The Long and Winding Road to a Residency: ZAINAB A.

MALIK, AKU CLASS 2000 (Pediatrics Residency, Duke University Medical Center) Those of you reading this are most probably in the same shoes I was not too long agowhen I graduated from AKU, I thought that the most difficult part of the road to a career was behind me, and what lay ahead would probably be a piece of cake.in a very short while, I realized how mistaken I wasnot so much at the magnitude of effort required to score well on the USMLEs, but the numerous things that needed to be done, all at the perfect time. Things like finding suitable programs to apply to, when to apply, how to go about traveling, studying for the CSA, etc, etc had I had a timeline in front of me, and known exactly what needed to be done, and when, it wouldve been a great deal easier, rather than pestering seniors (who were busy with their residencies) at every step of the way. This isnt meant to discourage any of yourather, its to give you all an idea of what to expect, and how to go about doing things.and for you not to make the same mistakes I did The Electives: I think that in order to get a good chance at a residency in the US, you need to start off from your electives. Most Residency programs in the US require at least a 2 or 3 month of US clinical experience.the key word here is Clinicalwhich means that they need to know that you evaluated and followed up patients in the inpatient and outpatient setting in the USif you have that experience, then it tells them that you would be able to adapt to the US Medical environment well, and this would give you an edge over other IMGs who lack this experience. So when youre preparing to apply for your electives, you should be going in for an Elective, rather than an Observer shipin the latter, you will not be able to touch patients, and will only be a silent bystanderhence it will not count towards Clinical Experience in the US! Try to do as many of your final year electives in the US as possible finances are the major limiting factor here, but if theyre not, then there is no reason why you shouldnt be doing all three months in the US. Try to apply to 50% of places which are known to take AKU students for their electives (like UT, West Virginia, SUNY Syracuse, etc) and 50% of places which are really topnotch where youd love to go and work, despite the fact that they dont always end up accepting elective students (like Harvard, Stanford, UCLA, Duke, Baylor, Northwestern). A common mistake some students make is, that they focus on applying only to programs for their electives which are mediocre quality, but are known to accept AKU students into their residency programsthey argue that if they did electives there, they would stand a better chance of getting into those residency programs. After having gone through the entire process of interviews, etc, I have realized that a letter from a great university will work everywhere.and if you ever have the option, Its a much better experience to work in an amazing program, because you end up learning so much more than you could in a mediocre program..and believe me, its definitely no fun in spending all that money and time, and ending up doing electives in a place like UT Houstoni did that, and realized that had I stayed back at AKU and done an ER elective, Id have ended up with a richer experience!!
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The bottom line is, go to the US for Clinical Electives (not Observer ships), and try to go to a top-notch program!! Another important thing is, that you should aim at getting the Letter of Recommendation with you when you come back home.after all, the entire effort was for that single piece of paperso you should make sure that you have it with you when you come back to Pakistanfar too many letters of recommendation have been lost to follow up, or secretarial goof-upsso aim at having it with you when you come back! Another important thingkeep in contact with the US attending(s) with whom you did your electivessend them AKU cards on Christmas; e-mail them from time to time to let them know at what stage of studies you are, when youll be applying, etcin this way, if you need a push to get an interview call from the place where youd done your electives, they will be your greatest allies! Before Graduation: If you dont have a US passport or Green card, then around June-July of the year youre supposed to graduate from AKU, apply for a US visitors visa (stating that youd like to go there for a vacation)if youre lucky, youll be stamped a 5 year multiple entry visa, which will save you a great deal of headache when youre supposed go to the US for your interviews and CSA. The advantage of applying at this stage is, that youre still in Medical School, so the embassy will be confident that since youre still technically a student, youre not going to stay back in the USits always good to have a valid visa on your passport just in case the US Embassy closes down close to your CSA date or interview invitations (like we had the September 11). As Soon as You Graduate: The day you take your last exam of the final proff., Amin Lakhani will give you an envelope with the required forms, etc to get yourself registered with the PMDCit is essential that you get your PMDC certificate made very soon (before you forget that you need to get it done), because when you match at a residency program and are applying for the J1 visa, you need this document to get a No Objection Certificate from the Ministry of Health in Islamabadand at that point in time youre pressed for time already, without the added hassle of waiting two weeks to get the PMDC certificate made.so get this out of your way ASAP!

