Category: Applicant Advice

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The Alphabet Soup Of Residency Visas And The Radiology Alternate Pathway: A Guide For The Foreign Radiology Residency Applicant

Due to increasing governmental bureaucracy, static to slightly increasing numbers of residency slots, and increasing numbers of American medical student positions applying for residencies, it has become harder than ever to get a residency slot as a foreign medical student in the United States (1). That is not to say it is impossible to get one, but rather it is just significantly more difficult. Even though this is the case, since a large proportion of my readers are from foreign countries (approximately 1/3) and are interested in the mechanics of obtaining a radiology residency in the United States, I have decided to create a post about the world of visas and the radiology alternate pathway for ABR certification. Hopefully, this will be of some assistance to those of you with competitive applications and a burning desire to come to the United States for training. Also, I think it is informative and interesting for the United States residency applicant and radiology resident to understand what the additional requirements are for those that are applying from foreign countries.

In order to organize this post, I am dividing it into two sections. The first section will talk about the different types of visas with an emphasis on J-1 visas since this is the usual pathway that most foreign residents take to get a residency in this country.  I will also briefly mention J-2 visas and go through some relevant information about H-1B visas and green cards/permanent resident status. The second part of this post will talk about the alternate pathway specific to radiology and what requirements are needed to satisfy the ABR if you have some foreign radiology experience and are considering not going through a standard four-year residency. Finally, I would also like to give a special thanks to Debbie Paciga, our graduate medical education secretary, who was nice enough to take the time to share her vast knowledge on the topic of visas after many years of experience with numerous entering and graduating residents. Without her help, I could not have written this article!

Visas

J-1 Visas

A J-1 Visa is the most common type of Visa used by non-immigrant status foreigners for completing a residency program in the United States. Essentially, the J-1 Visa is an exchange visitor program for trainees from foreign countries. So, it is not expected that the J-1 Visa holder will become a permanent resident or citizen of the United States, but rather that the holder will be here for the limited time period of training.

Once the foreign graduate student has met the requirements of the ECFMG (Educational Commission For Foreign Medical Graduates), he/she can apply through the online system called The Physician Applicant System Access (OASIS) to obtain a J-1 Visa. However, the J-1 Visa requires a hospital sponsor in order to complete the application. The liaison between the teaching hospital and the ECFMG is called the Training Program Liaison (TPL) and this person accomplishes much of the work needed to obtain the J-1 sponsor. Typically, this person is a secretary or administrator whose responsibility it is to make sure that all the appropriate paperwork is submitted. This assigned person uses a system called The Training Program Liaison System Access (EVNet) on the EFCMG website to manage the application for the foreign graduate. Therefore, as a foreign graduate, you need to make sure that you are in constant contact with this person in order to complete all the necessary requirements for the J-1 Visa so that all the appropriate paperwork is submitted to this EVNet system.

So, what are some of the items that need to be submitted to obtain the J-1 Visa? You need to have a passport, a passport biography page, a curriculum vitae, a signed contract by the hospital and graduate student/resident with all the necessary information, the appropriate online filled-out forms (including the DS-2019 form- a form submitted by the sponsor), and of course all of the fees. Also, just as important, if you have a family that needs to travel to the country of the residency, you need to make sure that they have submitted a J-2 Visa which also needs to be approved by the sponsoring institution.

But alas, obtaining the J-1 Visa is not so simple as this… (It could never be that easy when it comes to anything that has to do with the State Department!) Each country has its own requirements for the applicant to be able to apply for a United States graduate education program. In fact, some countries have significantly limited the availability of these J-1 Visas. Each foreign applicant needs to obtain a statement of need from their home country embassy in order to be able to apply for the J-1 Visa. Some countries have severely curtailed the numbers of statements of need in order to prevent applicants from leaving their home country. The purpose of limiting the numbers at these particular countries is usually due to a lack of expertise or increased numbers of physicians needed in the applicant’s home country. These countries do not want applicants to leave their home country and emigrate to the United States but rather want them to train and practice medicine in their home country overseas. Currently, some countries that limit the numbers of applicants the most to obtain a medical residency training J-1 Visa include South Korea, Sweden, and Canada. Then, there are countries such as India and Pakistan that tend to issue as many statements of need as warranted. Of course, this is a moving target and can change from year to year depending on a country’s needs.

