USMLE

And practice of Medicine in

the United States

Speaker:
Sriram Gubbi
Wait. First of all,
what is USMLE?
USMLE stands for United States Medical Licensing Examination.

The United States Medical Licensing Examination is a three-step

examination for medical licensure in the United States and is sponsored by
the Federation of State Medical Boards (FSMB) and the National Board
of Medical Examiners (NBME).
USMLE comprises of three examinations:

1. Step 1

2. Step 2
a. Step 2 Clinical Knowledge (CK)
b. Step 2 Clinical Skills (CS)

3. Step 3
 USMLE
STEP 1
Examination
Step 1 assesses whether you understand and can apply important concepts of the
sciences basic to the practice of medicine, with special emphasis on principles and
mechanisms underlying health, disease, and modes of therapy.

Subjects:

Anatomy
Physiology
Biochemistry
Pathology
Pharmacology
Microbiology
Immunology
Behavioral Sciences, Biostatistics and Ethics
Duration of the exam:

8 hours!

Format of the exam:

A) Till the week of May 11, 2015:
1. It is a one day examination
2. It has 322 MCQs
3. Has 7 blocks of one hour duration with each block containing 46 questions
4. You will have 45 minutes break
5. There will be a 15 minute tutorial session at the beginning of the examination.
6. If you finish the tutorial early or complete a block early, the remaining extra time can be added to your break
time.

B) On or after the week of May 11, 2015:

1. It is a one day examination
2. It has 308 MCQs
3. Has 7 blocks of one hour duration with each block containing 44 questions
4. You will have 45 minutes break
5. There will be a 15 minute tutorial session at the beginning of the examination.
6. If you finish the tutorial early or complete a block early, the remaining extra time can be added to your break
time.
Composition of the exam:

1. Pathology forms the bulk of the questions. I would probably estimate about 50%.
2. Other subjects (obviously) account for the remaining 50% with almost equal weightage distributed among all of the
subjects (distribution of questions might vary from session to session.)

Pattern of the questions:

All questions will be MCQs

1. Traditional MCQs
2. Audio questions
3. Video questions
4. Multiple item questions
5. Sequential item questions
6. Pictorial questions
7. Numerical questions

Ideal duration of study:

5 – 6 months
Contents of the exam:
1. Anatomy

a. Most questions will be pictorial. You need to correctly identify a certain anatomical/histological structure in most
questions.
b. No need to mug up origins and insertions of muscles and the course and branches of different parts of arteries.
(Thank God!!)
(Too bad our Indian PG counterparts have to mug these things up. LOL!....Sorry)

2. Physiology

a. Highly application based.

b. Having only knowledge is not sufficient. You’ve got to apply your mind just like in Physics or Mathematics.
c. Many questions will be based on graphs and formulae.

3. Biochemistry

a. Probably the toughest subject.

b. Most questions will be factual.
c. A few Genetics questions will be analytical and numerical in nature.
(And you thought you had seen the last of me in first year, didn’t you?....... hahahaha..HAHAHAHA )
4. Pathology
a. The most important subject for this exam, mainly because of its volume.
b. Questions will be more or less straight forward, two thirds of them being on pathophysiological mechanisms.
c. A lot of questions on Histopathology. Many pictorial questions.
d. A few cardiovascular system questions will be audio questions.

5. Pharmacology
a. The bulk of the questions will be from general pharmacology and autonomic pharmacology.
b. The questions from the above topics will mostly be graph based or numerical questions.
c. There will be factual MCQs on most of the other topics.

6. Microbiology and Immunology

a. Mostly factual questions.
b. You have to know in depth about each major bacterium and virus.
c. Immunology has some new information. Questions will be mainly theoretical.

7. Behavioral Sciences, Biostatistics and Ethics

a. Behavioral Science is a new subject. Half of its content is comprised of Psychiatry.
b. Biostatistics has many graphs and numerical problems in the form of MCQs.
c. Ethics. Totally alien subject to us. Tricky subject because it messes with your head even during the actual exam.
(Government hospital staff be like: “Ethics? Wtf is that??”)
Study materials:

1. Kaplan notes (with Qbook) and Step 1 First Aid.

2. Goljan Pathology (pronounced as Goliyan) . Study from this book for Pathology. You can skip Kaplan notes for this subject.

3. USMLE World (Uworld)

The most important source of preparation
a. Has around 2000 practice MCQs. You will also get Self Assessment set. It can give an estimate of your actual exam score.
b. Has detailed explanation for each answer and for each option.
c. The difficulty level is similar to the actual exam and maybe sometimes tougher than the actual exam.
d. The pattern, length, contents and the options are very similar to the actual exam.
e. Has subscription options for 1, 2 and 3 months and can be extended for one week.

4. USMLE sample practice materials

a. Available in the website usmle.org, the official website of USMLE.
b. Has a few blocks (3-4) of questions along with a block of 5 audiovisual questions. All blocks do not have explanations but
you will get answer keys.

5. NBME model test papers

a. Similar to other online practice sources but no explanations. You have to pay quite an expensive amount to even get the
answer key (aargh!)
b. Try to find NBME blocks online which have free and complete answer keys available.
Other sources
1. Kaplan Videos are very famous among many students. It is basically an audiovisual form of Kaplan notes. While some
find it useful, others find it to be a bit too stretched out. I personally have not used the videos.
2. For Neuroanatomy, refer to your Neuroanatomy text book mainly for diagrams. Also refer Embryology text book for
diagrams.
3. For Histopathology, refer Robbins for diagrams and also study the descriptions of those slides which he would have
given in a colored box (Very important!)
4. If you feel you need to know more about any subject or any topic, you can go ahead and refer to any of your text
books but the ones mentioned above are specifically useful.
5. I also personally found “Sleep disorders” “Language, learning and memory” chapters from Harrison Volume 1 and
“Stroke” chapter from Volume 2 to be quite useful.

How to study for Step 1?

