Residency Training in the US: USMLE and NRMP 101 2025 edition
Definitions
Organizations/Institutions
IMG (International Medical Graduate): Physicians who have graduated from medical schools outside the country where they intend to practice. For example, if you completed your medical education in Ghana but want to practice in the United States, you would be considered an IMG.
ECFMG (Educational Commission for Foreign Medical Graduates):
Purpose: Assesses the qualifications of international medical graduates (IMGs) to ensure they are ready to enter US residency programs.
Unique Trait: Certification by ECFMG is required for IMGs to apply for residency and take the USMLE Step 3 exam.
USMLE (United States Medical Licensing Examination):
Purpose: A three-step exam that evaluates a physician's ability to apply knowledge, concepts, and principles necessary for effective patient care.
Unique Trait: Passing all three steps is essential for obtaining a medical license in the US.
NRMP (National Resident Matching Program):
Purpose: Uses a computerized algorithm to match medical school graduates with residency programs based on their preferences.
Unique Trait: Known as "The Match," it ensures a fair and transparent process for residency placement.
Training/Phases
Elective:
Definition: An elective is a period during medical training where students or residents choose to study a specific area of interest. It is typically a short-term rotation that allows them to gain experience in a particular specialty or subspecialty.
Unique Trait: Electives are planned in advance and are not required for immediate medical necessity.
Residency:
Definition: Residency is a stage of graduate medical training where a physician practices medicine under the supervision of experienced doctors. It follows the completion of medical school and provides in-depth training in a specific specialty.
Unique Trait: Residency programs vary in length, typically lasting from three to seven years, depending on the specialty.
Intern Year:
Definition: The intern year, also known as the first year of residency (PGY-1), is the initial year of post-graduate training for medical school graduates. During this year, interns gain hands-on experience in patient care under close supervision.
Unique Trait: Interns perform many of the same duties as doctors but are closely supervised as they transition from medical school to more independent practice.
Fellowship:
Definition: A fellowship is an optional, advanced training program that physicians undertake after completing their residency. It focuses on a subspecialty within a field of medicine.
Unique Trait: Fellowships typically last one to three years and allow physicians to become experts in a specific area, such as cardiology or oncology.
ECFMG Certification
Medical School Requirements:
Ensure your medical school is listed in the World Directory of Medical Schools with an ECFMG note indicating it meets eligibility requirements.
Application for ECFMG Certification:
Submit an application to confirm your intent to pursue ECFMG Certification and your understanding of its purpose.
Examinations:
Pass Step 1 and Step 2 Clinical Knowledge (CK) of the United States Medical Licensing Examination (USMLE).
Pathways for Clinical and Communication Skills:
Complete one of the ECFMG Pathways to meet the clinical and communication skills requirements. This often includes passing the Occupational English Test (OET) Medicine.
Final Certification:
Once all requirements are met, you will receive your ECFMG Certification, making you eligible to apply for residency programs in the US.
The Match
Timeline
Registration:
Opens in September: Medical graduates and residency programs register for the Match through the NRMP's Registration, Ranking, and Results (R3) system.
Application and Interviews:
September to January: Applicants submit their applications to residency programs via the Electronic Residency Application Service (ERAS). Programs review applications and conduct interviews.
Ranking:
January to February: Both applicants and residency programs submit their rank order lists, indicating their preferences for each other.
The NRMP Match algorithm is designed to fairly match applicants with residency programs based on their preferences.
Applicant-Proposing:
The algorithm starts with each applicant's top choice program on their rank order list (ROL).
Tentative Matches:
If a program has an open spot and the applicant is ranked by that program, a tentative match is made.
If the program is full, the algorithm checks if the applicant is preferred over someone already tentatively matched. If so, the less preferred applicant is "bumped" and the new applicant is tentatively matched.
Iterative Process:
The bumped applicant is then considered for their next choice program. This process continues until all applicants have been considered for all their ranked programs.
Final Matches:
Once all applicants and programs have been processed, the tentative matches become final. This ensures that each applicant is matched to the most preferred program possible that also prefers them.
Match Week:
Mid-March:
Monday: Applicants find out if they have matched to a residency program.
Tuesday to Thursday: The Supplemental Offer and Acceptance Program (SOAP) takes place for unmatched applicants to secure unfilled positions.
