S. And the closest experience they can ever get is working in a lab. So the lab experience is some way of trying to figure out how good or get some local letters of approval from people here. So I don't think it intrinsically demonstrates that they have a significant interest in research.

It's rather a system where they can get a foothold into the U. S. system. Yeah, no, I think

that's really insightful that, you know, there's plenty of medical schools abroad that don't even have that Dean's Letter structure, like you mentioned, Dr. Agravendran, and I guess, you know, my question is, because I think so much weight is placed off of that as kind of the, like, repository of clinical evaluation for U.

S. medical grads, if that MSP structure or evaluation system doesn't exist at your school, What can an international medical graduate do to either bolster that side of their application or see if they can acquire that information to broadcast that to program directors in the U. S. Yeah, if Dean's letter doesn't include any of that, when we read the applications, we're going to look elsewhere to try to find that information.

The personal statement is 1 area, but that's really coming from the applicant. We want to hear from. Other surgeons who have seen them do clinical care. So really it only leaves the ledger recommendation. So that's when you need to get at least two of the ledger recommendation from surgeons who are practicing somewhere that you did some clinical care

probably during your medical school in your home country.

And make sure those ledgers are updated even if you've done some research in the U. S. to kind of talk about that. The other alternative is to go to the dean's office and say, look, you know, I need to have some evaluation comments in my dean's letter. You know, these are the ones I gathered up from people that I worked with in the hospital.

Can you put these in the dean's letter? Those are really, really good suggestions. I see that happening more and more often because there are groups of medical schools which have sort of formed a pipeline for sending students to the U. S. for further training. So they have adapted. So, their system has adapted to what the U.

S. requirements are, and it's still challenging for them because there is lack of standardization, and there are so many new medical schools, for instance, that are popping up all over India, as an example, and the standards are so variable, and that's the

problem. It is really, really hard. So, my one other suggestion I would have for program directors, so when you have a committee looking at the applications.

It may really help to have some representation for a foreign medical graduate. in that committee who has the potential to analyze and evaluate resident applications where the standards are different. Dr. Hughes, I especially wanted to go back to the several recommendations you had on like how IMGs can improve their application and their chances of getting selected for an interview.

And I wanted to spend some time kind of talking about some of these points. And John and I have a couple of questions. So, that might help make these a little bit more tangible or feasible or have some action points for students to sort of implement. And Dr. Raghavendran, I know you probably have some insights as well, so feel free to chime in.

John, you want to get us started? So, yeah, I think it's pretty clear that trying to provide some transparency into what your clinical training was like outside of the United States is critical because

it is so variable, like you mentioned, the first suggestion of demonstrating that clinical training quality in your application.

I know you mentioned the personal statement. Is there anywhere else in the application where you feel like that could be more elucidated? Or is the personal statement kind of the place, your opportunity to say those things? And if so, what's the best way to do that? Is it providing some numeric context?

Is it providing anecdotes? Like, what do you kind of think is the most compelling argument there? Yeah, for the personal statement, I think it's important that the applicant kind of describe where they came from obviously why they got into medicine in the first place. Many international medical graduates have had some formative experience in their home country that made them seek out becoming a surgeon, including that can help demonstrate the distance travel that we talked about a little bit.

If they could talk about experience taking care of patients, that's really, really important. And that's the chance for the applicant to say it in their own words in their personal statement. Leisure recommendation is a great place for that as well. Typically it needs to come from

surgeons who are clinically active, either in the home country or in the U.

S. system that they may have had some experience in, if they're able to get that. Talking about, you know, how they relate with patients, how they relate with team members, the clinical decision that they make, the fact that they prepare for cases, prepare for clinic by reading ahead they have great medical knowledge.

All the same things that make a successful surgery resident, we want to see at least starting to be formed in an applicant that comes from any medical school, be it a U. S. or a foreign medical school. The dean's letter can be helpful too. The dean's letters look very different from school to school, but most of the U.

S. medical schools at least include evaluation comments from all the clerkship and sub I rotations, which program directors like to look at to make sure that the applicant has functioned well on their clerkships, which is really the same type of stuff they're going to do as a surgery resident. So if the dean's letter from the International Medical

Schools can include those evaluation comments, that'd be really helpful.

Dr. Hayes, you mentioned that a lot of students will try to come and get research opportunities at U. S. institutions, and I'm sure a lot of people want to talk about that in their application. So how do you balance talking about your clinical experience as well as highlighting all the research you've done in the U.

S. Do you feel like you should talk more about your clinical experience, less about your research, 50 50? What do you find to be like a good ratio or mix? Yeah, I'd say a little bit of both. You don't want to dedicate your entire personal statement or the letter of recommendation to your research. Research is a small part of residency training.