1. Start at least 5-6 months before your planned examination date.
2. Start with Kaplan notes. Try to complete them in the first 4 months. (If you cannot revise them later, do not worry)
3. Subscribe to Uworld 2 months before your exam date. In the meantime, start studying from First Aid.
4. Finish all the questions and revise them at least once (if running short of time, then revise only the tough ones or
the incorrectly answered questions).
5. Please keep a note book. Write down all the formulae and PLEASE make notes especially if you learn a new concept
or on how to interpret graphs. (See videos only if you absolutely want to.)
6. In the last one month, solve NBME and USMLE website practice test materials. Also start revising Uworld.
7. In the last 10 days, do Uworld self assessment and complete revising Uworld and First Aid.
8. Now you are fully prepared to ace the exam!!
 USMLE
STEP 2 Clinical Knowledge
Examination
Step 2 assesses whether you can apply medical knowledge, skills, and understanding of
clinical science essential for the provision of patient care under supervision and
includes emphasis on health promotion and disease prevention.

Step 2 CK is constructed according to an integrated content outline that organizes

clinical science material along two dimensions: physician task and disease category.

Subjects:
Internal Medicine
Surgery
Obstetrics and Gynecology
Pediatrics
Psychiatry
Duration of the exam:

9 hours!

Damn!!

Format of the exam:

1. It is a one day examination.

2. The total number of questions cannot exceed 355 MCQs.
3. Has 8 blocks of one hour duration with each block containing 42-45 questions
4. You will have 45 minutes break
5. There will be a 15 minute tutorial session at the beginning of the examination.
6. If you finish the tutorial early or complete a block early, the remaining extra time can be added to your break
time.
Composition of the exam:

1. Internal Medicine forms the bulk of the questions. I would probably estimate about 60%.
2. Other subjects account for the remaining 40% with almost equal weightage distributed among all of the subjects
(distribution of questions might vary from session to session). Probably Pediatrics might have slightly more number of
questions.

Pattern of the questions:

All questions will be MCQs

1. Traditional MCQs
2. Audio questions
3. Video questions
4. Multiple item questions
5. Sequential item questions
6. Pictorial questions
7. Numerical questions
8. Drug ads
9. Research abstracts

Ideal duration of study:

4 months
Contents of the exam:

General features of all the subjects:

a. Most questions will be “What is the most probable diagnosis?”
b. The answers will be based on sophisticated protocols of treatment and you MUST stick to the protocols. These protocols
will be regularly updated. So you have to study from the most recent study materials.
c. Don’t worry, no one’s going to ask you about some rare feature or symptom of some unheard of diseases.
d. They will test you in depth your knowledge on the more common diseases.
e. Study well in final year. The residual knowledge that you retain from that year is more than enough.

1. Internal Medicine
a. It has the maximum weightage.
b. Studying Harrison in Final Year helps (if you haven’t then don’t worry! There is NO need to go back and start mugging up
the book!)

2. Surgery
a. Most questions will be on trauma and management of acute and emergency surgical and orthopedic situations. (about
90% of the questions!)
b. Screening procedures like Colonoscopy and Mammography are almost always asked.
c. Do I have to study some high level books?
(Bailey and Lovuuu bareee dovuuu)
4. Obstetrics and Gynecology

a. In obstetrics, antenatal management and modes of delivery during different situations are the usual topics.
b. In gynecology pap smear and HPV testing and vaccination are hot topics.

5. Pediatrics

a. Second most extensive subject.

b. CVS disorders and Cystic Fibrosis is to USA as Malnutrition is to India.
c. Immunization, Neonatology are also widely tested.

6. Psychiatry

a. Frankly speaking, this subject is a near perfect repeat of the Behavioral Sciences, Biostatistics and Ethics.
b. Only thing is there are more nerve wracking questions on Statistics and Ethics
(As I told you, drug ads and research abstracts. Facepalm!)
Study materials:
1. Kaplan notes (with Qbook)

2. Master the Boards (MTB) Step 2 CK by Conrad Fischer.

You might have order this book from the US via amazon.com. If you can, also order MTB for Step 3 along with your Step 2 CK
book.

3. USMLE World (Uworld)

The most important source of preparation
a. Has around 2250 practice MCQs. You will also get Self Assessment set. It can give an estimate of your actual exam score.
b. Has detailed explanation for each answer and for each option.
c. The difficulty level is similar to the actual exam and maybe sometimes tougher than the actual exam.
d. The pattern, length, contents and the options are very similar to the actual exam.
e. Has subscription options for 1, 2 and 3 months and can be extended for one week.

4. USMLE sample practice materials

a. Available in the website usmle.org, the official website of USMLE.
b. Has a few blocks (3-4) of questions along with a block of 5 audiovisual questions. All blocks do not have explanations but
you will get answer keys.

5. NBME model test papers

a. Similar to other online practice sources but no explanations. You have to pay quite an expensive amount to even get the
answer key (aargh!)
b. Try to find NBME blocks online which have free and complete answer keys available.
Other sources
1. Kaplan Videos are very famous among many students. It is basically an audiovisual form of Kaplan notes. While some
find it useful, others find it to be a bit too stretched out. I personally have not used the videos.

How to study for Step 2 CK?

1. Start at least 3-4 months before your planned examination date.
2. See videos only if you want to. If not then not required.
3. Start with Kaplan notes. Try to complete them in the first 1-1.5 months (Revision is not required except for Antenatal
and Cervix related topics in OBG, Trauma management in Surgery and some Biostatistics.)
4. Subscribe to Uworld 2 months before your exam date. In the meantime, start studying from MTB.
5. Finish all the questions and revise them at least once (if running short of time, then revise only the tough ones or
the incorrectly answered questions).
6. Please keep a note book. Write down all the formulae and also write down any new concepts you learn. PLEASE
make a note of ALL THE PROTOCOLS
7. In the last one month, solve NBME and USMLE website practice test materials. Also start revising Uworld.
8. In the last 10 days, do Uworld self assessment and complete revising Uworld and MTB.
9. Now you are fully prepared to ace the exam!!
 USMLE
STEP 2 Clinical Skills
Examination
Step 2 assesses whether you can apply medical knowledge, skills, and understanding of
clinical science essential for the provision of patient care under supervision and
includes emphasis on health promotion and disease prevention.

