Otolaryngology is a small surgical specialty that consistently attracts very bright and dedicated physicians. As a result, the residency positions are very competitive. It is no secret that being an international medical graduate (IMG) and pursuing a match in a surgical specialty such as Otolaryngology-Head and Neck surgery can be a challenge. In the 2020 National Residency Matching Program (NRMP) annual report, only 5 IMG applicants matched in otolaryngology for the 350 spots that were offered.

Historically, IMGs tend to apply to “IMG friendly” specialties such as internal medicine or family medicine. So, for all of you working against these odds, good luck! If you truly feel that this specialty is what you want, there is no reason why you should not give it your best shot. Here is some advice that may be beneficial:

The sooner the better: The sooner you realize in medical school that you want to come to the US for training, the better you can prepare yourself to be a competitive candidate.

The work starts at home: Doing well in your medical school courses is the first step to becoming a competitive candidate. Try to be in the top 10% of your class. But if it is too late for this, do not worry, you have a second chance: doing well on the USMLE steps scores. This is going to be the true measuring stick that reviewers will go by. Nevertheless, it helps to have good scores in your clinical rotations at home, as it will also make the USMLE easier.

Doing an away rotation or at least an observership at a US program: An away rotation is a good reason to start working on your goal early. Go to the program websites, where you can find information about how to apply for an away rotation, just as a US med student would do. Keep in mind that some programs will not accept foreign medical students. You will probably have to pay some fees such as a malpractice insurance fee among others and fill out paperwork. Some medical schools will not have an official block during your curriculum for these rotations, so you may have to sacrifice 4 or more weeks of your vacation time for this experience. One of the reasons why doing an away rotation is so important is that as a visiting medical student on an away rotation you will have the complete experience. You will see patients in the clinics, scrub in the OR, and help the residents. In contrast to an away rotation, an observership is something that you can do once you are already an MD. During an observership, you cannot have any direct patient contact. If you are at this point of your career, email the programs directly to try to set up an observership. Although not as good as an actual student rotation, it is the second best option you have. The observership will give you a general idea about the environment and structure of a residency in the US and will also help you get a couple of letters of recommendations (LORs) from the chairperson and/or program director. During your time there be sure to schedule a sit down visit with the program director and/or chairperson of the department. It is good to get some advice from them and ask any questions that you may have. Since you are going to need at least 3 LORs for your applications, it would be ideal to actually set up 2 or 3 of these meetings/rotations if feasible.

Letters of recommendation: Strong letters of recommendation are crucial, especially for IMGs. It is one more tool to demonstrate that you are reliable, intelligent, and capable of becoming an excellent resident in otolaryngology. The challenge is to get good letters of recommendations from otolaryngologists from the US. These are the letters that you want in your application because the letter is not only proof that you are a good candidate, but it also shows that you have participated in otolaryngology in the US. This demonstrates that you understand the US medical system by having been exposed to it and having done a great job by acquiring a recommendation. It also shows that you were already able to adapt to this new system. Of course, to get a recommendation you have to first meet people and participate. IMGs in the past have spent time in the US participating in clinical or basic science research, clinical electives or observerships, and/or volunteering on surgical mission trips. If you have already graduated or are late in pursuing an elective in otolaryngology, seek research opportunities or a surgical mission trip. Perhaps, clinical research can ultimately be more helpful for residency application purposes because it allows you to interact with patients, which can add to show your ability to establish good rapport with the writer of the letter of recommendation you hope to obtain. Clinical research can also facilitate meaningful publications in a shorter period of time. 

Ace the Boards: Themean USMLE Step 1 and Step 2 CK scores for US seniors who matched in otolaryngology are high, often >250. That means you also have to ace those exams. One difference is that most US applicants apply only with the USMLE Step 1 score; they will usually take USMLE step 2 CK and CS after or during the interview period. While this works for them, it will not necessarily work for you for these two reasons: (1) Programs often prefer that by the time you apply you will already have your ECFMG certificate, which requires that you pass USMLE Steps 1 and 2 CK/CS. Passing these exams show residency programs that you are already ECFMG certified and can start your training on day one of your residency if you were to match in their program. (2) If by any chance you did not ace your USMLE Step 1 score, getting a high score on USMLE Step 2 CK will help a lot, since most programs will take into account the best of the two scores. 

