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10 Things I Wish I Knew as a Foreign Medical Graduate

Updated: Sep 1, 2019

Two years ago, I left my home country of Trinidad and Tobago. After graduating in 2012 and leaving behind four years of actively practicing medicine, I decided to pursue residency in the United States and migrated with my husband. It was a difficult process, leaving my family and friends but I knew in the long run it would be the best thing for my future and my patients. I always dreamt of specializing internationally and this was my chance. I had no idea what was in store and I’ll admit I was a bit naive. Now, I have learned so much, developed a thick skin, more confidence and I am certain of where I’d like to be as a medical resident and in which specialty. 

Here are some important things I really wish I knew but was not warned of, before starting this chapter of my journey.  

*Before I begin, I’d like to differentiate that I did not attend a medical school which offered any US based exams or rotations. Everything was completely done in Trinidad under a British-based system. I am classified under a Foreign Medical Graduate (FMG) as opposed to an International Medical Graduate (IMG) who attended St. George’s university for example or any other Caribbean medical school which has a US affiliation. However, the terms IMG and FMG are still used interchangeably.

1. This process is expensive

This to me, is the most important thing to keep in mind. It requires support and savings, especially if you come from a developing country. Do not use the last of the money in your bank account as a "leap of faith". The costs add up, for example, Step 1, 2CK, 2CS and Step 3 USMLE exams alone can amount to more than $3000 (USD). Whereas American graduates do these throughout med school until internship, we have to do them back to back. 

Before you apply, you will have to apply to the Educational Commission For Foreign Medical Graduates (ECFMG) which includes getting your medical school on board and paying for official transcripts to be sent to the ECFMG. Then you will have to pay for the application fee for this, exams, materials such as UWORLD, text books, NBME exams and external courses, the costs are going to add up. Also, there will be costs to fly to one of the 5 states which offer the step 2 Clinical Skills and your accommodations. In the event you decide to defer your exam and extend your eligibility, or do an observership, additional costs can be incurred. Very early on, I was infatuated with the thought of doing an observership at Harvard Medical School, which cost me $2500 USD. This was just to go there for 2 weeks and still be denied a letter of recommendation as it wasn’t enough time for the doctors to truly get to know me. With all my other costs, including flights and living in Boston for 2 weeks, I just couldn’t stay longer. 

Everything comes with costs. 

Then after all of this, comes the actual process of applying to residency - buying an ERAS token and applying to each program (for Foreign grads we’re looking at >80 programs) and of course, the flight and hotel costs to interviews. So take a deep breath before you make any drastic decisions and have an idea of the overall costs. 

2. It is not easy

Before I embarked on this journey, I had friends who matched right away and others who claimed the exams were "so easy". Also, on forums, many international students claimed to get very high scores (260 - 270). They made it seem like a piece of cake. 

It's not. Maybe that was the case for them, but I can honestly tell you, from talking to other FMGs in real life and having been through the process, it's usually not. Do not overestimate your ability, these are not exams of knowledge. You might already be a doctor, you know you’re brilliant but these are exams of grit and stamina. American students are trained for this. Do not think because they say 6 weeks of dedicated study time is all you need that you will not need more. They have reviewed this material multiple times. Do not compare your ability or think you are any less because your scores are lower or you just can’t get a topic right away. 

3. Do the necessary research and get a mentor who is an FMG

Again, research the process from start to finish. From Step 1 to residency application. It's important to have a mentor who has been through it to guide you. I didn’t know about this, studied on my own and it was one of the hardest times I’ve ever had and I compromised a good Step 1 score.

It would have been helpful to know in advance that many programs have a score cut off and a number of years since graduation cut off (3-5years). I did my personal statement, resume and overall application the first time without having a US attending review it. This was definitely a huge mistake. There are also things to bear in mind  - what is a preliminary year, a categorical program, an advanced program, the SOAP process??? It can make your head spin! 

4. Do not follow advice given by American Medical Graduates (Wait, hear me out)

This is not to say they do not have valuable tips. They have certainly been through it and are amazing doctors. There are many great videos on YouTube by American medical students talking about how long they studied and even give plans. BUT - These are not your plans. Do not get taken up by this. The average time for a foreign grad to study properly - as in dedicated study time for Step 1 for example, is 9-12 months. It is advisable to seek an external source of help, like Kaplan or Doctors in Training. The resources AMG’s use are those they’ve been using since the beginning of med school. Not you, you need to start from scratch and finish in a shorter time. The most useful ones are UWORLD and First Aid for USMLE. Advice on how to properly utilize these can be helpful. 