Step 2 CS uses standardized patients to test medical students and graduates on their
ability to gather information from patients, perform physical examinations, and
communicate their findings to patients and colleagues.
Duration of the exam:

8 hours!

What? Not again!!

Format of the exam:

1. It is a one day examination.

2. You will have 12 patient encounters
3. These are highly trained actors who make you feel that you are facing a real patient.
4. Each patient encounter lasts for 15 minutes. When there are 5 minutes remaining, you will get an
announcement.
5. After the patient encounter, you have to type the patient notes on the computer. You will be allotted 10 minutes
to complete the note.
6. There will be an orientation in the beginning of the day during which you can familiarize yourself with the clinical
setting.
7. After 5 cases, you will have a half an hour break. After 8 cases, you will have a 15 minute break.
Composition of the exam:

A) The patient encounter:

Duration: 15 minutes. An announcement will be made at the beginning of the last 5 minutes.
1. You will have 12 patient encounters.
2. They are actually actors and you won’t face a real patient.
3. The case starts with you standing in front of the patient’s examination room. The door will be closed.
4. The name, age, sex, chief complaints and vitals will be printed on a board attached to the door.
5. You have to knock the door, enter and introduce yourself to the patient.
6. You have to take a detailed history. They will usually answer to the point. Sometimes the lenient ones might also give
you some clues!
7. After taking the history, summarize the information you have gathered to the patient.
8. This is followed by physical examination. You should wash your hands with soap and water/wear gloves/apply sanitizer
before examining the patient.
9. Take consent before you begin the examination.
10. Do only relevant examination. Ex: No need to do CNS examination for a patient with cough, sputum and wheezing.
(It’s obviously Asthma or some RS thing… duh!)
11. Examination is followed by closure. You have to basically tell what are your findings and the probable diagnoses. Then
you have to mention what investigations you need to do. Some examinations like breast, pr, genital, pelvic and corneal
reflex should not be performed. But you have to mention them in the closure. Also counsel regarding smoking, drinking and
other habits.
12. Ask if the patient has any questions. All the patients will ask you one ‘challenging question’ and you must be ready to
answer that. Ex: “Doctor, can I take this herbal medicine which my friend suggested to me?”
Fatigue cases are the toughest. They require elaborate history and physical examination
(including cvs,rs, gi, cns, general physical….along with history taking, summarizing and closure…..
…..IN 15 MINUTES!!)
B) The patient note:
Duration: 10 minutes.

1. Immediately after completing the patient encounter, you have to come out of the room and head to your designated
desk.
2. The computer will have the patient note page open and you have to start typing the note.
3. It comprises of:
a. History
b. Physical examination
c. Three most probable differential diagnoses and the history and physical examination findings supporting each of them
d. Investigations, special examinations (like per-rectal) and counselling (like to quit smoking)

So is it really possible to type all this in 10 minutes?

Frankly speaking, YES.
Even if you don’t know to type well, you can still complete it.
The reason is:
1. You can use short forms. Ex: “Patient complains of” can be written as “Pt c/o”.
2. You can use phrases. Ex: Instead of “The patient does not complain of difficulty in breathing, difficulty in swallowing, blah
blah….”, you can write “No c/o dypnea, dysphagia, b/b irregularities, palpitation, bleeding pr.”
So how will I be evaluated?

Your performance will be based on 3 components:

1. Integrated Clinical Encounter (ICE) which is basically how complete is your history and physical examination. The actor-
patients have a checklist in which they tick the questions you have asked and the examinations you have done after you
leave the room. This component is also assessed by real physicians as they evaluate your patient note. Nowadays, this is
becoming the toughest aspect for many candidates to pass.

2. Communication and Interpersonal Skills (CIS):

a. Most foreign candidates falter here.
b. It basically tests how well you presented yourself, whether you were empathetic and whether you gave appropriate
reactions to specific concerns of the patient.

3. Spoken English Proficiency (SEP) which tests your English speaking skills. They don’t judge you based on your accent.

Ideal duration of preparation:

1 month
Sources of preparation:

1. First Aid Step 2 CS: This book literally has everything you need to know about the exam and prepares you thoroughly.
2. A partner: You need to find someone with whom you can practice. If you don’t get anyone, ask one of your family
members to act as a patient.
3. Youtube videos: Yes, you read that right! Youtube can definitely help you get a residency position in the US. It has some
good videos of sample cases.
4. Neeraj notes: A small online pdf document that you can freely download. It gives various ways to make mnemonics in
order to remember the points to ask in history and things to do during examination.

So how do I study for Step 2 CS?

1. Start preparing at least one month prior to the scheduled exam date.
2. Study from First Aid. Try and make your own mnemonics to remember stuff.
3. Try your best to practice with a fellow candidate. You can switch roles to be either the doctor or a patient.
4. Watch some videos online. They are quite helpful.
5. If you have US clinical experience before giving the exam, it will definitely help. So I would suggest you to give the exam
after a few weeks of your elective/observership.
6. If you want you can even practice in front of the mirror and improve your bady language and posture.
(Awkward, isn’t it?)
And be confident. Don’t panic. The exam is not as scary as you think!
7. Practice and practice till the day before the exam. You can even relax on the day before the exam because….
Now you are all set to face the exam!!
 USMLE
STEP 3
Examination
Step 3 assesses whether you can apply medical knowledge and understanding of
biomedical and clinical science essential for the unsupervised practice of medicine,
with emphasis on patient management in ambulatory settings. It is the final
examination in the USMLE sequence leading to a license to practice medicine without
supervision.

Subjects:
Internal Medicine
Surgery
Obstetrics and Gynecology
Pediatrics
Psychiatry
Duration of the exam:

16 hours!

That’s right. 16 freakin hours!!!!