How do you do well on the USMLE? Without a doubt you need to study hard. Most find that it works best to stick to no more than two books and prioritize answering question banks. Question banks not only help you refresh your memory, but also show you how questions and answers are phrased. Set a timeline and be sure to establish a plan of attack that includes a mock test at least 10 days prior to the date of your exam. If you do not like the outcome, I strongly suggest you take your time and reschedule your exam so that it will give you more time to raise your score. While you will hear stories of people being able to raise their score >10 points in a week, this is severely optimistic. The reality is that you may want to invest more time to get this step of the process done right.

Research, research, research: ...research, research. If you have the opportunity to take part in a meaningful research project during your medical school years, take it. It does not matter if it is otolaryngology related or not, or if it is clinical or basic science. For better or worse, research has more weight if presented at US meetings compared to national meetings in your country, or if published in a US journal. Consider investing one year after medical school doing a research fellowship in an otolaryngology program in the US. Participating in a year of research is extremely important not only for the educational experience, but also because it gives you a chance to get yourself known, complete several abstracts at national meetings, or even produce some publications to improve your CV. One way to find these research spots is by emailing programs and asking if they have any positions available. A warning to keep in mind is that most of these positions are not subsidized. You may need to email a number of places before you receive a reply. Do not be discouraged; be persistent. Suffice it to say, if you obtain a research spot, work extremely hard on your project from day one. But do not stop there; you also have a great opportunity to become known by the program. One way you can do this is by going to grand rounds every week, journal clubs, or any other departmental activity. Besides being a great learning experience you will get to know the residents and faculty, and they will get to know you. Also make sure that one of your letters of recommendation comes from the principal investigator of your project.

Getting your application ready: Programs receive hundreds of applications every year and they generally only offer around 10 or so interviews per spot. Once they are done choosing those lucky few, they close the gate. So send in your applications as early as possible. This means no more than 1 or 2 weeks after the initial application date starts. In order to increase your chances, you should consider applying broadly. Applying to many programs is a big expense, but if you made it this far, do not take any chances and think of the money you are spending as an investment. Be assured that standards of training are generally very high in surgical specialties such as otolaryngology that there really are no bad programs out there.

Interview time: All the work you have put in over the past few years has been for this, the dreaded interviews. It is a scary feeling when your first job interview might be in a foreign language. The key is to prepare yourself. One way to do this is to setup some mock interviews with your US mentor or research principal investigator. This experience will make you feel more confident of your interviewing skills. As an IMG, there are a couple of questions that are going to come up frequently during the interview trail. The most common one is about your plans after residency and if you want to eventually go back to your country or stay here in the US. Another common topic is questions about your medical school and if there are otolaryngology residency programs in your country and why you do not want to do your training there. So be ready to answer these types of questions since they are sure to come up at any point during an interview. Also keep in mind that this is your moment to shine. As an IMG, you have a unique background that may help you stand out from the rest. For example, you may have previously worked as a general medicine doctor in a rural or underserved area. So make sure to find a way to bring out these unique experiences into the interview.

Know the visa paperwork: Another thing to keep in mind is the visa options available for you. Again, you can find detailed information in the ECFMG website, but the standard visa is the J-1. People will ask you about this, especially regarding timeframes for when you would be able to get the visa, since the concern is that your visa will not be approved, and then the residency spot will go unfilled. Ensure that the university/residency program works together with you to complete all the required information. While there are not many otolaryngology residency programs that have trained IMGs in the past, you can take a look at what other specialties within the university have done and bring this up with the program if necessary. Usually there is a single international department that assists with all the visa-related processes within a university, and it is helpful for people to learn that the path has been walked successfully by the university in the past.

Remember that otolaryngology programs are not used to dealing with visas and all the associated paperwork. They may ask you what your visa options are. Be ready to explain this in a straightforward and simple manner. They may have the idea that is a complicated process, but in reality it is not.

And last but not least: Try to enjoy the process. The positions are indeed limited, but someone has to fill the spots, so why not you?! As with everything in life, luck plays a big part of all this - being in the right place at the right time. Stay positive, try your best, and best of luck!