Hurdles in US Surgical Training for International Medical Graduates.

Non-US citizen foreign graduates make great sacrifices to obtain a residency position in the USA. They must overcome financial, social, and geographical challenges when moving to America. Obstacles such as ECFMG certification, United States Medical Licensing Examination (USMLE) testing, application fees, interview travel costs, and obtaining a visa all add up to a great financial burden which can be approximately $25,000 for some international medical graduates (IMGs) [1]. The decision to undertake this path is a difficult one to make, and is compounded by a lack of data demonstrating that completion of a preliminary year in surgery directly benefits the applicant. It would be beneficial for these candidates to have a realistic idea of the likelihood they have matching into a categorical position in the future. The overall match rate for all specialties for non-US citizen IMGs in 2015 was 49.5 % [2]. The competition experienced by IMGs when applying for a 5-year categorical position in general surgery is overwhelming. Applicants are often left unmatched, and applying for a 1-year preliminary surgery position is an attractive option as a way to gain experience and strengthen applications for a categorical position the following year. However, completion of a preliminary surgery year does not always guarantee the candidate a categorical position in the future and accepting this position can be risky. The preliminary position is essential to training programs in order to balance work-hour restrictions and personnel requirements. In return, these positions can be valuable in that they provide experience and a path toward a career in surgery. However, the position has been referred to as a Bdead end^ for those looking to continue on in general surgery [3]. Although there are a number of residents who are IMGs, the number of US medical graduates accepted to categorical positions far exceeds the IMG. In the 2015 match, 121 out of 1085 IMG applicants matched categorical surgery. There were a total of 1219 categorical positions filled, of which 1101 (90 %) were filled by American graduates and 121 (10 %) by IMGs, both US citizen (n = 71, 5 %) and non-US citizen (n = 50, 4 %). The majority of IMGs matching to categorical positions completed a preliminary year [2]. The small number of IMGs matching into general surgery (GS)-categorical positions can possibly be explained by the program director’s perceptions of these candidates. Moore and Rhodenbaugh published a study showing that a majority of GS residency program directors believe that IMGs are subject to discrimination during the candidate selection process [4]. They also reported that 20% of the PDs that responded to their survey felt pressure to rank less qualified American graduates above IMGs who were more qualified. Several other factors for IMG applicants to overcome include obtaining high scores on the USMLE Step 1 and 2 and making an exceptional impression on interview day [5]. Makdia et al. published a recent study examining the criteria used to select candidates for residency positions in GS [6]. They reported that the number one most important factor in the screening process is USMLE Step 1 scores, followed by USMLE Step 2 scores, as well as if the applicant was a graduate from a Liaison Committee on Medical Education (LCME)-accredited medical school. The LCME accredits schools located in the USA and Canada and does not accredit foreign medical schools. This study also noted that the most important factor for ranking a candidate was the interview. While this study does not reflect the criteria of all training programs in the * Elizabeth A. Lax Vijay.Mittal@providence-stjohnhealth.org