Format of the exam:

1. It is a 2 day examination.
(I know what you people are thinking: “phew, I thought it was on a single day..”)
2. You will have 45 minutes break on each day and also tutorial sessions
4. If you finish the tutorial early, the remaining extra time can be added to your break time
Day 1
Step 3 Foundations of Independent Practice (FIP)

1. It is a 7 hour long exam.

2. There will be 256 MCQs divided among 6 blocks of one hour with each block containing 42 – 43 questions.
3. There is a 45 minute break.
4. An optional 5 minute tutorial will be there in the beginning of the exam.
5. If you finish the tutorial early or complete a block early, the remaining extra time can be added to your break time.

Day 2
Step 3 Advanced Clinical Medicine (ACM)

1. It is a 9 hour long exam.

2. It is divided into two parts
3. First part comprises of 198 MCQs, divided into 6 blocks of 33 questions; 45 minutes are allotted for completion of
each block. It also has a 5 minute tutorial in the beginning.
4. Second part comprises of Computer-based case simulations (CCS).
There are 13 ccs cases after a 7 minute CCS tutorial. Each case is allotted about 10-20 minutes.
5. There is a 45 minute break.
6. If you finish the tutorial early or complete a block early, the remaining extra time can be added to your break time.
Composition of the exam:
1. Internal Medicine forms the bulk of the questions. I would probably estimate about 60%.
2. Other subjects account for the remaining 40% with almost equal weightage distributed among all of the subjects
(distribution of questions might vary from session to session). Probably Pediatrics might have slightly more number of
questions.
3. There will be Step 1 like questions too (from preclinical subjects) most probably on the first day of the exam.

Pattern of the questions:

All questions will be MCQs

1. Traditional MCQs
2. Audio questions
3. Video questions
4. Multiple Item questions
5. Sequential item questions
6. Pictorial questions
7. Numerical questions
8. Drug ads
9. Research abstracts

Ideal duration of study:

2-2.5 months
Contents of the exam:

General features of all the subjects:

a. Most questions will be “What is the next step in management?” as you will already be knowing the diagnosis from the
question itself. Very few “What is the most probable diagnosis?” type of questions appear.
b. The answers will be based on sophisticated protocols of treatment and you MUST stick to the protocols. These protocols
will be regularly updated. So you have to study from the most recent study materials.
c. Don’t worry, no one’s going to ask you about some rare feature or symptom of some unheard of diseases.
d. They will test you in depth your knowledge on the more common diseases.
e. Study well in final year. The residual knowledge that you retain from that year is more than enough.

1. Internal Medicine
a. It has the maximum weightage.
b. Most questions will be on investigations and treatment.

2. Surgery
a. Most questions will be on trauma and management of acute and emergency surgical and orthopedic situations. (about
90% of the questions!)
b. Screening procedures like Colonoscopy and Mammography are almost always asked.
4. Obstetrics and Gynecology

a. In obstetrics, antenatal management and modes of delivery during different situations are the usual topics.
b. In gynecology pap smear and HPV testing and vaccination are hot topics.

5. Pediatrics

a. Second most extensive subject.

b. CVS disorders and Cystic Fibrosis is to USA as Malnutrition is to India.
c. Immunization, Neonatology are also widely tested.

6. Psychiatry

a. Frankly speaking, this subject is a near perfect repeat of the Behavioral Sciences, Biostatistics and Ethics.
b. Only thing is there are even more nerve wracking questions on Statistics and Ethics.
Study materials:

1. Master the Boards (MTB) Step 3 by Conrad Fischer.

You might have order this book from the US via amazon.com. If you can, order MTB for Step 3 with your Step 2 CK book.

2. USMLE World (Uworld)

The most important source of preparation
a. Has around 1400 practice MCQs. You will also get Self Assessment set. It can give an estimate of your actual exam score.
b. Has detailed explanation for each answer and for each option.
c. The difficulty level is similar to the actual exam and maybe sometimes tougher than the actual exam.
d. The pattern, length, contents and the options are very similar to the actual exam.
e. Has subscription options for 1, 2 and 3 months and can be extended for one week.

3. Uworld CCS
a. This has around 50 case simulations
b. It has detailed explanation regarding how to go about with managing the case.

4. USMLE sample practice materials

a. Available in the website usmle.org, the official website of USMLE.
b. Has a few blocks (3-4) of questions along with a block of 5 audiovisual questions. All blocks do not have explanations but
you will get answer keys.
c. There are 3-4 CCS items with explanations regarding how to manage the case.
How to study for Step 3?
1. Start at least 2-2.5 months before your planned examination date.
2. Start with MTB. Try to complete the book in the first two weeks (Revise it as and when needed).
3. Subscribe to Uworld 2 months before your exam date.
4. Finish all the questions and revise them at least once (if running short of time, then revise only the tough ones or
the incorrectly answered questions).
5. Please keep a note book. Write down all the formulae and also write down any new concepts you learn. PLEASE
make note of ALL THE PROTOCOLS
6. In the last one month, subscribe to Uworld CCS package. Also start revising Uworld.
7. In the last 10 days, do Uworld self assessment and complete revising Uworld and MTB.
8. Now you are fully prepared to ace the last exam of the USMLE!!
So, you are saying that
if I get great scores in
USMLE, I will get a
residency position in
the US?
Well….. Not really.
Then what else is
required to make me
a strong candidate?
Factors determining the strength of your application:
(In the descending order of importance with 1 being the most important and so on.)
1. USMLE Scores

2. Letters of Recommendation

3. US Clinical Experience

4. Research

5. Year of Graduation: Within 2 years of graduation, you are considered as a ‘fresh graduate’. You should apply for
residency within 3-5 years of graduation. (that is why it is wise not to do PG in India first and then apply. Apply
immediately after MBBS.)

6. Other academic achievements and volunteering works

7. Personal Statement

Other factors which give you an edge independent of the above mentioned factors:
1. Contacts
2. US Citizenship/Permanent residency status (Green Card)
1) USMLE Scores:
A very good USMLE score is the most important aspect of your application. Step 1 and Step 2 are the most important exams
and both are of almost equal importance.

