Clinical, Columns, Featured, Internal Medicine, Surviving IM/G
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The U.S. Medical System as an IMG: My Path

In my last installment, I mentioned I would like to write about my process of getting into a residency program in the United States. As soon as I promised this, I remembered the number of steps involved, so please forgive me if I forget to mention something. The path has substantially changed since COVID and differs greatly by individual circumstance. What made the whole process so confusing was having to create multiple accounts and profiles for multiple websites; the next step was often unclear until I called the Educational Commission for Foreign Medical Graduates (ECFMG) and explicitly asked for instructions.

For all international medical graduates (IMGs) reading this, I am sure you can relate: licensing is a strenuous and tedious process! They (yes, an undescriptive ‘they’) do not make it easy for you.

Let me start at the beginning: one of the first things I needed to do was to sign up with ECFMG. You initially create a profile and then receive a USMLE/ECFMG number: store it safely because you will need it often. Hopefully, your home base medical school is already registered with ECFMG (mine was); otherwise, things may take even longer to start your personal process. Once registered, you can access and use ECFMG online services. Those services will guide you through the United States Medical Licensing Examination (USMLE) exam and ECFMG licensure applications.

So, first things first: in order to apply for an ECFMG certificate, you must pass the USMLE Step 1 and 2 CK exams. Go ahead and ignore the ECFMG certificate stuff for a while until you finish Steps 1 and 2. For each of these steps, you will pay the same amount of money as U.S. medical students. An additional fee is applied if you take the tests outside of the United States.

You will need to have all grades that you received during medical school sent to ECFMG from your home university. They need to be in English and potentially converted to an American-comparable letter grade system. These grades need to be submitted in an envelope and cannot be forwarded by you. This process took me a while. You will also need your medical school certificates and a police record from your home country, both translated and notarized. The nine-hour time difference and foreign landlines (tip: use Skype!) made it very difficult to ship med school grades from Germany.

After having applied for and passed Steps 1 and 2, you will continue with your application process for the ECFMG certification. Since COVID, there are so-called ‘pathways’ (six different options) that determine which clinical and communication competencies must be demonstrated. Some factors that influence your pathway include prior clinical practice in your home country or prior objective structured clinical examinations (OSCEs). One way or another, you must prove English language proficiency. While waiting for certification (it can take a couple of weeks), you may start setting up your profile with ERAS.

At this stage, things proceed as they would for U.S. medical school graduates. Your program selection and sorting depend on your score, your competitiveness, and the length of time since medical school (you should be mindful of that — programs likely aren’t joking if they have specific requirements). To match and enter a U.S. residency, you will need to be ECFMG-certified; but, as mentioned above, these things will likely run in parallel. Remember that you will not be able to start your residency without the ECFMG certificate; some programs will not even consider your application without it.

Having said all that: would I do it again? After a long day of wards, I’m not too sure. But, when better rested, my answer would be yes. The training and teaching is pretty amazing in the United States and, even though my program is far from perfect, I enjoy all the new learning opportunities.

As always, feel free to comment below or reach out to me if you have any questions.


Surviving IM/G

I am an international medical graduate in internal medicine residency (IM/G), sharing my experiences with all of you. If you are an IMG, hopefully you can relate to some of the stories and feel encouraged, because we are not alone. If you are an American-based resident: I hope these stories help you better understand your IMG colleagues a bit better. And above all, I am hoping to hear from you as well: let’s share knowledge, experiences, and pave a path for the many other IMGs seeking to fulfill their dreams in the United States.

Aline Gottlieb, MD, PhD Aline Gottlieb, MD, PhD (3 Posts)

Resident Physician Columnist

Hillsboro Medical Center


Aline went to medical school at the University of Essen in Germany. She started training at the University Hospital Essen in Internal Medicine with the focus on GI/Hepatology. She then followed one of her former supervisors in 2017 to the University Hospital Magdeburg and continued her training for two years. In 2019, she started a two-year research fellowship at Johns Hopkins University with a scholarship by the German Research Foundation. During that time, she decided not to return to Germany and instead attempt to become a physician in the US. She has started her internal medicine residency this year at Hillsboro Medical Center in Oregon.

Surviving IM/G

I am an international medical graduate in internal medicine residency (IM/G), sharing my experiences with all of you. If you are an IMG, hopefully you can relate to some of the stories and feel encouraged, because we are not alone. If you are an American-based resident: I hope these stories help you better understand your IMG colleagues a bit better. And above all, I am hoping to hear from you as well: let's share knowledge, experiences, and pave a path for the many other IMGs seeking to fulfill their dreams in the United States.