Getting into US Plastic Surgery Residency as an International Medical Student: Blood, Sweat, and Tears

Bashar Hassan*

Corresponding Author: Bashar Hassan American University of Beirut Faculty of Medicine, Beirut, Lebanon.

CopyRight: © 2021 Bashar Hassan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Date Received: June 20, 2021

Date Published: July 01, 2021

Introduction:

Over the years, matching of international medical graduates (IMGs) into very competitive residency programs, like plastic surgery, in the United States (US) has not only been regarded as difficult, but almost impossible (1). While this is changing, international medical students continue to fight tooth and nail to make it into plastic surgery residency in the US. Many factors contribute to the hardships IMGs face before and during their application process into competitive specialties like plastic surgery. In this opinion article, I shed light on these factors, which perhaps may seem obvious to many, but to my knowledge, have not been previously discussed in a scientific journal. I hypothesize that these factors can be traced back to international medical schools’ curricula and their incongruence with the US medical education system. I end this article by encouraging further studies that can characterize these factors to better be able to target them and calling for action on behalf of international medical schools, hoping for change.

It all starts in medical school… International medical schools outside the US have curricula that are inherently different than that of medical schools in the US, which are more oriented towards the United States Medical Licensing Examinations (USMLEs), rendering US medical students intrinsically more prepared for their USMLEs. International medical students would thus be at a disadvantage, being less prepared for the material tested on the USMLEs. This would necessitate international medical students putting great self-effort to better be acquainted with the USMLE style to score high enough to compete against US medical students in the Match.

Furthermore, more preparation often means more time sacrificed: most international medical students delay their USMLE exams, compared to US medical students, to have more time to study and score high. On the other hand, most US medical students tend to sit for their USMLE Step 1 exam before their clinical years, allowing them to have more time to study for their clinical rotations and to apply to competitive clerkships in their last year of medical school. Aside from the necessity of scoring high in the USMLEs (while being less prepared for them), another reason international medical students tend to delay their USMLE exams is the pressure to excel at their home institution too. They are pushed and pressed to score high on their in-house exams in order to have  better profiles and letters of recommendation for their future applications.

It is true that delaying USMLE Step 1 into the clinical years, or even research fellowship years, would give more time for international medical students to be acquainted with the USMLE material, prepare better, and score higher, however, this comes with a price. Delaying their USMLE Step 1 into the clinical years would necessitate shifting focus from clinical rotations and would decrease the chances of them getting accepted at clerkships that require/prefer USMLE scores (if they had not done the USMLEs yet). This would also mean that they would be giving less time for research, a vital part of their application and future practice. Less research experience backfires at students who are applying to research fellowships before commencing their residency training. Although most research fellowships do not require prior research experience, it is very much favored over no research experience at all. This is the case with almost all competitive specialties, where most international applicants go into research fellowships before their residency training. A great example is plastic surgery residency.

While all the aforementioned factors apply to international medical students targeting competitive residencies in the US, they are more signified when it comes to plastic surgery, one of the hardest specialties to match into (2). In 2021, less than 10% of applicants who successfully matched into Integrated Plastic Surgery were non-US MDs (2). Only 16.7% of US IMGs and 33.3% of non-US IMGs who ranked plastic surgery as their only choice in the 2021 Match did match, compared to 80% of US MD Seniors and 100% of US DO (Osteopathic) Seniors (3)! These percentages help us understand how much of a competitive specialty plastic surgery is, especially for IMGs.

Due to this extreme competition, almost all IMGs planning to apply to plastic surgery in the US dedicate years of their life for the sake of research, to maximize their chances of matching. For example, IMGs who matched in the 2020 Plastic Surgery Match had an average of 59.8 publications (4). The increasingly competitive requirements of plastic surgery have put IMGs at an increased pressure to excel in all directions before applying to the Plastic Surgery Match and have made years of research almost a must before matching. The unfavorable circumstances international medical students go through, added to the incredible competition from US medical students and the necessity of having several gap years and a great number of research publications render the path of IMGs to US plastic surgery residencies full of “blood, sweat, and tears,” as the name of the article suggests.

If we trace the factors detailed in this article backward, we can find that some challenges faced by international medical students applying to US plastic surgery and other competitive specialties trace back to their medical schools and early USMLE preparation and completion. The more medical curricula are oriented towards USMLEs, the higher the students’ scores, the less the time devoted for USMLE preparation, the more the time allocated for research and clerkships, and thus the better their overall opportunities. Better qualifications obtained throughout their medical school years would in turn limit the number of years devoted for research by IMGs aiming for plastic surgery and other competitive specialties.

To end, this opinion article is the first to discuss the hardships faced by international medical students applying to competitive US residencies like plastic surgery. Further studies are needed, such as case-control studies of IMGs who have matched into US plastic surgery to better pinpoint their challenges in medical school, to possibly mitigate them early on in their journey. Little weight is given to these challenges, and thus little action. Hence, I call on curriculum committees of medical schools outside the US, that follow an American medical education system, to orient their medical curricula more towards USMLEs, as that would spare their students time, effort, and extra miles.

References

1.Leto Barone, A., & Kokosis, G. (2020). The black swans: Matching in plastic surgery as international medical graduates. American Society of Plastic Surgeons. Retrieved 21 June 2021, from https://www.plasticsurgery.org/for-medical-professionals/publications/plastic-surgery-resident/news/the-black-swans-matching-in-plastic-surgery-as-international-medical-graduates.

2.NRMP MATCH STATISTICS - 2021. #Lifeofamedstudent. (2021). Retrieved 21 June 2021, from https://lifeofamedstudent.com/2021/03/26/nrmp-match-statistics/.

3.Results and Data - 2021 Main Residency Match. National Resident Matching Program. (2021). Retrieved 21 June 2021, from https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2021/05/MRM-Results_and-Data_2021.pdf.

4.Charting Outcomes in the Match: International Medical Graduates. National Resident Matching Program. (2020). Retrieved 21 June 2021, from https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/07/Charting-Outcomes-in-the-Match-2020_IMG_final.pdf. [3] Rosenfeld M, Farrell PM, Kloster M, Swanson JO, Vu T, Brumback L, et al. Association of lung function, chest radiographs and clinical features in infants with cystic fibrosis. European Respiratory Journal 2013. https://doi.org/10.1183/09031936.00138412.