So what is a good USMLE score?

For Step 1 and Step 2CK: You will get three digit scores. Two digit scores are not given now.

<220 – You need luck to get a residency

220 – 229 – Average (OK score for Peds, need a better score for Medicine)
230 – 239 – If your overall application is great, this score should not be bad.
240 – 249 – Good score. Great for Peds but need a little push for Medicine.
>250 – Great score! You are now absolutely safe!
>260 – You are God!! _/\_ (but I feel you won’t have any advantage over a person with >250 score)

For Step 2 CS: The result will be a pass/fail. This exam is the bottleneck. This exam filters out a lot of candidates.

Pass: Good enough. You have to pass in the first attempt.

Fail: You need a lot of luck and a really strong application.

For Step 3: A three digit score is given. But all that matters is whether you pass the exam.
Basically, all you need to do is pass the exam in the first attempt.
2) Letters of Recommendation (LORs):
A strong letter of recommendation gives you a huge edge over other applicants. Very good and very strong LORs are
probably the second most important aspect of your application after your Step scores.

1. A letter of recommendation is a letter given by the faculty under whom you have studies/worked during your medical
course.
2. The letter is written on the official letterhead of the institution.
3. The letter describes the duration of your work, type of work (student/observer), places where you worked (different
hospitals, wards, opds), how well you performed during that rotation, your knowledge and analytical skills, special
attributes and your future career interests.
4. You need a minimum of 3 LORs. 4 LORs is ideal.
5. You can get as many LORs as you want and use different combinations of LORs while applying to different programs.
6. All your LORs have to be from a United States physician.
7. You must also have one LOR from your Medical College professor from the department which is your specialty of choice
for the residency.
8. Among the US LORs, University letters have more weightage than Community Hospital LORs.
9. Clerkship/Elective LORs have more weightage than Observership LORs.
10. Waived LORs (the letters that are directly uploaded online by the faculty; you won’t know the content of these letters)
have more weightage compared to Unwaived LORs (Those letters that are given to your hand and you know the
contents.)
11. Letters from Professors/HODs have more weightage compared to letters from faculty in a junior position. (But still it is
not such a big deal.)
3) U.S. Clincal experience (USCE):
1. Your clinical experience in the U.S is one of the most important components of your application. Almost all the
programs require you to have some amount of U.S clinical experience.
2. The ideal duration of USCE is 3 months. More than 3 months of USCE is obviously better.
3. The main purpose of USCE is to obtain strong letters of recommendation and to build contacts.
4. You can get USCE in university hospitals, community hospitals and private clinics.
5. USCE also prepares you well for your Step 2 CS examination.
6. Most of these positions can be found by going to ‘FREIDA Online’. It is a webpage that shows the list of US Programs
from which you can select the places and specialties in which you want to do your rotations.
7. If you have contacts in the U.S getting USCE might get a lot easier!

USCE is of two types :

1. Elective/Clerkship

2. Observership
 Elective Observership

1. You can apply for an elective only BEFORE 1. You can apply for an observership only AFTER
graduation. (when you are still a student) graduation.

2. You will attend rounds, take history and examine the 2. You will attend rounds, observe students or residents
patients, present the case to the staff, involve in case as they take history and examine the patients. You
discussions, type in patient notes. must involve yourself in case discussions.

3. Most elective positions are offered by university 3. Observership positions are offered in both university
hospitals. and community hospitals.

4. You will obtain hands-on experience. (main advantage 4. You will not (officially) get hands-on experience.
of an elective) Certain observerships called ‘Externships’ offer hands-
on experience.

5. More expensive than Observership 5. Less expensive compared to Clerkship.

6. More difficult to get as many places require a Step 6. Easier to get because many people would have
One score. finished Step 1 before applying for an observership.

7. You will get more university interviews. 7. You will get more community hospital interviews.
How to apply for an Elective?

1. Go to the Frieda webpage. There are about 150 Medical Schools in this page.
2. Find the Universities of your choice. Go to their webpage and select the department of your choice.
3. Search for ‘Electives/Clerkships’. It will usually be under the ‘Education’ or the ‘Medical Students’ section.
4. Find out the documents required which will be mentioned in the above page.
5. Email the elective co-ordinator that you are interested and re-confirm the documents required to begin the process.

The usual documents required:

1. Curriculum Vitae (CV)

2. TOEFL score: An English exam to be cleared by you. (Easy exam, don’t worry too much about it.)
3. Vaccination titers.
4. Mantoux test. (Chest X-ray if reactive)
5. LORs, about 2 to 3 from the faculty of your medical college.
6. Personal Statement.
7. Medical School Transcript: It is a document containing a few pages which describe the subjects you have studied in
your college, duration of postings in each department, your final exam results and your general conduct. It can be
obtained from the college office.
8. Step 1 scores (or Step 2 CK scores). This is the main filtering factor. If you don’t have a score, then your options are
limited to just 5-6 places (They are Harvard, Mt. Sinai, Weil Cornell, Northwestern, Yale and NIH. Does not mean that
the are easy to get either!!)
The elective application process:

1. Most electives have an application fees of about $200.

2. Electives can cost $500 to $2000 per week of rotation!
(Yup, very expensive!!)
3. Some electives can actually be free of cost. For example: UT Houston offers free electives.
(Whaaaat? Yay!)
4. You have to submit all the documents mentioned before.
5. Some institutes might ask you to get a background check
(Don’t panic! You need to just visit some website and answer a few questions. No big deal.)
6. Some places might also require you to complete an online Health Insurance Portability and Accountability Act
(HIPAA) training.
(Again no big deal. Relax!)
7. Be in touch with the elective co-ordinator.
(they have hundreds of applications. They might even forget about your existence!)

Visas:

Most places want you to come on F1 (Student) Visa. Very few places require you to come on a B1/B2
(Business/Tourist) Visa.
How to apply for an Observership?