The USMLEs: The cardinal rule in taking these exams is, to take them in chronological sequencei.e., you MUST take step 1 before step 2. Those of you who had Medicine as the last rotation in Phase III will be tempted to take step 2 earlier, but the fact of the matter is, that step 2 takes it for granted that youre well versed in basic science knowledge, so some of the questions are aimed at step 1 subjectsit can add a couple of points to your score sheet if youve taken step 2 having the step 1 base well coveredand in step 2 more than step 1, every point matters!!!

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I wont go into details of what to study, and how to go about studying for your USMLEs, because they are pretty dynamic exams, and the books change almost every other year. Its best to ask the class immediately senior to yours where they studied from, and what to focus on in both exams However, I do have a few suggestions to make: Step 1 preparation will take you almost 50% more time, and a lot more effort than step 2. so dont get discouraged at any stage. Theres a lot more to know, and a lot of things that youve forgotten since those biochem. yearsso just relax! Id advise you to take step 1 by the end of March at the latest, and step 2 by the end of August/ early September latestif you delay them, then despite the fact that you may have stellar scores in these exams, you wont have your step 2 result by the time the interview season starts, and thus youll lose out on good interview calls. As review books, you must definitely use First Aid for Step 1; and Crush the Boards for step 2I found them indispensable! When youre doing practice questions for step 1, youll find that there are millions of Qs out theretry doing practice questions from the more recent sources, otherwise you may end up with obsolete concepts and drugs that have been pulled off the market. There arent enough practice Qs for step 2 do all, and any questions that you can get your hands onKaplans Qbook is a very good source for questions also. do this, AS WELL as the Qbank for step 2 (you cant have enough practice questions for step 2). Id highly recommend doing the Kaplan Qbank over the Internet for step 1 and step 2apply for the 30-day subscriptionthe 3-month subscription is not cost effective. Apply for the 30 day period towards the end of your revision period, so that youre halfway through your 3rd revision when you start the Qbank, and there are still 2 weeks left to your exam by the time your subscription expiresthis would be the ideal timeline for doing the Qbank. Despite other reasons, why I highly recommend the Qbank is, that it is a pretty recent bank of questions, which introduces you to the latest drugs, techniques and concepts through questionsand you will probably not find some of these things even in the latest editions of booksI found out about a lot of newer drugs from the Qbank that I was tested on in the exam. When you apply for your USMLEs, and say, you want to take step 1 in Marchthen select the testing period Feb-April. in this way, you will still be able to delay your exam in case something unfortunate throws you off your study schedule; but you just have about 4 weeks to the end of this period, so you wont be able to delay the exam toooooooo far back in case you get cold feet close to the scheduled exam date (it happens fairly frequently!). When you apply to register for any of the USMLE steps, theyll send you a CD with the exam tutorial, and three blocks of questions for both step 1 and step 2, which means a total of 150 practice questions per exam. The answer key has only the answers. not the explanations. In order to find the explanations, go to the Kaplan website www.kaptest.com, and you can click on step 1 or step 2 to
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download very comprehensive explanations of the USMLE Released Items for steps 1 and 2 (you need Adobe Acrobat on your computer to download them). You should subscribe to the following e-newsletters: 1. http://www.kaptest.com/edge_modify.jhtml this is a free e-newsletter circulated by the
Kaplan people. it gives pretty useful updates on preparing for USMLEs, residency Updates, and quizzes on disease of the month and drug of the month.

