PURSUING MEDICAL/SURGICAL

RESIDENCY IN THE U.S.: A BRIEF

OVERVIEW
May 9, 2012 by Nurul Hariadi in Career
Hi everyone! I am Nurul Itqiyah Hariadi (Nurul), currently a 2nd year Pediatric Infectious Diseases Fellow at the
University of Michigan, Ann Arbor, Michigan. Prior to my current fellowship, I finished pediatric residency training at
Childrens Hospital of Michigan (1st year) and UCLA Pediatric Residency Program (2nd and 3rd years). Martin kindly
asked me to write about medical/surgical residency and fellowship in the U.S., which may be of interest for some of
you. I will not discuss about medical school in the U.S., since I did my medical school in Indonesia, hence I have no
experience about U.S. medical school system.

Since I dont expect everybody to be interested in or well acquainted with medicine, Ill try to be brief and clear. I think
Q&A will serve this purpose the best. Ill provide the link to helpful websites to find further information as we go along
this discussion, and feel free to email me with questions.

First Id like to clarify a few terms. Residency is a training program to be a specialist in a certain area (e.g. Internal
Medicine, Surgery, Pediatrics, Ob-Gyn), while fellowship is a training program to be a subspecialist in one particular
specialty following residency (e.g. Pediatric Hematology-Oncology, Pediatric Infectious Diseases, Pediatric
Endocrinology).

Q: Why should I consider pursuing residency in the U.S.?

A: The answer can be different for each person. For me, I started considering it when I got married to my husband,
who at that time was in the first year of his doctoral study in California. Since we knew it would probably take him
several years to finish, we decided that I should try to do residency in the U.S. For others, it may be the interest of
specializing or subspecializing in a specific field that has not been available in Indonesia.

One thing I can attest to, at least for pediatric residency, is that even though U.S. residency programs are not perfect
by any means, I feel blessed that I have been given this opportunity. The learning experience that Ive had so far in
my former residency and current fellowship programs has been wonderful. They really put great emphasis on
balancing resident/fellow education and clinical service in a very conducive learning environment.

Q: Can all international medical graduates pursue residency in the U.S.?

A: Yes, as long as the medical school you graduate from is listed in International Medical Education Directory (IMED).

Q: What are the steps of pursuing residency in the U.S.?

A: In a nutshell, the process to get into residency in the U.S. is as follows:

Apply to Educational Commission for Foreign Medical Graduates (ECFMG). You will get an eligibility period
assigned to complete United States Medical Licensing Examination (USMLE)

Apply for USMLE

Pass USMLE Step 1, Step 2 CK (Clinical Knowledge), and Step 2 CS (Clinical Skills)

Obtain ECFMG certificate (by passing the USMLE tests above)

Apply for residency through a centralized system (National Resident Matching Program/NRMP): starting
September each year

Interview for residency programs: October until February

Rank the residency programs you have been interviewed at: deadline in February

Match day: third Friday of March each year

Start residency: July 1st each year in most programs

Q: Where do I start if I am interested in pursuing residency in the U.S.?

A: The first two websites Id suggest are Educational Commission for Foreign Medical Graduates
(ECFMG) and United States Medical Licensing Examination (USMLE).

Q: Do I need specific immigration/visa status for residency in the U.S.?

A: If you are not a U.S. citizen or permanent resident (green card holder), you will be on J1 or H1B visa when you do
your residency. If you prepare for the tests in Indonesia or other country, you will need a visitor visa when you take
the Step 2 Clinical Skill exam or come for residency interviews.

However, if you prepare for the tests in the U.S., you can be on any types of visa at that time, as long as you maintain
valid status of your visa. For example, I was on F2 visa (dependent of a student) when I was preparing for the tests
since I came to the U.S. as my husbands dependent.

There are advantages and disadvantages for each of these visa types. Considering the complexity of the this topic, it
will be better explained in a separate discussion.

Q: How expensive is residency in the U.S.?

A: Residency programs in the U.S. do not charge the residents fee because they are funded programs, mostly by the
government through Graduate Medical Education portion of Medicare, and partly by the hospitals/universities where
the programs take place. Resident receives monthly or bi-weekly salary, which differs based on specialty, level of
training, and geographical area.

Q: How long are residency programs in the U.S.?