1. Go to the Frieda webpage. There are about 150 Medical Schools in this page.
2. Find the Universities or Hospitals of your choice. Go to their webpage and select the department of your choice.
3. Search for ‘Observerships’. It will usually be under the ‘Education’ or the ‘Medical Students’ section.
4. Find out the documents required which will be mentioned in the above page.
5. Email the program co-ordinator that you are interested and re-confirm the documents required to begin the process.

The usual documents required:

1. Curriculum Vitae (CV)

2. Vaccination titers. (some places)
3. Mantoux test. (Chest X-ray if reactive) (some places)
4. LORs, about 2 to 3 from the faculty of your medical college. (some places)
5. Personal Statement.
6. Medical School Transcript: It is a document containing a few pages which describe the subjects you have studied in
your college, duration of postings in each department, your final exam results and your general conduct. It can be
obtained from the college office.
7. Step 1 scores (or Step 2 CK scores) and TOEFL scores are usually NOT required.
The observership application process:

1. Many institutes may ask for an observership fee.

2. Electives can cost $500 to $2000 per week of rotation!
(Yup, very expensive!!)
3. Some observerships can actually be free of cost
4. You have to submit all the documents mentioned before.
5. Some institutes might ask you to get a background check and complete online HIPAA training.
6. Be in touch with the program co-ordinator.

Visas:

Most places want you to come on a B1/B2 (Business/Tourist) Visa.

Externships:

1. These are basically observerships which allow you to get some hands-on experience.
2. These positions are offered almost exclusively by Community Hospitals and Private Clinics.
3. Externships are not available in all the states of U.S.

Order of importance: Elective>University Observership>Community Externship>Community Observership>Private

Clinic Observership/Externship.
4) Research:

Even if the first three factors are not the best in your application, with a strong research experience you will actually be
preferred more than a candidate with superb scores and extensive USCE. (especially the university programs)

There are 2 types of research you can do:

1. Basic Science Research/Bench Research:

a. This is done in a laboratory setting.
b. Takes a long time to complete research. Centers of basic science research are not many. (Ex: IISc, NCBS, JNCASR in
Bangalore)
c. University hospitals prefer candidates with bench research experience. (This does not mean that others won’t be
considered)

2. Clinical research:
a. This is done in a clinical/hospital setting.
b. Usually, it does not take too much time. (Maybe about an year, unlike bench research which might take 2-5 years or
longer)
c. Community hospitals prefer candidates with this type of research experience rather than bench research. (Again, this
is just a minor criteria for selecting candidates)
Some noteworthy points about research experience:

1. Although research forms an important part of your application, it is not an absolute MUST HAVE. (If your scores, lors
and usce are very good, you will still get a lot of interviews)

2. Anyway, if there are 2 candidates with similar credentials, the one with research experience definitely has the
advantage and will also land up with more interviews than the candidate without research experience.

3. Publications are the most important outcomes of a research experience. (Just like how LORs are the most important
outcomes of USCE)

4. International publications are more valued compared to publications at a national level.

5. Even if you do not manage to get a publication, still having an experience in research will give you an advantage.

6. A U.S research experience is more valued compared to a non-U.S. research experience. (You can apply for research
electives in the U.S. Follow the same procedure as applying for electives or by taking help from contacts.)

7. If you have research experience, you will get more university calls.

8. Absolutely important if you are applying to competitive specialties like Radiology, Dermatology, Anesthesiology,
Ophthalmology and Surgical specialties.
5) Academic achievements and volunteering works:
Academic achievements can be the following:
1. Presenting a case in National and International Conferences.
2. Presenting a research paper in National and International Conferences.
3. Poster presentations at a national/international level.
4. Work done at an international level is definitely given more weightage.
5. Membership in national or international medical associations.

Volunteering work includes the following:

1. Conducting health camps in underprivileged sections of the society.
2. Donations given for certain causes.
3. Volunteering work in disaster stricken areas.
4. Health education workshops for the general public.
5. Guess what? All of you have done a very important volunteering work during your MBBS. You wanna know which one?
Yes, it is the Pulse Polio Immunization camp. Feel proud y’all!
So how do I let
them know that
I’ve done all these
things?
Curriculum Vitae (CV)

It is a document that provides your personal details along with your professional qualifications and
interests.

A very important document that needs to be updated from time to time.

Here is an sample format of a CV.

 CURRICULUM VITAE

Name:
Date of Birth:
Place of Birth:
Address:
Email:
Citizenship:
Education:
Qualifications:
Licensure:
Clinical Experience:
Research Experience:
Volunteering Experience:
Professional Interests:
Academic honors and awards:
Membership in Professional Organizations:
Other skills/achievements:
Hobbies:
6) The personal statement

The personal statement is a document in which you describe about yourself in the form of an essay. It is an important part
of your application when you apply for electives, observerships and for residency interviews.

1. It should be a 3-5 paragraph long essay which should preferably fit in one page in Microsoft Word.

2. It should basically describe what started your interest in a particular subject, how your interest amplified, what factors
played a role in considering a career in that field, your future interests in the field and your personal qualities that
make you a good fit for a career in that particular subject/field.

3. It should not be over-dramatic and you should be honest in what you say.

4. Here you get an opportunity to explain certain things that you can’t put in your CV. Ex: If you failed to clear an exam,
you can explain why it happened and how you overcame the situation.

5. When applying for USCEs in different specialties, modify the CV accordingly.

6. Some applicants get called for residency interviews just because of their impressive personal statements.

7. You can get access to a lot of sample personal statements online. Do not plagiarize. The faculty can easily identify if
your statement is original.
7) Independent factors:
Contacts:

1. If you have your relatives/family friends in the U.S who are in the medical field or know people who are in the medical
field, you can ask them to help you to get USCEs and interviews.
2. Many people end up getting many USCEs free of cost and also get interviews in highly reputed places just because they
know people in those institutes.

So yeah, though it is an unfair advantage, HAVING CONTACTS CAN MAKE WONDERS!!