2. The ECFMG Reporter is an e-newsletter by the ECFMG people. you can subscribe to it at the site: http://www.ecfmg.org/reporter/subscribe.html Its important to subscribe to it in order to keep up to date with any changes with the system, CSA, ERAS and important dates and deadlines for residency application. It would also be a good idea to sign up for OASIS (on-line applicant status and information system) at the ECFMG website at: http://oasis.ecfmg.org/ This gives you information on when your application (for step 1, 2, or CSA) reached the ECFMG; whether theyve mailed your permit or not; when your score report for a particular exam was mailed; has your TOEFL score been accepted by the ECFMG, and the status of your ECFMG certification. Signing up with OASIS saves you a great deal of anxiety and keeps you up to date with your paperwork at ECFMG.

The TOEFL: You should aim at taking this as soon as possible, and get it out of the way. I took this a week before my step 1, and thought it was a good way to get myself familiarized with the environment of the testing center (in Islamabad, the TOEFL and USMLEs are administered in the same area), and know what to expect before the big day of step 1. At the end of the exam, you will be asked which educational institution youd like your TOEFL score report to be transmittedyou MUST click on ECFMGif you cant find it, then ask the proctor to help you. this is important. Dont forget it! When you come back home, go to the ECFMG website, and download a certain form from there, called the TOEFL Acceptance Formyou must mail this form along with a check/draft for US$40 to the ECFMG, so that they can accept your TOEFL score report when it comes to them. This entire business is a pretty long-drawn process, so thats why Im emphasizing that you take your TOEFL as soon as possible, and get it out of the way. It would be a pity if your ECFMG certification were delayed because of issues with TOEFL score reporting. ECFMG Certification. What is it? When International Medical Graduates have completed all requirements to practice medicine in the US, they are certified by the ECFMG that means that they are now officially M.Ds. All IMGs need to be ECFMG certified by the time they begin their residency. but some programs like Baylor College of Medicine, Houston, do not even give interview calls to IMGs if they are not certified.
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In order to be certified by the ECFMG, you need to have PASSED: USMLE step 1 USMLE step 2 TOEFL CSA Once you have the results of your last exam, it takes about 4-6 weeks for the ECFMG to issue you a fine-looking certificate that is the fruit of all your hard work. Once you get into a residency program, you need to get this certificate permanently validatedbut in the meanwhile, youll just have to let programs know that you have your ECFMG certification, and fax them your certificate so that they may call you for an interview! Applying for a Residency: By May/June of the year youll be applying for a residency, you should register yourself with the National Residency Matching Program (NRMP), and the Electronic Residency Application System (ERAS). The NRMP registration will allow you to participate in the Matchthis is the site where you will make your Rank Order List (ROL), and will find out where youve matched on Match Day. To find out when the registration opens and other important dates, keep checking the NRMP website: http://www.nrmp.org/ ERAS is your main site where youll fill out the CAF (common application form) to apply to all programs; where youll select programs to apply to, compose your personal statement, and to which youll mail your Letters of Recommendation (LoR) and Deans Letter to be scanned and placed on your site. All the information at this site will be transmitted to all the programs that you apply to, and once youve applied to programs, you will NOT be able to change anything in your CAF and personal statement, nor will be able to un-apply to any programs youve already applied to! Therefore, you must be very careful and sure of what you put down at this site, and get it double-checked by your mentor in order to insure that you havent made errors of any kind (mistakes can reflect quite poorly on you). To apply to ERAS and find out more about the timeline, etc, visit the following site: http://www.aamc.org/about/progemph/eras/start.htm I would highly recommend getting the book First Aid for the Match. It gives pretty good guidelines regarding the application process, interviews, traveling, etc. I found it especially useful in writing my personal statement since it has many sample personal statements, different ones for various specialties, and gives wonderful feedback on what not to write in your personal statement. Which Programs to Apply To? If youre going in for Pediatrics, you should aim at applying to around 50 programs (apply to more programs if youre going in for a competitive specialty like surgery). Its generally a good idea to follow the rule of one-third! According to this rule, you should apply to 33% programs that are really top- notch, despite knowing that
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you stand a very slim chance of being called for an interview by these programs (i.e., U Penn., Duke, Harvard, etc.); another 33% should be programs where you stand a pretty good chance of being called for an interview, and are good-quality training programs (like Baylor, U Arkansas, Mayo, U Conn., etc.); and the last 33% should be okay institutions where youll definitely be invited to interview..these are the backups! Your selection of a training program will depend, to a large extent, on what you want from a Residencysome people are limited geographically, others have preference for certain visas, etc. I wanted to get into a residency program which would give me top-notch training, and wasnt looking for an H1, and neither was I limited geographically. I basically wanted to get into a medium sized (15-20 residents/year), University based program that had a good standing in the field of Pediatrics. I figured that if the program took more than 20 residents a year, then there wouldnt be too much opportunity for one-on-one interaction with the attending, and I would just be a face in the crowd. University based programs are good, because they are more academically oriented and its easier to get into fellowships after graduating from here, than after doing your residency from a Community based program. So I went to the AMA (American Medical Association) Frieda website: http://www.ama-assn.org:/vapp/freida/srch/1,2667,Y,00.html and e-mailed secretaries of all the programs that I was interested in (U based, 15-20 residents/year), giving them a brief introduction on myself and asking them what their criteria were for IMGs, and applied to those which responded positively (I started this process around June). It takes a couple of weeks for the secretaries to respond. I applied to some of the programs like Harvard, Baylor, Duke, etc, despite their discouraging, IMG non-friendly responses (I said to myself, what the hell, at least give them a shot, and it worked!!). Anyhow, I ended up applying to around 47 programs. Its a good idea to see which programs invited people from AKU for interviews in your specialty, and make sure you DEFINITELY apply to those programs alsothese would be sure-shot interview calls, and its good to have all your bases covered! Those, which invited me for interview, were: 1. Baylor College of Medicine, Houston 2. University of Texas, Houston 3. University of Arkansas, Little Rock 4. University of Illinois, Chicago 5. Mayo Clinic, Rochester 6. St. Johns Hospital, Detroit (did not rank) 7. State University of New York, Buffalo 8. State University of New York, Syracuse 9. Massachusetts General Hospital for Children (Harvard Medical School) 10. Penn State University, Hershey 11. University of North Carolina, Chapel Hill 12. Duke University Medical Center, Durham 13. Michigan State U 14. Cook County Hospital, Chicago
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15. Miami Childrens Hospital 16. U Illinois at Peoria 17. William Beaumont, Royal Oak 18. West Virginia University 19. Cleveland Clinic, Metro health 20. Wayne State U/ Henry Ford Hospital

