General Surgery Residency for International Students

International medical graduates (IMGs) constitute a critical component of the health care system in the United States (US). Nearly 25% of the graduate medical education (GME) pool and practicing physicians graduated from schools outside the US. However, there is a disparity in the proportion of IMGs among the different specialties. While IMGs made up almost 40% of the internal medicine GME pool, they only made up 16% of the general surgery pool.

The difficulty of getting into a surgical residency as an IMG can be largely attributed to the smaller number of programs and spots compared to other specialties, such as internal medicine. But there is some good news! Getting a general surgery residency in the US is not impossible for IMGs, and many applicants have succeeded in their pursuit. Let’s go over the structure of general surgery residency and the pathways that IMGs can take to become general surgeons in the US. 

The Two Main Pathways of General Surgery Residency

Through the NRMP match, applicants can match into one of two possible general surgery (GS) programs: categorical and preliminary (prelim). Many programs offer both pathways to applicants. Categorical GS is a 5 to 7-year training program (some programs have 2 years of research in addition to the 5 years of clinical training). This path ensures complete training in general surgery and offers trainees eligibility for board certification by the American Board of Surgery. Prelim GS, on the other hand, offers only 1 year of training, at the end of which, the candidate needs to find a subsequent position for continuing GME, an additional 4 years. Because of this, categorical spots are more competitive than prelim spots.

The National Resident Matching Program (NRMP) 2020 data shows that not only do IMGs make up a larger portion of prelim residents, but also that there is a greater ratio of supply to demand for preliminary GS overall. The greater number of unfilled positions in prelim gives IMGs a greater chance of being accepted to this track as opposed to the categorical GS track.

A consideration not included in this data is that of the few IMGs who matched into categorical GS, some may have done prelim GS prior to matching into Categorical GS. IMGs are more likely to start with a preliminary year for several reasons. First, residency program directors are not aware of the quality of medical education outside the US. Therefore, they are more likely to accept IMGs into a 1-year program rather than a 5-year program. During the prelim year, directors are able to assess the abilities of these foreign graduates and determine whether they would be a good fit for their residency program. Other barriers for taking IMGs directly into categorical general surgery include language, culture, and a lack of familiarity with US healthcare systems. These qualities can be assessed during a prelim year prior to offering a resident a full 5-year position. Another critical factor is that there is a greater need for prelim residents given that almost half of the spots go unfilled.

The details may seem confusing but just remember this. There are two main pathways for IMGs to get into general surgery: Prelim (1 year) or Categorical (5 years). IMGs are more likely to match into preliminary programs during which they can prove their qualities and fit for the program. 

What Happens After a Preliminary Year?

After the preliminary year, applicants are responsible for finding a spot to continue their GS training. Their first option is to re-apply to the match for post-graduate year-1 (PGY1) in categorical GS. This can either be accomplished in the same program that you complete your preliminary year in or a different program. Some programs have a tradition of taking one or more of their prelim residents into categorical PGY1 the next year. In these instances, residents will complete 5 more years of training for a total of 6 years. After the prelim year, applicants can also apply to other surgical or non-surgical specialties. 

Another option is to find PGY2 categorical positions outside of The Match. These positions open in different programs as a result of resident attrition or residents taking research years. If you match into a PGY2 categorical after a PGY1 Prelim, you continue 4 years of training before graduation, leaving you with a total of 5 years of training, one less than if you match into PGY1. In this situation, you would have the same number of years of training as residents matched directly into PGY1 Categorical GS after medical school.

Another option to pursue is an additional year of Prelim (PGY2 prelim). After the PGY2 Prelim, you can either apply to PGY2 or PGY 3 categorical spots. These positions are often found outside The Match and are open for the same reasons mentioned above (resident attrition or residents taking research years). After PGY2 prelim, you can also apply to The Match for PGY1 positions if you do not require J1 visa sponsorship. 

If you are not able to secure any position after a Prelim year, you could always take a gap year to do research while looking for open positions and apply to residencies the following year.

How Well Do IMGs Do After a Preliminary Year?

A study from the Mayo Clinic- which asssessed outcomes of their prelim residents across 25 years- found that after PGY 1 prelim, 21% of residents went into PGY1 Categorical GS, 20% into PGY2 categorical GS, 22% into PGY2 prelim, and 20% into non-surgical specialties.

In more recent years, a greater proportion of IMGs went into PGY2 prelim and PGY1 categorical as opposed to PGY2 categorical. Following PGY2 prelim, the majority matched into categorical PGY3, while the rest matched into PGY1 or PGY2 categorical GS or other specialties. Only 1 left GME after PGY2 prelim compared to 18 after PGY1 prelim. Finding categorical PGY3 positions after PGY2 prelim might be easier than finding PGY2 categorical positions after PGY1 prelim given that there is less demand (less PGY2 prelim applicants compared to PGY1 prelim) and more supply (more empty positions as most residents who do research during GS do it between second and third year). Therefore, despite the uncertainty of two prelim years, the PGY2 prelim year can offer applicants the chance to go into PGY3 categorical. 

How to Increase Your Chances of Matching into Categorical General Surgery

Although many IMGs start through the prelim route, some are successful in matching directly into categorical GS. Several aspects of your application can help you achieve this including Step1 and Step 2 CK scores, passing Step CS on the first attempt, research, letters of recommendation from well-known surgeons, clinical rotations, and personal knowledge of the applicant.

As an IMG, you should try to get electives in GS prior to graduation. Electives are only offered for medical students and once you graduate, you will not be able to demonstrate your US clinical experience. Since Step 1 is usually required for such electives, IMGs should plan to sit for the exam prior to applying for electives. These electives relieve many of the concerns PDs have about IMGs because they work with candidates directly and can better undestand a candidates skillset.

Participating in scientific research is another opportunity to become a more competitive applicant, especially for IMGs who graduated and did not have the chance to do electives. The benefit of dedicated research time in the US goes beyond publications and presentations. It allows for the evaluation of IMGs’ work ethic, personality, and understanding of the culture and language, all of which are required characteristics for surgery applicants. Moreover, it helps establish a personal connection with faculty that can help the applicant secure a categorical spot! However, applicants should be careful regarding the amount of time they spend on research. Additional years of research don’t necessarily increase your likelihood of matching. Applicants should always look for guidance along the residency path and follow mentors’ advice regarding the optimal timing to apply to residencies. 

Overall, matching into general surgery for IMGs is difficult but not impossible. IMGs are more likely to start as prelim residents and progress to categorical spots. However, it is feasible to match directly into categorical GS with adequate clinical experience, research, USMLE scores, and good mentorship/guidance. If you want to improve your USMLE scores or need guidance on residency applications, take a look at Med School Insiders tutoring and advising! You won’t find any group of residents and doctors more dedicated to seeing you succeed than those at MSI.