U.S. Citizenship/Green Card:

1. This gives an advantage because you won’t have any issues related to Visa and you can travel to U.S. and stay there for
any duration without any restrictions.
2. Quite a few programs accept only permanent residents or citizens.
So,……tough luck Visa seekers. (But don’t feel bad, there are too many programs that sponsor visas! So..Calm down!)
So how do I get
started?
Plan your schedule well in advance!!
The first step towards applying to USMLE is to obtain an ECFMG ID. (it is basically an 8-digit number)

The Educational Commission for Foreign Medical Graduates (ECFMG) is a board in the U.S that facilitates foreign
graduates to take USMLE exams.

Your aim is to get an ECFMG certificate. This certificate basically implies that you have all the qualifications to start a
residency in the United States.

To be ECFMG certified, you need to fulfill 2 criteria:

1. Pass Step 1, 2 CK and 2 CS.

2. Verify all your documents and credentials by your college and also by ECFMG and your graduation.

Visit the website ecfmg.org and visit ‘Applicant Portal’ section. You will get all the necessary details.

There are certain forms to be filled (These forms are different for students and graduates). The ECFMG will verify these
documents and sent you a Scheduling Permit (Hall ticket) using which you can schedule your exam date.

The entire process takes about 2 months. Once documents are verified, you need not re verify for each exam unless
you apply as a student for one exam and as a graduate for the other exams. (as mentioned above, you need to send
the different set of forms meant for graduates)
Ideal timeline of events:
1. Plan to give Step 1 in June-July 2015 of your internship year. Get started during your final year vacations. Please do not
delay because if the test centers will be booked very fast. You need to book at least 3 months in advance.

2. During your final year vacations, obtain ECFMG ID, start all the office work.

3. You can skip internship till June-July 2015. Study for Step 1 thoroughly during that time.

4. Once you get the results for Step 1, immediately start applying for electives. Also, begin your internship.

5. Once you get to know the elective dates, apply for Step 2 CS within the span of electives. (Usually between April 2016
and July 2016)

6. Do your internship till your elective dates (July 2015 - March 2016). Then travel to U.S, complete your electives, give
Step 2 CS. (April 2016 – July 2016)

7. Return back, complete your internship (August 2016 – January 2017), apply for Step 2 CK and observerships.

8. Give Step 2 CK (March or April 2017), do observerships from May 2017 to June/July 2017. Return back in July/August.

9. Apply for residency programs in September 2017, travel to U.S. for interviews. (September/October 2017)

10. Attend interviews (till January 2018) and in the mean time, give your Step 3 exam. After that, relax till March 2018!
Centers for examination:
1. For Step 1 and Step 2 CK: Bangalore, Hyderabad, Gurgaon and Allahabad.

2. Step 2 CS:
a. Philadelphia, Pennsylvania
b. Chicago, Illinois
c. Atlanta, Georiga
d. Houston, Texas
e. Los Angeles, California

3. Step 3: Anywhere in the United States.

Some Important details:

1. ERAS (Electronic Residency Application Service): This is the website in which you upload your CV, LORs, Personal
Statements and apply for interviews by selecting programs. It usually opens on July 1 st every year. You can access ERAS
then by getting an ERAS token (basically an identification number) from the ECFMG site.

2. NRMP (National Residency Matching Program): This is the website in which you enter your residency programs of
choice after your interviews and the programs enter their candidates of choice. This website usually opens on January
15th every year. This website basically tells you in which program you have got your residency position.

3. Pre-match: Few programs offer seats outside of the match. If you take the pre-match, you will not be able to
participate in the match. Not many programs offer pre-match (and it is also not worth taking).

4. Federation of State Medical Boards (FSMB): This is the website through which you should schedule your Step 3 exam.
(Remember that for all the other steps, you apply through the ECFMG website)
The Interview Process:
After you submit your completed ERAS application to all the programs in September, your interview season begins.
You will get your interview calls via email and also to your ERAS account. The more programs you have applied to, the
higher the chances of interview. Other factors determining your chances of interview have already been discussed.

The interview season typically starts in the last week of September and goes on till the first week of February.

Interview plays a huge role in influencing a program whether to rank or not rank a candidate. Your interview is as
important as your step scores and LORs.
If a candidate with stellar credentials performs poorly in the interview and a candidate with ordinary credentials
performs very well, the latter will be selected for the program!
(So you basically got how important an interview is. Right?)

This year (2015) was a unique season because many foreign graduates got an unprecedented number of interviews.

As far as the number of interviews go, what is a good number?

If you perform extremely well, even 1 interview might be sufficient to get you a residency. But if you have 20 interviews
and perform poorly you might go unmatched. But then, these 2 cases occur very rarely.
So, the chances of matching would be:
1 – 3: Very low.
4 – 8: Decent chance
9 – 15: Almost certain
16 and above: You will match!
How much money does
the entire process cost?
1. ECFMG Certificate: $65
2. USMLE Step 1: $865
3. USMLE Step 2 CK: $865
4. USMLE Step 2 CS: $1505
5. ERAS token: $105
6. Total expenses including taxes: around $3600

7. ERAS residency program application with USMLE transcripts: from $800 to $4000 (depending on the number of
programs you apply to (applying to 100 programs may cost you around $2500)
8. Travel to U.S, Visa, electives/clerkships: Highly variable. Might go over $8000. If you get free USCE with free housing
(relative’s house) your cost may come to just $2000 - $3000
9. Interview season travel and hotel expenses, registration for match: $200 - $2000

10. Estimated total expenditure over the entire process: around $7,000 (minimum) to $14,000 (maximum) that is about
Rs. 5 lakh to Rs. 9 lakh (which is actually…. Not too bad, right?)

Moreover, residents will be paid around $3000 per month (around Rs. 1.8 lakh). That’s a lot of money!! For a PG!!
Even though your expenses will be equally high, you still save enough money to lead a comfortable life…. And in the mean
time, make up all the money you had spent for the entire process just within a few months!
 Visas for
foreign
graduates
Visa is a an official document (a paper stuck to one of the pages of your passport) that allows you to legally travel to a
foreign country.