I interviewed at the following programs and ranked all (except one): Baylor College of Medicine, Houston University of Texas, Houston University of Arkansas, Little Rock University of Illinois, Chicago Mayo Clinic, Rochester St. Johns Hospital, Detroit (did not rank) State University of New York, Buffalo State University of New York, Syracuse Massachusetts General Hospital for Children, Boston (Harvard Medical School) Penn State University, Hershey University of North Carolina, Chapel Hill Duke University Medical Center, Durham Some points: You will have loads of people telling you what to say in the interviews, how to go about traveling for your interviews, etc., so I wont cover that. But there are some things Id like to add here: 1. DONT EVER write anything in your application that is untrue basically, because its wrong, and secondly, it can get you into trouble at one stage or another. If youve been doing nothing clinical, just sitting at home and studying for your USMLEs after graduation, then you shouldnt try and make something up to write in your application. You should be honest and straightforward, and if you make an impression on a program, they will take you despite knowing that youve been sitting at home and studying for your USMLEs for 6 months after graduation, and have done no work for that period of time. I did not attend any clinics during my USMLE preparation, and in each and every interview I was asked what Id been doing since graduation I simply told them Ive been studying for my USMLEs; and it was fine with them! Always keep in mind that youre no longer a student. youre a professional, whos interviewing for a job. You represent your institution and Pakistan if you make a false statement or have a smart-alec attitude, it will go down very poorly with your interviewers, and make it more difficult for other people from Aga Khan and other Pakistani doctors who apply to the US for residencies. 2. Try and schedule your interviews as soon as you receive the invitation to interview at a program. If you start your interview season early (I started my
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interviews around the end of October), you will have no problem scheduling interviews on dates of your choice, and will be done with most of your interviews before the real interview season begins i.e., December and January. If, for any reason, you are unable to interview with a program despite scheduling your interview, then make it a point to call up the secretary or send an e-mail at least a week before the scheduled date to cancel your interview. This will allow them to accommodate some other candidate in your place, and is the proper way to do things. At two of the programs I interviewed, the secretary mentioned that in the previous interview season a candidate from Aga Khan failed to show up for a scheduled interviewneedless to say, I was highly embarrassed and apologetic, because small foul-ups like these reflect poorly on other applicants from AKU. So make it a ground rule not to make this mistake whenever you start interviewingus IMGs have it hard as it is, without social blunders like these messing up our chances and creating prejudices against us. Interview at around 10 to 12 programs at the maximum. At the end of your interview season, you should have at least 10 programs to rank on your Rank Order List. Theres no point in interviewing at programs which you know youre not going to rank anyway; since it becomes very expensive, tiring and monotonous by the end of the interview season. It leaves a very good impression if you either send individual Thank You emails or letters to those people who interviewed you. You can get an idea of what to write in the letter/e-mail from the book First Aid for the Match. Its a good idea to geographically cluster your interviews so that traveling is convenient, and you dont end up going round in circles around the US! I found the Greyhound 60-day pass very cost-effective (costs US$500, but lets you travel anywhere and everywhere during the entire 60 day period). Due to this pass I ended up taking only two airplane flights throughout the interview season, despite interviewing at 12 programs. The buses are very clean and comfortable, but you should try and avoid reaching your destination after nightfall, since most of the Greyhound stations are located in city downtowns, which are not the safest places to be after dark. However, theres no reason to be unnecessarily scared, because Greyhound is the only means of traveling which will end up saving you a great deal of money, and will take you even to the smallest towns in the US where there are no airports or Amtrak stations. www.greyhound.com