A: The answer depends on the specialty. Most of the primary care specialties such as family medicine, pediatrics,
internal medicine, general surgery, and obstetrics-gynecology have a 3-year residency program. Once you finish the
residency training, you can go into practice or pursue further subspecialty training. To subspecialize, there are
fellowship programs that vary in length. In pediatrics, for example, most subspecialties require 2-3 years of additional
training.

Q: What tests do I need to pass to be able to apply to residency programs in the U.S.?

A: There are 3 tests that you need to pass to be able to apply to residency programs: USMLE Step 1, Step 2 CK,
and Step 2 CS. Step 1 tests your knowledge in pre-clinical science (anatomy, physiology, pathology, etc.), and Step 2
CK (Clinical Knowledge) tests your knowledge in clinical science (internal medicine, pediatrics, surgery, etc.). As the
name implies, Step 2 CS (Clinical Skill) tests your clinical skills, which include history taking, physical examination,
communication, and most importantly, interpersonal relation using standardized patients. It also serves as an
evaluation tool for your English.

Once you are in residency program, you also need to pass Step 3 in your first year, which is similar to Step 2 CK with
addition of simulated cases. Some people take Step 3 before starting residency, which in my opinion is a smart
decision because it takes a significant burden from your first year of residency, which undoubtedly will be very busy.
In addition, passing Step 3 is needed if you want to apply for H1B visa. Information about each specific test can be
found on USMLE website.

Q: What study options do I have to prepare for the tests?

A: You have several options, with their own advantages and disadvantages. First, you can always study on your own,
although I recommend having USMLE targeted books to guide your studying. It has the advantage of being the least
expensive. However, you need to be very consistent with your study schedule. Second, you can take online courses

available from various sources, which may result in a considerable cost. Third, you can enroll in a course held by test
preparation centers to intensively study for the USMLE, which is usually the most expensive option. However, it has
the advantage of a set time limit to study, which will help to focus all your effort for the tests. I chose the third option,
which I think was an investment worth every penny. On the other hand, I also have friends who did well by studying
on their own, or by studying with someone who was enrolled in a course held by a test preparation center.

Explore your study style and financial resource, and choose the method that will suit you the most! If you decide to
enroll in a course held by a test preparation center,Kaplan is one of the most well known for USMLE.

Q: How expensive are the tests?

A: Honestly speaking, USMLE tests are relatively expensive. For international medical graduates, the list of current
fees can be seen at http://www.ecfmg.org/fees/index.html.

Q: What will I need to do after I pass the tests?

A: After you pass Step 1, 2 CK, and 2 CS, you will be ECFMG certified, which means that you will be able to apply to
residency programs through NRMP (National Resident Matching Program). The residency programs you apply to will
decide whether they want to invite you for interview based on your application package. Needless to say that higher
USMLE scores open more doors. After the interviews, you will rank the programs you have interviewed at, and the
programs will also rank the applicants they have interviewed. NRMP is the organization that matches the applicants
rank order list with the programs, which will result in a match.

Q: What else do I need for a good application package in addition to excellent USMLE scores?

A: You will need letter of recommendations, preferably with at least one of them from a U.S. physician or a globally
renowned physician from Indonesia in the specialty you would like to pursue. To be able to obtain a letter of
recommendation from a U.S. physician, you can go through various paths such as being a volunteer, an observer, or
a researcher in a medical facility in the U.S. There are also opportunities to do an elective at limited U.S. teaching
hospitals. There is a group on Facebook for Indonesian physicians in the U.S. (Indonesian Doctor Club in America)
where you can ask for information regarding these opportunities.

You will also need a personal statement, which should be able to tell your story and why you are the perfect
candidate for the program you apply to. Ive noticed that writing a personal statement is difficult for a lot of Asian
graduates since we are not taught to brag about our story.

These two topics, along with how to excel in residency interview, also deserve a separate in-depth discussion.

Q: Can I work in the U.S. after finishing residency?

A: The answer depends on your type of visa. If you are on J1 visa, you have to fulfill a 2-year home country
requirement before you can return to the U.S.. If you are on H1B, you can directly work in the U.S. after finishing your
residency. However, when you are on J1 visa, there are limited waiver opportunities that enable you to directly work
in the U.S. without having to stay for 2 years in your home country. Again, since this question is related to
immigration/visa requirement, this will be better addressed in a separate discussion.

