U.S.A. Residency Guide

PART I: Basic Requirements

The following represents the basic requirements in order to apply for a residency position in the United States of America. Some students opt to take time off after graduation to study for and take the required exams. However, it is recommended that you complete them during medical school just as US students do. This is because grades reflect your performance under time constraint. If you take months and months to study for an exam, it is expected that you’ll do much better, and a strong score will look less impressive. Furthermore, most residency programs prefer fresh graduates.

This exam is very challenging, in part because it is vast in scope, and in part because it will be your first standardized examination. This is an 8-hour MCQ exam taken in 7 question blocks with 50 minutes of break. When considering this examination, you should think about the following:

Where am I going to take it? There are locations throughout the world. Go to the Prometric website to find the location best suited for you. Note that if you decide to take it outside of the US and Canada, it is more expensive.

When should I take it? The best time to take this exam is immediately after 3rd year. Study hard throughout your first 3 years, and use the summer to prepare for and take this exam. If you are reading this and you have finished your 3rd year already, begin studying for it as soon as you can and think about taking it during the next available summer vacation.

How should I study for it? Many opinions on this subject exist and there are many forums in which students/recent test-takers actively discuss this. We encourage you to read and participate in these discussions to get an up-to-date perspective. Notable forums/discussion spaces are:

Otherwise, the consensus seems to be to use the following tools:
  • Get a flashcard application called Anki. It is free to download on your computer and you can get it on your phone so that you can do flashcards on-the-go. Watch YouTube video guides on how to use it. It is invaluable to memorizing minutiae.
  • During school years: Kaplan Lecture Notes (Books) along with Kaplan videos. These can be found on their website for purchase. Additionally, Pathoma is the gold standard resource for Morpho/Physiopathology, and Sketchy – Microbiology is an amazing tool for memorizing microbiology.
  • During dedicated study period (i.e. your summer): UFAPS Method!!! This means UWorld Question Bank, First Aid for the USMLE Step 1, Pathoma, and Sketchy Micro, plus any Anki flashcards you have made throughout the years.

How long do I need to study for it? Most US and Canadian students need about 6-7 weeks of dedicated study time before they take it. However, many foreign students and graduates use much more time, but remember that studying for this exam is intensive and requires 10-12 hours a day of preparation. If you study for more than 6-7 weeks at this pace, you will burn out. A good foundation acquired during years 1 to 3 is essential to making sure you can perform well after 6 weeks of dedicated study.

This exam is generally considered to be more manageable to study for than Step 1. It is a 9-hour MCQ exam taken in 8 question blocks with 50 minutes of break. When considering this examination, you should think about the following:

Where am I going to take it? There are locations throughout the world. Go to the Prometric website to find the location best suited for you. Note that if you decide to take it outside of the US and Canada, it is more expensive.

When should I take it? There are two good times to take this exam but each has its pros and cons

  • OPTION 1: Immediately after Year 5
    This option is more difficult to undertake, but the benefit is that you can use your 6th year for improving your CV and doing elective rotations. It is more difficult because it involves studying for subjects that you will only take in Year 6 (notably OBGYN, Psychiatry, Emergency Medicine, Family Medicine, and some subspecialties of Internal Medicine).
  • OPTION 2: After first semester of Year 6
    This option allows you more time to study for the exam and gives you the chance to rotate through some of the specialties that will be covered on the exam. However, you will have less time to work on your CV and do rotations.
  • Why not take it after I’ve graduated? While this is certainly possible, bear in mind that our graduation happens some time in July, US residency application deadline is usually in early-mid September, and scores take 4 weeks (but sometimes up to 6 weeks) to be released. As such, you would be cutting it very close with the deadlines. Furthermore, it is ideal to take this exam before Step 2 CS, and scores for that exam take 2-3 months to be released.

How should I study for it? Many opinions on this subject exist and there are many forums in which students/recent test-takers actively discuss this. We encourage you to read and participate in these discussions to get an up-to-date perspective. Notable forums/discussion spaces are:

Otherwise, the consensus seems to be to use the UWorld Question Bank and Anki. It is free to download on your computer and you can get it on your phone so that you can do flashcards on-the-go. Watch YouTube video guides on how to use it. It is invaluable to memorizing minutiae. Some students also like to use American textbooks while doing rotations. The most widely used seem to be Step-Up to Medicine and books from the Blueprints Series>(especially Peds, OBGYN, and Neuro)
During your dedicated study period, the most common approach is to simply study using UWorld QBank along with your Anki flashcards. Some people prefer to also have a book to go along with it like First Aid or Master the Boards. These are, however, not necessary and many people do great on this exam without them.