Friday: Match Day! Applicants learn where they have matched and celebrate their residency placements.
Post-Match SOAP:
March: Unmatched applicants participate in SOAP to apply for unfilled residency positions.
Start of Residency:
July: Residency programs typically begin in July, marking the start of training for new residents.
USMLE Steps
USMLE Step 1
Content: Assesses basic science knowledge, including anatomy, biochemistry, microbiology, pathology, pharmacology, and physiology.
Structure: Consists of multiple-choice questions (MCQs) divided into seven 60-minute blocks, with a total of up to 280 questions.
Scoring: Reported as a three-digit score. A passing score is typically around 194.
Duration: One-day exam, approximately 8 hours long, including breaks.
Location: Administered at Prometric test centers worldwide. In Africa, centers are in Egypt, Ghana, Kenya, South Africa, and Uganda.
USMLE Step 2 CK (Clinical Knowledge)
Content: Evaluates clinical knowledge and skills in patient care, including internal medicine, surgery, pediatrics, psychiatry, and obstetrics and gynecology.
Structure: Consists of MCQs divided into eight 60-minute blocks, with a total of up to 318 questions.
Scoring: Reported as a three-digit score. A passing score is typically around 209.
Duration: One-day exam, approximately 9 hours long, including breaks.
Location: Administered at Prometric test centers worldwide. In Africa, centers are in Egypt, Ghana, Kenya, South Africa, and Uganda.
USMLE Step 3
Content: Assesses the ability to apply medical knowledge and understanding of biomedical and clinical science essential for the unsupervised practice of medicine.
Structure: Two-day exam:
Day 1: Foundations of Independent Practice (FIP) - 232 MCQs divided into six 60-minute blocks.
Day 2: Advanced Clinical Medicine (ACM) - 180 MCQs divided into six 45-minute blocks and 13 computer-based case simulations.
Scoring: Reported as a three-digit score. A passing score is typically around 198.
Duration: Approximately 7 hours on Day 1 and 9 hours on Day 2, including breaks.
Location: Administered at Prometric test centers in the US and its territories.
USMLE Registration Process
Log in to IWA (Interactive Web Applications):
Use your ECFMG ID and password to log in to the IWA portal on the ECFMG website.
Select the Exam:
Choose the USMLE Step exam you wish to take (Step 1 or Step 2 CK).
Complete the Application:
Fill out the application form with your personal information, medical education details, and other required information.
Pay the Exam Fee:
Pay the required fee for the exam. Fees can be paid online through the IWA portal.
Submit the Application:
Review your application for accuracy and submit it. If your medical school participates in the EMSWP (Electronic Portfolio of International Credentials), your application will be sent electronically. Otherwise, you may need to mail certain documents.
Receive Scheduling Permit:
Once your application is processed and approved, you will receive a scheduling permit via email. This permit is necessary to schedule your exam.
Schedule Your Exam:
Use the scheduling permit to book your exam date and location through the Prometric website. Choose a convenient test center and date.
Prepare for the Exam:
Study and prepare for the exam using various resources and practice materials.
Take the Exam:
On the scheduled date, go to the Prometric test center with your scheduling permit and identification to take the exam.
Research
Experiences
Research Fellow
Definition: A research fellow is a physician or scientist who has completed their medical degree and often additional training, such as a residency or PhD. They engage in advanced research projects, often independently or with minimal supervision.
Role: Conducts high-level research, publishes findings, and may mentor junior researchers. They often work on specialized projects within academic or medical institutions.
Research Associate
Definition: A research associate typically holds an advanced degree (master's or PhD) and works on research projects under the supervision of a principal investigator (PI).
Role: Assists in designing, conducting, and analyzing experiments or studies. They may also be involved in writing research papers and grant applications.
Research Assistant
Definition: A research assistant is usually a graduate or doctoral student who supports research projects. They work under the supervision of a PI or senior researcher.
Role: Performs tasks such as data collection, literature reviews, and preliminary analysis. They help with the day-to-day operations of research projects.
Research Intern
Definition: A research intern is often an undergraduate or early graduate student gaining practical experience in research. Internships are typically short-term and provide foundational skills.
Role: Assists with basic research tasks, such as data entry, sample preparation, and administrative support. Interns learn about the research process and gain hands-on experience.