Other Miscellaneous Requirements And Issues For The J-1 Visa Holder

Once the J-1 Visa is obtained, there are numerous other requirements that the J-1 Visa holder needs to be aware of. For instance, the J-1 Visa holder cannot arrive into the country more than 30 days prior to beginning their residency. Sometimes, this can be a difficult issue since there is such a rush to get everything the applicant needs ready prior to beginning residency (housing, etc.).

Other recurrent issues include updating the J-1 Visa on a yearly basis with a new signed contract, obtaining recurrent statements of need from the home country of origin (sometimes the statements of need are time limited for less than the time of the residency program), and making sure to bring all the necessary documents when entering and leaving the country (up-to-date passports, diplomas, and so on…)

Applicants also need to beware of the legal system within the United States. The state department tracks illegal activities for residents with J-1 Visas on a yearly basis. Any conflict with the law can be a potential reason for the applicant to be sent back to his/her home country.

Finally, it is important to recognize that a research J-1 Visa is not the same as a J-1 Visa for a clinical residency. So, if you are a foreign national applying for a residency program, you need to obtain an entirely new J-1 Visa in order to start the program. (Whew, that’s a lot of stuff to remember!!!)

H-1B Visas

So, what exactly is a H-1B Visa and how does it work for the residency applicant? An H1-B Visa implies that you are going to be working in a specialty field/occupation that has a need for a foreign worker that cannot be met by a United States resident. The H1-B visa holder is permitted to stay in the country indefinitely, different from the J-1 Visa holder.

Typically, the hospital needs to sponsor an H-1B Visa for an applicant in order to get the foreign graduate into one of its residency programs. In addition, the number of H-1B Visas is capped each year, making it more difficult to obtain one. It often costs the sponsoring hospital thousands of dollars to work on an H1-B Visa due to the necessary legal and processing fees. So, for these reasons, an H1-B Visa is an uncommon route for the foreign radiology resident applicant. At our institution, it has been only used for exceptional circumstances. One example would be an applicant that is already in a program in the institution but cannot get a J-1 Visa because this person has a D.O. degree and is from Canada. (Apparently a D.O degree does not qualify for the J-1 Visa pathway). Since it is a rarely used method for foreign applicants to obtain a radiology residency, I am going to limit discussion on this topic

Green Card/Permanent Resident Status

Finally, the goal of some foreign resident applicants is to declare permanent residency within the United States in order to remain within the country with a full time radiologist position and with the possibility of eventually becoming a citizen. The United States lists several mechanisms of obtaining a Green Card including via job offers, investing in enterprises, and self-petition (typically an individual of extraordinary ability). Many applicants will often get their green card once they have graduated from a residency program and have been accepted for a permanent radiologist position in the United States. At that point, the employer is required to file a petition for the employee so that he/she can undergo the application process and the applicant needs fill out the appropriate paperwork. Usually, this process occurs only after the J-1 Visa is no longer active.

One other pathway to obtaining green card status includes finding a position in an underserved area for a period of time, usually 5 years. This applies to not only primary care physicians, but also specialists as well. But again, it is usually completed after the radiology residency has ended.

The Radiology Alternate Pathway

In a past response to a question from a potential foreign applicant in the “Ask The Residency Director” section of this site about the alternate pathway, I briefly went over some of the requirements for the foreign radiology applicant to obtain ABR certification. The question asked about applying outside the typical route of a four-year qualified ACGME radiology residency based upon the applicant’s previous radiology experiences. This process is called the Radiology Alternate Pathway. According to the ABR policy, the applicant can satisfy the requirements only at institutions with an ACGME-accredited radiology residency-training program. The applicant needs to have 4 years of continuous work in the capacity of a “resident, ACGME accredited fellowship, non-ACGME accredited fellowship, or faculty member”.  In addition, the candidate must also have “4 months of clinical nuclear medicine training.” The nuclear medicine training needs to be dedicated although the applicant can get the training at an affiliated institution if that is available.