How long do I need to study for it? Most US and Canadian students need about 3-4 weeks of dedicated study time before they take it. Many foreign students and graduates use much more, but data on students taking this exam have not found a correlation between study time and scores. The strongest predictor was actually grades during clinical rotations. As such, a good foundation acquired during years 4 and 5 is essential to doing well on this exam.

This exam is generally considered to be relatively easier, as it is not scored (i.e. it is only Pass/Fail). It is an 8-hour exam where you are seeing 12 patients who are actors in stations that last 25-minutes each (15 minutes for the patient interaction and 10 minutes to type up a patient note). When considering this examination, you should think about the following:

Where am I going to take it? Unfortunately, there are only a handful of locations where this test is administered, and they are all within the US. Go to the CSCE website to find the location best suited for you. Note that you need to plan to take this exam and have it scheduled MONTHS in advance because spots fill up very fast.

When should I take it? Timing for this exam is relatively flexible as this exam is considered to be easier to pass and it is not scored. Our recommendation is to take it soon after your USMLE Step 2 CK, if you are able to, so that medical knowledge regarding differential diagnosis and investigation is fresh in your mind.

How should I study for it? The general consensus is that the most important thing is to get plenty of practice with one or more study partners, either in person or over online voice and video applications. The information needed to successfully pass the exam should be contained in First Aid for the USMLE Step 2 CS. Additionally, multiple forums/discussion spaces discuss tips and tricks for preparing for this exam, most notably:

You can also find Facebook groups for international students looking to take the exam where you can find study partners.

How long do I need to study for it? Because you are simply required to pass this exam (unlike the previous two where high scores are important), most US and Canadian students need less than 1 week of dedicated study time to prepare for this exam. However, many foreign students and graduates take more time to prepare. Some opt to take preparatory courses in order to obtain formal practice, and these are usually 4 days to a week in length. Many foreign students claim they helped them, however, we are not aware of any evidence showing that these courses help to improve pass rates.


PART II: Being a Stronger Applicant

The following items are not requirements for application to a residency position, but having them will make you stand out and significantly improve your chances of matching to a program that you like. Programs are generally looking for well-rounded individuals who demonstrate the ACGME's 6 Core Competencies. The following information should give you some idea of what you can do and where to find these opportunities.

While it is self-explanatory that good USMLE or Canadian exam scores will put you ahead of the competition, exactly how important these are and how impactful they are to your overall application needs some detailing. In the US, each program can set its own cut-off points when viewing applicants. Some programs do not have any, most are around the 25th - 50th percentiles, and some competitive programs set theirs as high as the 90th percentile. Afterwards, each program who sends you an interview decides how much these scores are weighed.

The importance of involvement in research depends drastically on your goals. If you intend on pursuing an academic career and therefore, completing residency at an academic program, research is basically a requirement and you should be prepared to talk at length about your involvement in it. Conversely, community programs are less likely to value research. Nevertheless, being involved in research is never a negative and doing it will help you tremendously in learning to read and interpret studies, which is a necessary component of practicing evidence-based medicine as a physician. ISOT is currently in discussions with the University on making research more accessible to students and we will keep you updated on the matter. In the meantime, you can spend your summer in the US or Canada doing research experiences at different universities. Obtaining these is less standardized, and so you should do your own search about which institutions take foreign students. Here are some starting points:

This is probably the most important part of your application aside from great exam scores. Most institutions in the US and Canada want to see that you have clinical (i.e. hands-on) exposure to their medical system, and that you have been able to perform well while doing so. As evidence of this, doctors with whom you work while on these rotations may write you a letter of recommendation describing your performance and character. Strong letters of recommendation can often make up for an otherwise lackluster CV, and will boost your chances of getting a great residency position significantly.

What is an elective rotation?In the US and Canada, medical school is 4 years long. Years 1 and 2 are preclinical, like our years 1 to 3. Year 3 is where clinicals begin, and is called the ‘Core Clerkship’ year because medical students rotate through all of the ‘essential’ specialties of medicine. Core clerkships are family medicine, internal medicine, general surgery, neurology, obstetrics & gynecology, psychiatry, and emergency medicine. Afterwards, year 4 is called an ‘Elective’ year because students choose which rotations they want to undertake, and these are 2 to 4 weeks long. For example, surgically-inclined students will take more surgical electives, and internal medicine folks will take more medicine electives. Foreign students can also participate in these electives at host universities and get the chance to be exposed to these medical systems and impress the doctors they work with. This is similar to ERASMUS, but different in that you are doing only one rotation as opposed to a whole semester.