Outputs
Abstracts
Definition: A brief summary of a research study or article. Abstracts highlight the main objectives, methods, results, and conclusions of the research.
Purpose: To provide a quick overview of the research, helping readers decide whether to read the full paper or attend a presentation.
Presentations
Definition: Oral or visual displays of research findings, typically given at conferences, seminars, or meetings.
Purpose: To share research results with peers, receive feedback, and engage in discussions. Presentations can include slides, posters, or live demonstrations.
Publications
Definition: Written documents that report research findings, usually in peer-reviewed journals, books, or conference proceedings.
Purpose: To formally disseminate research results to the scientific community, contributing to the body of knowledge in a particular field.
Grants
Definition: Financial support provided by organizations or institutions to fund research projects.
Purpose: To enable researchers to carry out their studies, covering costs such as equipment, materials, and personnel. Grants are often awarded based on the merit and potential impact of the proposed research.
US Clinical Experience
Electives
Definition: Electives are hands-on clinical experiences for medical students, usually in a hospital setting.
Activities: Involves taking patient histories, performing physical examinations, charting on electronic medical records (EMR), participating in patient rounds, and sometimes performing procedures under supervision.
Eligibility: Typically available to final-year medical students.
Benefits: Provides direct patient care experience, helps build clinical skills, and offers opportunities to obtain US letters of recommendation.
Observerships
Definition: Observerships are shadowing experiences where IMGs observe the daily activities of a physician in a hospital or clinic.
Activities: Includes watching patient interactions, attending rounds, and observing surgeries or procedures. No direct patient care is involved.
Eligibility: Available to both medical students and graduates.
Benefits: Helps IMGs understand the US healthcare system, build professional networks, and gain familiarity with medical practices in the US.
Other US Clinical Experiences
Sub-Internships (Sub-I)
Definition: Advanced electives where final-year medical students take on the role and responsibilities of an intern or first-year resident.
Activities: Similar to electives but with more responsibility, including managing patient care under supervision.
Benefits: Provides a deeper insight into residency life and helps in building strong letters of recommendation.
Externships
Definition: Hands-on clinical experiences similar to electives but designed for medical graduates.
Activities: Involves direct patient care, similar to electives, but tailored for those who have already graduated from medical school.
Benefits: Offers practical experience and helps in obtaining US letters of recommendation.
Graduate Degrees
Masters and PhDs: GRE
Cost
ECFMG Registration and Certification
ECFMG Certification Application: $160
Form Certification: Included in the application fee
USMLE Step 1 Registration (Outside North America)
Step 1 Exam Fee: $1,000
International Test Delivery Surcharge: $195
Step 1 Resources
UWorld (3 months): $269
AMBOSS (3 months): $89.97
Boards and Beyond (3 months): $149
First Aid for USMLE Step 1: $46.32
Pathoma (3 months): $84.95
UWorld Self-Assessments: $40 each
USMLE Step 2 CK Registration (Outside North America)
Step 2 CK Exam Fee: $1,000
International Test Delivery Surcharge: $220
Step 2 CK Resources
UWorld (3 months): $269
AMBOSS (3 months): $89.97
NBME Self-Assessment: $62 each
UWorld Self-Assessments: $40 each
NBME Clinical Mastery Series (CMS) Forms: $21 each
Occupational English Test (OET)
OET Medicine: $587
ERAS (Electronic Residency Application Service) Fees
ERAS Token: $165
Application Fees:
Up to 10 programs: $99
11-20 programs: $19 each
21-30 programs: $23 each
31 or more programs: $27 each
For 50 programs:
$99 (first 10) + $190 (next 10) + $230 (next 10) + $540 (next 20) = $1,059
For 80 programs:
$99 (first 10) + $190 (next 10) + $230 (next 10) + $1,350 (next 50) = $1,869
NRMP (National Resident Matching Program) Fees
Registration Fee: $70 (includes up to 20 programs)
Additional Programs: $30 each (for programs beyond the initial 20)
For 50 programs:
$70 (first 20) + $900 (next 30) = $970
For 80 programs:
$70 (first 20) + $1,800 (next 60) = $1,870
Additional Costs
USMLE Transcript Fee: $80 (once per ERAS season)
Travel and Accommodation for Interviews: Varies depending on location and number of interviews