Step 3: Unlike steps 1 and 2, this exam is not administered by the ECFMG. It comes under the FSMB (Federation of State Medical Boards). Its a two-day exam, eight hours of exam time each day. The questions are similar to step 2, but on day-2, there are nine simulated cases, which are different from step 2. You need to take this exam if youre going in for an H1 visa. In order to be eligible for an H1, you need to have your scores by Match Day (you basically need to passscores dont count on this exam).
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Everyone else needs to take this exam during the first year of his or her residency. Passing this exam makes you eligible for the DEA license, or the license to prescribe all drugs, including narcotics, all over the US. I would strongly advise you all to take this exam towards the end of your interview season, before you come back to Pakistan, irrespective of whether youre going in for an H1 or a J1. Its a pretty simple exam, and doesnt require much studying. Since its basically step 2 stuff, and you wouldve recently taken step 2, youll end up scoring pretty well in it. If you dont take this exam now, when youre relatively freer, youll have to take it during your intern year, which can be very tough on your nerves! You can download the forms from the website: www.fsmb.org When you go to this site, click on Connecticut, and download the forms for the Connecticut boards (since this state does not require you to have done your first year of residency before sitting for this exam). Once your scheduling permit arrives, you can make an appointment by telephone and take the exam ANYWHERE within the US. You dont even have to specify a geographical location on the form when you apply, so youre pretty free to sit for it anywhere, from California to Albany! If youre planning to take the exam while still in the US, you should buy the following from Pakistan and take them with you to the US (or else, end up spending a whole lot of $$$ if you buy them from the US): 1. Kaplans Step 3 CD-Rom (costs Rs.40); 2. The book, Family Practice Review by Swanson (costs around Rs.100 in the Urdu Bazaar).

Well, thats about all the stuff I could think of for the time being. Id like to wish all of you the very best for this long (and never-ending) process Work hard, and dont give up at any stage! Many people have done it before you, and youll also end up in a great residency!!

Zainab A. Malik June 1, 2002

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