5. Do not compare

This ties in with 2 & 4. It's really hard to be sitting studying, for hours a day and see your colleagues back home, working and progressing in their careers. Stay focused, keep your eye on the prize and your time will come. Also, try not to compare yourself to peoples' claims online either. A lot of what is put out there is for this exact reason, to psych you out. And for the love of all that is holy - stay off of Student Doctor Forum!

6. Do not do it alone

At the same time, it's important to study in a group or with partner if possible. Online or otherwise. You need a community. Facebook has many great groups and if you use something like Kaplan’s live or online courses, you will meet people in your same position who created WhatsApp or Skype study groups. Kaplan also comes with an advisor who helps you set goals and reviews your UWORLD and NBME practice scores. This is very important. Even more importantly, if you can, try to have a good support system. Your parents, spouse, friends, anyone that can help you through those moments of self-doubt, which will definitely come. This can be a very frustrating time, with lots of hours spent studying and being prone to burn out, you need someone to vent to or have around to enjoy a meal or a hug. I felt I should have been studying constantly and renounce the world. This was not sustainable and I quickly burnt out. Thankfully my husband was always there to help me feel better. 

7 . Try to get US clinical experience

So this is a catch 22 for us. Many programs require US clinical experience in order to be eligible as an applicant, but almost none offer it. It's easier if you get this while being a medical student but paradoxically, very difficult as a graduate. It requires many calls, emails and a thick skin but try hard to at least get an observership (preferably one you do not have to pay for) in the field you want to match in. If you do land an observership, let them know straight off the bat you need a letter, or 2, so that they can find ways to assess you as you will not be able to interact with patients. Apply for observerships to places which you may actually want to match in, and keep in mind that just because it's an Ivy or top tier school doesn’t mean you will have a fulfilling experience. There are also paid externships which you can find online, I could not find any reliable ones, they all seemed a bit shady and very expensive so I cannot comment on these.

8. Step 3

I have heard more than once, many FMG’s applied to hundreds of programs with great scores yet get only 1 or no interviews. Things that improve your chance of an interview or place are completing the Step 3 with a good score and also being already capable of gainfully working in the US. I have been reliably told that many programs will shy away from FMG’s they will have to sponsor if accepted into their programs.  

9 . Have a contingency plan if you do not match

That brings us to this. The worst outcome. It’s not the end of the world! You might feel like it was all a waste, for nothing and you completely disappointed yourself and everyone else. Deal with these natural emotions, but remember - life continues, you have another day. You are a brilliant doctor, you have family and friends who love you and respect your sacrifices. There are things you can do until the next match cycle, complete Step 3 and get involved with research. If you are in the US and need income, apply for a job as a medical assistant, writer or tutor. I was able to speak to a residency director at the Brigham and Women’s hospital, who told me that favor individuals who are strong advocates of their respective fields. If you are into something, start a movement, show your interest, be a leader or an expert in your field. It doesn’t have to be too big, if you care about women’s rights, start a group or get involved with one. If you care about ending human trafficking, start spreading the word and make your voice heard. It's not just the scores but an overall applicant. A person. 

Or, if your dream is to start your family, start your family. For women, many hospitals do not offer paid maternity leave and if you do take extra time off, you will graduate after your colleagues. If you have time before the next match cycle and you're finished with your exams, consider starting the family you dream of. Life doesn’t wait. And we women can do anything. And do it all. I did my Step 3 at 19 weeks pregnant, 2 days in a row, 8 and 9 hours straight respectively. I maintained networking, researching and writing throughout and I never, ever give up. 

10. You can do it!

There will be times you doubt yourself, think you’ve made the biggest mistake and should have stayed at home and continued your job. But then you remember why you left, how unfulfilled you were and how you’ve always wanted more. The medical system in the US is one of the most grueling but also one of the best, and there's a reason why it's sought after. The tears, sacrifice and determination are worth it. You will grow as a person, learn things you never knew and meet amazing individuals. I certainly feel like a much better doctor now than when I started. I see it all as a learning process and know that when I do match I will make it the best experience of my life. Stick with it, and keep going. After all, you miss 100% of the chances you don’t take.

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