To apply for a Visa, you first need to have a Passport. I you don’t have a passport, go get it done as soon as possible!!

For residency:

1. J1 visa
a. Also called as ‘exchange student’ visa.
b. All programs accept J1. This visa is sponsored by ECFMG.
c. It is valid for 7 years. After 7 years, you have to either return to your home country and travel anywhere outside the
country for 2 years OR work in an underprivileged area in U.S for 3 years (called J-1 Waiver).
d. Advantage: Most universities accept only J1. Better fellowship opportunities
e. Disadvantage: This is not the ideal visa if you have long term plans of staying in the US

2. H1 visa
a. Also called ‘worker’ visa.
b. The number of programs accepting H1 visa is less. It is sponsored by your residency program.
c. It is valid for 6 years. You can apply for extension/apply for other visas/apply for Green Card
d. Advantage: Ideal visa if you plan to apply for GC. No need to return back/do waiver jobs
e. Disadvantage: There are not many universities under H1 visa. Fewer fellowship opportunities
For USCE:

1. F1 visa
a. Also called as ‘student’ visa.
b. This is the visa for most electives
c. It is valid for 5 years.
d. During your stay, you cannot usually venture out of the city where you are doing your elective unless you have a valid
reason (like for giving Step 2 CS)

2. B1/B2 visa
a. Also called ‘visitor/tourist’ visa.
b. This is the visa for most observerships.
c. It is valid for 1, 5 or 10 years.
d. You can stay in the U.S. for a maximum of 6 months. In that time, you can travel anywhere in the U.S.
 Practice of
Medicine in the
United States
Why do Indian doctors go to the U.S?

1. Better infrastructure and advanced facilities.

2. More subspecialty options.

3. You will be respected by your colleagues and treated well by your seniors and faculty.

4. Better research opportunities.

5. Spouse gets a job/is working in the U.S.

6. To make lots of money.

Medical field is one of the highest paid professions in the U.S.

So more money, more Bling!!....like this guy:

Common specialties available for foreign graduates:

1. Internal Medicine

2. Pediatrics

3. Neurology

4. Family Medicine

5. Psychiatry

6. Pathology

Do you mean to say that other specialties are not available?

Well, they are available but they are very difficult to get as they are extremely competitive. You must have stellar
credentials to land in these competitive specialties.
 Difference in
medical practice
between India
and United
States
 United States India

1. Patient management is highly protocol driven 1. Patient management is entitled to individual doctor’s
opinion (as long as it’s ethical and medically right)
2. Involves a lot of discussion with patients along with
counselling and catering to their emotional needs. 2. Patient management is straight forward. Only in private
places there will be some detailed discussions with
3. Doctors are a paid a lot.. I mean A LOT. patients.

4. If you work in a big setup, you will have access to the 3. Doctors are paid well but not as much as their western
latest technology. counterparts.

5. All institutes must meet the standards. So all hospitals 4. Advanced technology is available in only few institutes.
will be well equipped. Insurance controls the type of
healthcare a patient can afford. 5. Government hospitals.. Need I say more?? Also insurance
does not play a huge role.
6. Highly regulated practice, lawsuits are higher
6. Not so much regulated, lawsuits are also lesser.
7. Universities have lots of research activities
7. Our country still needs a lot of time to reach such
8. You can still have a luxurious life research standards.

8. Comfortable life with comparatively lesser work pressure

Match Statistics
Statistical Facts:

1. About 41,000 candidates applied for over 30,000 residency positions distributed among 4,756 programs.

2. The number of candidates who applied for 2015 match increased by 940 compared to 2014.

3. The number of residency spots increased by 541 in 2015 when compared to 2014. There has been an increase
in the number of non U.S. citizen IMGs by around 700 – 900 since 2013.

4. Internal Medicine programs offered 6,770 positions, 246 more than in 2014; 98.9 percent of positions filled, and
49.0 percent filled with U.S. seniors

5. Family Medicine programs offered 3,195 positions, 86 more than in 2014; 95.1 percent of positions filled, and
44.0 percent filled with U.S. seniors

6. Pediatrics programs offered 2,668 positions, 28 more than in 2014; 99.5 percent of positions filled, and 70.8
percent filled with U.S. seniors

7. Among the non-U.S citizen international graduates, 49.4% matched to PGY1 and 50.6% were unmatched in
2015 compared to 49.5 and 50.5 respectively in 2014. In short, almost similar statistics since 2 years. But the
match rate now is way higher than 2013 (47:53) and 2012 (40.6;59.4)!

8. There is an increasing trend in match rates for IMGs every year. So….. GREAT HOPES FOR Y’ALL!!
So how many international graduates are from India?

Which countries have the maximum number of IMGs applying for residency?

What is the match rate among different countries?

Indian IMGs will form the majority of applicants. Pakistan IMGs form the next biggest group. This is followed by IMGs
from Philippines, Egypt, Iran and the remaining nations.

For fields like Medicine, Pediatrics, Family Medicine, Neurology and Psychiatry, Indians form the majority of applicants
followed by Pakistan IMGs.

For other specialties and surgical branches, the distribution many times does not follow any specific trend.
What all did you get to know in this session? Some important websites and pages:

1. What is USMLE? www.ecfmg.org

2. Different Steps of the exam. www.usmle.org
3. How to study for each of them? www.fsmb.org
4. Duration of study. www.aamc.org
5. What is a good score in various exams? www.nrmp.org
6. USCE and letters of recommendation. www.uworld.com
7. Role of research. FRIEDA Online
8. CV and Personal Statement. USMLE Forums
9. ECFMG
10. ERAS
11. FSMB
12. NRMP
13. Cost of the process
14. Visa
15. Difference in the practice of Medicine between India and U.S.
16. Common residencies available for IMGs.
17. The current trend of residency match among foreign graduates.
 Now, here is a
message to you all
from the president
of the United States
of America
THANK YOU