Does the University give us time to do these electives?As of this writing, the University does not officially grant dedicated time to do such electives, and you must do them on your own time. We are in talks with the administration to allow us blocked time to do away electives.

Does an away elective count for school credit?As of this writing, electives do not count for school credit. We are currently in talks with the University to change this policy.

How can I obtain elective rotations? Unfortunately, most universities in the US require that you have completed all of your ‘Core clerkships’ (see above) before you can undertake an elective. This rule is also applied to foreign students. This is prohibitive because our curriculum is organized in such a way that we will not finish our core clerkships until we actually graduate. Once you are a graduate, you are no longer eligible for elective rotations due to medicolegal issues. However, a handful of universities, like Yale University, offer electives to foreign students without this requirement. Please take a look at each institution’s requirements as these change from year to year. We are also currently discussing with school administration to allow flexibility in curriculum arrangement so that these rotations are done by the beginning of year 6. Please bear the following in mind:

  • You have to apply for rotations many months ahead of actually doing them. As such, you should start planning for them during your summer break or at the beginning of the year.
  • Most places require that you pass USMLE Step 1 before the start of an elective rotation. Others require this before you even apply.
  • Elective rotations can only be done during a student’s final year (Year 6).

I saw some companies offer electives rotations for a fee. Can’t I just do that?There do exist companies that advertise rotation opportunities in the US and Canada for a substantial fee (sometimes as high as $3,000+ per rotation). However, please be advised that in the VAST MAJORITY of cases, these are simply observerships sold under the guise of an elective. As the name implies, observerships are experiences where students simply observe a doctor while they work, but are not allowed to participate in patient care. This is because you can not participate in patient care as a medical student unless sponsored through a medical school on an official elective. As such, most of these companies pair you up with an attending physician who takes you on as an observer. However, please note the following:

  • The companies that offer these services generally try everything possible to conceal the fact that they are only offering observerships. This may include misleading answers to direct questions about this issue.
  • A letter of recommendation from such an experience can not contain crucial information about your performance because the physician would not have had the opportunity to witness it. In some cases, relevant items on such letters are fabricated, but this is highly unethical and strongly discouraged.
  • Most residency programs do not count observerships or their letters for the aforementioned reason.
  • If you want them, observerships are FREE in most cases. You can apply for them directly through different universities' websites

How many months of North American clinical experience and LoRs do I need?There is a large variability in program requirements. Some do not require any while others require as little as 1 and count observerships. Most programs require 2-3 months and do not count observerships, while some very highly competitive programs require 6 months or greater. As a general rule, having 3 months of US clinical experience is a good safe place to be that satisfies the criteria for approximately 95%+ of programs. Please note that most of these programs will count Canadian electives towards US experience as the systems are often intertwined. Regarding LoRs, most programs require 3, but you can submit up to a maximum of 4. Some programs (very rare), will allow you to submit more via e-mail (as ERAS allows a maximum of 4), and others require EXACTLY 3 letters (also rare). These letters can come from anywhere, but you should assume that they will likely have very little impact unless they are written by US or Canadian doctors. Having one good letter from a well known professor at our university who is in the field that you are applying to can be a plus. But the rest should come from US/Canadian doctors.

This can be medical or non-medical in nature. Many students choose the former as it gives you more opportunities to involve yourself in the medical community and early exposure to clinical medicine. However, both are acceptable and encouraged.

Engaging in experiences where you work as part of a team and take on leadership roles, outside of school, are very important in developing you as a future doctor. We encourage you to involve yourself in such activities not just for the sake of building a strong CV, but especially because it will help you be a better doctor. The following are some examples of such activities:

  • Joining clubs, both within and without the University
  • Working in a leadership position within student organizations
  • Promoting positive change in the University and within institutions in our city

Awards are given to students who demonstrate high achievement within whichever activity they engage. Aside from the title of Valedictorian, awards are unfortunately seldom given by our university or the hospitals in which we rotate. As such, most of these will come from extracurricular activities.

Upon graduation, you will be given a Medical Student Performance Evaluation (MSPE) or Report (MSPR), depending on whether you’re applying to Canada or the US for residency. In this report, there will be mention of your qualities and academic achievements, including in which quartile of performance you are situated. For example, if your grades are in the top 25% of students, you are said to be in the top quartile of your class. Residency programs that you apply to will see this Evaluation/Report, and it is strongly preferred for candidates to be within this top quartile. Grades matter!


Serban Maierean - North america Division leader

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