Q: Can I work in Indonesia with the specialty degree I receive from the U.S.?

A: The short answer is yes, but you need to do a special adaptation program (between 6 months to 2 years) available
at several universities in Indonesia. I have to admit that I dont know enough about this issue. I will share the
information once I obtain more of it.

Q: I am currently a medical student in Indonesia. When is the earliest time I can start preparing for residency
in the U.S.?

A: You can start as soon as you finish the 2nd year of medical school to apply to ECFMG as you can see at
http://www.ecfmg.org/2012ib/students.html. Although you may apply for and take the examinations after completing
the basic medical science component of your medical school curriculum, it is recommended that you complete your
core clinical clerkships, including actual patient contact, before taking Step 2 CK and Step 2 CS.

I am sure that you still have tons of questions. The links I mentioned above are useful to get started, but also feel free
to email me at nurul.hariadi@gmail.com. I hope this small discussion is useful!

Photo by Mercy Health via flickr

THE ANATOMY OF RESIDENCY IN THE

U.S.
July 4, 2012 by Nurul Hariadi in America, By Region, Career
Now that I have written about Pursuing Residency in the U.S., I realized that not all of us were familiar to the structure
of residency training. There are some aspects of residency training that you will find similar almost everywhere in the
world, but residency trainings in different countries also do some things differently.

So lets go through the anatomy of residency in the US that hopefully will provide some illustration for those of you
who are thinking about pursuing residency here. Just a little reminder, residency is specialty training, while fellowship
is subspecialty training. I will only discuss about residency in this article. We may talk more about fellowship in the
near future.

Q: I have finished medical school and do not want to pursue any specialties. Can I just take USMLE and
apply for a medical license to practice as a general practitioner in the US?

A: No. Everyone who has completed his/her medical degree needs to go into residency to be able to obtain a medical
license and practice in his/her area of interest.

Q: Then, who provide primary care in the US?

A: There are 3 specialties that are definitely considered as primary care in the US: family medicine, internal medicine,
and pediatrics. In addition, obstetrics and gynecology are sometimes considered as primary care for women.

Family medicine is probably the closest US equivalent to what we know as general practitioner in Indonesia, since
family physicians provide comprehensive health care for people of all ages.

Q: Do different specialties require different lengths of training?

A: Yes. Here is the concise table showing the length of training for different specialties. Of note, I will explain about
transitional/preliminary year in the next question.

Specialty

Length of residency
training (in years, not
including transitional
or preliminary year)

Transitional/preliminary
year needed

Anesthesiology

Yes

Dermatology

Yes

Diagnostic Radiology

Yes

Emergency Medicine

3-4

No

Family Medicine

No

General Surgery

4-5

No

Internal Medicine

No

Neurology

Yes

Neurosurgery *

N/A

Ob/Gyn

No

Ophthalmology

Yes

Orthopedic Surgery

No

Otolaryngology

No

Pathology

No

Pediatrics

No

Physical Medicine

Yes

Plastic Surgery *

N/A

Psychiatry

No

Radiation Oncology

Yes

Urology

No

* = Specialties that need specific number of years in surgery residency, but not the completion of the whole surgical
residency, as a prerequisite

Q: What is transitional/preliminary year?

A: Transitional year is a one-year position with rotations through various disciplines (Internal Medicine, Surgery, etc.)
preceding training in another specialty. Preliminary year is a one-year position in a given field (mostly Internal
Medicine or Surgery) usually preceding training in another specialty. As you can see, the transitional year is similar in
structure to the last two years of medical school, in terms of rotating through various specialties; while preliminary
year is only in one specific specialty. Transitional/preliminary year is required by certain specialties as described in
the table above.

Q: What is the clinical schedule like in residency?

A: Residency training is structured into blocks of rotation, which can be 2-week blocks or 4-week blocks depending
on individual programs.

Just as what you would expect with residency training everywhere, the first year is usually the hardest one in terms of
schedule. A first year resident is often called an intern. You will do a lot of inpatient care, have more in-house calls
compared to your second and third year, and usually only have one or two blocks of elective. During inpatient
rotations, you work in a team with a senior resident (2nd or 3rd year), (an)other intern(s), and an attending physician.
Sometimes, a fellow (subspecialty trainee) is also a part of the team.