The larger part is clinical training. And that's what program directors want to ensure is the kind of the bar for success. You have to be clinically successful. If you're going to be successful as an academic researcher, they have to go hand in hand. So I wouldn't recommend that applicants talk more than 50 percent about their research and it should definitely shouldn't dominate their entire application.

The

clinical stuff is important. Something else I wanted to discuss was letters of recommendation. I really appreciated the example, Dr. Hughes, that you included where the student just had one letter of rec from an actual surgeon and the other ones were from research mentors. I feel like I've heard this, or I get this question a lot as far as how you should Should you have more letters of RAC from people that are within the U.

S., or should you have more letters of RAC from people that maybe you have rotated on that can speak to that clinical aspect of your abilities? How do you sort of balance there? Again, what do you feel like is a good mix? Most applicants have four letters of recommendation. This includes both U. S. and international medical grads.

At least two or three of them usually come from someone that can at least talk about the clinical experience they may have worked with applicant during you know, a sub I or a, you know, a post I. Clerkship or some other clinical rotation as an international medical grad. One of them can definitely talk about

research, especially if it's going to be an important part of the applicant's kind of long term career path.

Having all three or really all four be about research, even if it comes from a well known U. S. medical institution, is, you, you, the applicant's lost that opportunity to talk about any kind of clinical performance, and if it's not in the dean's letter, it's not in any letter's recommendation. It's only coming from the applicant in their personal statement.

Program director is like, well, how can that really be verified? The more information, the better and the broader picture of an overall applicants background ability to do both clinical research, leadership, education, those are the things that the program directors will check off as we go through the application.

I guess one other question that that I think I have is that. You know, I know we talked about how important it is to demonstrate that clinical competency and quality of clinical training, provide a balance of kind of others vouching for you in terms of clinical and research experience, if that's part of your

application in a significant way.

But what do you think are some of the ways that an IMG applying to general surgery residency can set themselves apart from what's a pretty large pool of additional IMGs as well as us medical grads? Is there anything in particular that helps an IMG to really stand out and get those eyes on your application?

That's a great question, John. I think every applicant no matter where they're coming from, we want to try to get that application up at the top of the list of every program to, to review. You know, the application should speak for itself. You know, you should be able to demonstrate all the different qualities of a successful resident.

I understand why IMGs come to U. S. medical institutions to get those letters of recommendation from people they did research with. It does help to get their foot in the door. Those letters are coming from people that program directors recognize because they've worked with them either academically or professionally somewhere during their medical career.

So I understand that that's why they do it. And I think that does work to a certain degree. You got to let the

performance speak for itself, though. David, would you like to highlight the importance of preliminary spots? Do you see that as a way for a farm graduate to prove himself in a new environment?

What are your thoughts on that? A hundred percent. Being a successful prelim intern means you're going to be a successful resident. I mean, it's the, it's the same. curriculum. It's the same requirements that every other PGY1 surgical resident has. I see a lot of international medical graduates go through that route, and they're very successful, either staying at that same institution, or they develop a clinical acumen, they become a more mature applicant, and so forth.

They get letters from the program director that they did their prelim year at, and a letter from a program director from a prelim resident. It checks all those boxes that may not have been present in their initial ERAS application. That's an excellent point. All right, Dr. Hughes, I just have one last question.

So in

your last point, as far as things that IMGs can do to improve their application, you mentioned talking about ways that they will demonstrate their success as a surgical resident. So are there common challenges that you oftentimes see IMGs face that then they can highlight or discuss as strengths in their application to demonstrate that they will be successful?

That's a tough question because you don't really know the challenges you'll have as a surgery resident until you're actually a surgical resident. Sometimes those come out with medical knowledge, just clinical decision making. Those are things that we can help residents develop the communication style leadership skills.

Those things usually come out a little bit more in the junior and senior years of Clinical training. Those things can be taught as well. As long as a intern comes in willing to learn, willing to put in the extra work, to come prepared to the operating room, work with a diverse group of people that's on their surgical teams, those things

are important.

Those are the things we look for in the application. But again, those are really kind of abstract things you can't really know until actually In it. That's totally understandable. Well, in our last few minutes, do either of you, Dr. Hughes or Dr. Raghavendran, have any last thoughts or pieces of advice for our listeners?

Yeah, some of the best surgeons I've ever met President company included have come from international medical backgrounds. The drive, the resilience, the ability to adapt to a situation that is really outside of their typical comfort zone just makes people successful surgeons. The same things that got them there and the same things that's going to get them there in the future as they go off to be successful surgeons.

Well, Dr. Raghavendran, Dr. Hughes, thank you so much for taking the time to chat with us. I think we all found it really insightful and to all our listeners out there, thanks again for listening to Behind the Knife, dominate the day.