Over the last several months, due to the controversy surrounding the National Entrance cum Eligibility Test - Postgraduate (NEET-PG) exam in India, there has been a growing interest regarding residency positions in the United States of America (US).
Several NEET aspirants had taken to social media and had expressed their frustration regarding the NEET exam/results. Many had compared the NEET exam with USMLE and commented that perhaps residency in the US via United States Medical Licensing Examination (USMLE) exams is an “easier” pathway compared to securing a residency in India.
Although there is no doubt that the NEET exam is one of the most competitive exams globally, the pathway to residency in the US is anything but easy.
The preparation, mindset, and approach to the process between NEET and USMLE is dramatically different. In this article, we share with the readers the roadmap to residency in the US and provide guidance on various steps it takes a Foreign Medical Graduate (FMG) to become a physician in the US.
Let's look at USMLE
The pathway to a US residency programme is a complex, long, multi-step and often multi-year process. A successful candidate must pass multiple exams (USMLE steps) and English proficiency exam (Test of English as a Foreign Language - TOEFL, Occupational English Test - OET).
Students should secure clinical rotations in the US to gain US clinical experience and obtain strong letters of recommendation from supervising physicians. Medical students must show research experience and publications as evidence of scholarly pursuit and provide evidence of passionate volunteer work.
As part of the application process — to be considered competitive, the candidate must score in the top percentile on multiple USMLE steps, write a personal statement on why they should be considered for a residency position.
The candidate then applies to a chosen specialty (example, internal medicine/pediatrics or general surgery) at multiple hospitals all over the country through a centralised system called Electronic Residency Application System (ERAS). All the documents must be uploaded to this centralised application system by September 25 of the application year.
Often, FMGs apply to more than 100 programmes. The application is reviewed by the residency programme and based on the strength of the entire application, an interview might be offered.
The candidate interviews with the programme leadership and if the programme considers them a fit for the programme they are ranked from the pool of interviewees in the order of the preference of the programme.
The candidate also ranks the programmes in the order of their preference and submits the rank order to ERAS.
Now, if everything aligns in favour of the candidate, they find out that they have matched into a programme on the Match Day. Once the match is complete, the hospital in the US then requests paperwork to start the visa process. Residency starts at most programmes on July 1.
As highlighted above, this process requires a lot of effort outside of purely studying for an exam. Recently, lots of misinformation was spread by several accounts on X with a rather poor understanding of the process to secure residency in the US.
For example, an X account posted that you can take the USMLE exam three months later if you fail the exam without realising the implication of that statement.
Although technically correct that one can take the exam again, the failure to pass the exam in the first attempt stays on the record and significantly diminishes the chances of securing the residency position.
Impossible to get surgical residency in the US?
Another argument that is often seen on X is that it is impossible to get surgical residency in the US.
While it is true that the majority of FMGs train in non-surgical specialties in the United States such as internal medicine, pediatrics, psychiatry, it is feasible to secure even competitive surgical specialties such as orthopedic surgery, neurosurgery, urology in the US.
The pathway to secure these positions is much longer because the candidate must spend time building up their resume via research and publications and working with mentors in the United States.
This contrasts with securing similar residencies in India where your rank in the NEET PG exam solely determines the outcome.
Here, we must acknowledge that it is extremely competitive to get the specialty of choice in India via NEET PG. The sheer volume of qualified, deserving, and hard-working medical students competing against each other to secure a high rank make this one of the most intense competitions.
NEET PG, a once a year, couple of hours long, multiple-choice questions (MCQs) exam can seal the fate of the young physicians. There is no other criteria but the performance of the student on the day of the exam. Those who secure high ranks get to choose the specialty of their choice, the college/hospital, and the city of their choice.
However, for many the dream to pursue the specialty of their choice remains unfulfilled. Many must compromise with either the specialty or the hospital and often both and this can be clearly demoralising. In contrast, when a student applies for residency in the US, they apply for a particular specialty only.
Although they do not have control over which hospital they end up pursuing the residency, they have control over the specialty of their choice.
Many accounts on X stated that unlike the once-a-year NEET exam, a USMLE aspirant has the luxury of choosing the date of the exam. While it is true that the students can select the date of the exam, they are still working with a timeline because of the multiple steps involved and the deadline for the application cycle.
The application for residency in the US must be submitted by September 25 after graduating from medical school, requiring diligent long-term planning from the beginning of medical school to meet this deadline.
This requires discipline, self-awareness, and deep insight into the preparation.
Lastly, unlike the NEET PG exam, the cost of USMLE exams and the whole process might be prohibitive to many medical students. See the cost breakdown below.
In summary, the NEET PG and USMLE pathways have their own challenges but neither is “easier” than the other.
As you can see — unlike NEET PG, the USMLE pathway requires steps outside of studying for multiple choice questions. The candidate must perform at each stage because a low score on any of the USMLE steps, failure on any USMLE steps, inability to secure rotations in the US, lack of strong letters of recommendations, poor communication skills, poor interview or writing skills, lack of research or volunteer experience can significantly affect the selection of the applicant.
As a result, candidates who are successful in securing a residency spot tend to have consistency in several/all these steps. While the process for USMLE is clearly arduous, financially challenging and requires significant long-term commitment, there are clear rewards for successful candidates. In a way, it is a marathon and not a sprint. For those who pursue this pathway, the opportunities are limitless.
(Abhishek Bhardwaj, MD FACP - Fellow of the American College of Physicians (ACP), is a triple board-certified physician. He is an Assistant Clinical Professor at the University of California, Riverside and a practising pulmonologist and intensivist in Southern California. He is an alumnus of Kasturba Medical College, Manipal and the Cleveland Clinic. Views expressed in this article are his own.)