In second or third year, you will have more elective blocks where you can do rotations in subspecialties of your
interests. For those interested in pursuing fellowship after residency, they usually choose the respective subspecialty
as one (or more) of their elective blocks. Although the call schedule tends to get lighter in 2nd and 3rd years, the level
of attached responsibility increases. Senior residents are expected to be able to lead the team when they are in
inpatient services, formulate management plans for patients, and participate in teaching for interns and medical
students. In other words, they are learning to be ready for the real world.

Some residency programs provide opportunities for the residents to do international electives, which usually take
place in developing countries.

One of the interesting things about residency training in the US is that there are duty hour rules that have to be
followed by residency programs in order to maintain their accreditation status. Residents are only allowed to work
maximum 80 hours per week with 1 day per week allocated as a day off from all clinical duties, averaged over a 4week period. Dont worry, they also have vacation time, 3-4 weeks per year depending on the programs.

Q: What is the educational experience like in residency?

A: Residency programs are responsible in providing educational experience for the residents. However, just like
everywhere else, the quality of educational experience in residency will be determined by the commitment of the
individual program to resident education.

The structure of daily educational experience has some similarities to how it works in Indonesia. Generally, residents
have morning report/conference for about an hour and noon conference for another hour everyday. In between, there
is teaching round with their respective teams. The contents of these conferences may differ between programs, but
usually include case report, didactic teaching on core topics in the specialty (by attending physicians, chief residents,
or fellows), and journal club. It is important to note that this is the typical daily educational experience for non-surgical
specialties. In surgical specialties, the schedule may be different given the fluidity of their day (e.g. they may have
early surgeries scheduled etc.). In addition, non-surgical residents (e.g. Internal Medicine, Pediatrics, etc.) on
emergency and intensive/critical care rotations do not usually follow the same schedule for the same reason as those
in surgical specialties.

There is also a weekly grand round where distinguished speakers from the institution or outside are invited to give a
talk, and quality improvement conference (or what is known as morbidity/mortality conference) once every few
months depending on the programs. Some programs also have board preparation sessions for residents to prepare
for their board certification exam.

Q: How about the exams and evaluations?

A: For most specialties, especially non-surgical, the formal written (or computerized) exam is once yearly, which is
called in-training exam. There is no formal oral exam; however, residents will be evaluated by their peers,
seniors/fellows, and attending physicians on every rotation they do based on their performance. In a lot of programs,
the patients or patients caregivers and supporting staff are also given the opportunity to evaluate residents.

Each resident is assigned (or chooses) a mentor/advisor during his/her training, who is expected to provide guidance
on career plans and/or personal development. In addition, he/she also needs to meet with the program director twice
in a year to discuss about progress that have been made, areas that need improvement, and future career plans.

Q: Is research a component of residency training?

A: The short answer is yes. However, it is actually scholarly activity that is required during residency; which may
range from a quality improvement project, case report, chart review, up to clinical, translational, or bench research. In
other words, dont be intimidated by the word research or scholarly activity. It is feasible to fulfill.

Q: What is a chief resident?

A: There are two meanings of chief resident. In primary care specialties, a chief resident is a resident who has been
selected to extend his or her residency by one year and supervise the activities and training of the other residents. In
other specialties, a chief resident may refer to a resident in his/her final year of residency. A chief resident, especially
in primary care specialties, usually coordinates the clinical and educational activities of the residents. In some
programs, they may also function as junior attendings. Although it may seem like additional training with a lot of
responsibility, being a chief resident for a year gives a significant weight in the resume, especially for those interested
in pursuing a career in academics.

Q: What is board certification exam?

A: Once a resident completes his/her training, he/she will be eligible to sit for board certification exam to demonstrate
through either written, practical, and/or simulator based testing, a mastery of the basic knowledge and skills of his/her
respective specialty. A physician can still practice without being board certified because medical/surgical licensing is
a separate process from board certification. However, most hospitals/medical centers require their physicians to be
board certified. In addition, more fellowships (subspecialty trainings) expect the fellows to be board certified in their
specialty (e.g. a fellow in Pediatric Neonatology is expected to be board certified in Pediatrics), at least during their
subspecialty training.

I hope this gives some illustration on how residency works here in the US. As always, I can be reached at
nurul.hariadi@gmail.com if you have any questions.

Photo by Mercy Health via flickr