The challenge for the foreign radiology applicant is to find a program that is willing to recognize previous foreign training and accept him/her for a slot in one or more of these programs over a four-year period. Many programs are not willing to make an obligation of four years of employment in a mixture of residency, fellowship, or faculty positions and will require the applicant to go down the standard pathway of radiology residency. That is not to say it is impossible. But rather, it is not common and represents the exception rather than the rule.

Final Thoughts

Applying to radiology residency and performing well in a radiology residency program as a United States citizen without having to contend with the issues that arise from migrating to a new country can be challenging by itself. I can only imagine the additional difficulties that foreign applicants face applying to and attending radiology programs within the United States. There are certainly numerous hurdles and hoops for these applicants. But for those with the desire, ability, and grit/determination, it is still certainly possible to go through the process of getting a visa and obtaining a qualified residency spot or spot in an alternate pathway program. If this is your life’s desire, don’t let these hardships dissuade you!!!

Helpful Websites For The Foreign Medical Graduate

ABR Alternate Pathway Information- https://www.theabr.org/sites/all/themes/abr-media/pdf/PWIMG_DRandSubCert.pdf

ECFMG –   http://www.ecfmg.org/evsp/application-online.html

Governmental Green Card Website Information-  https://www.uscis.gov/greencard

Governmental J-1 Visa Website Information-  https://j1visa.state.gov/basics/common-questions/

Governmental J-2 Visa Website Information- https://j1visa.state.gov/basics/j2-visa/

Governmental H-1B Website Information-  https://www.uscis.gov/eir/visa-guide/h-1b-specialty-occupation/understanding-h-1b-requirements

 

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Radiology Personal Statement Mythbusters- Five Common Misconceptions About Radiologists

Since I started work on my radiology program’s admissions committee in 2009, every year, I notice a significant disconnect between the medical student impression of what radiologists do and the actual day to day work of the radiologist. The radiology personal statement is a shining example of this truth. In this post, I will debunk many of the myths espoused in the personal statement about what we do daily (Just like the real Mythbusters– this is going to be fun!!!). Let us begin…

Where’s Waldo?

Out of the thousands of personal statements I have reviewed, many use the Where’s Waldo analogy in one form or another. If I see another personal essay with a resemblance to Where’s Waldo?, I will scream very loudly!!! All kidding aside (I’m not kidding!): The Where’s Waldo analogy is one part of the radiology job that is not understood by many applicants.

So, what is it that a radiologist does? First and foremost- we read films and lots of them. Film reading heavily leans upon pattern recognition. And that is what we do. We use search patterns and compare our visual databank to the thousands upon thousands of images, we have already seen.

How does that differ from Where’s Waldo? In Where’s Waldo, the scenes typically change on each page, and you are expecting to find the same Waldo character in a sea of miscellaneous extraneous information. For the radiologist, the scene is usually the same, whether it is a chest x-ray or a CT scan or even a Brain MRI. And, the findings can vary widely in any given film. You may find a pneumothorax or a herniated bowel loop or an infarct. However, you are not looking for one specific thing. You are looking for everything. This general search for everything is very different from finding one Waldo, who is always going to have the same appearance. The analogy does not hold very well!

The One Fascinating Case

A personal statement will often talk about one fascinating case and how that led the applicant to the decision of choosing radiology as a career (I am sick of this conclusion!). Why does this point demonstrate so little insight into the day to day practice of radiology? Sure, every once in a while, something is fascinating- perhaps it is a bezoar or a sporadic tumor. And, sure, it is excellent to perseverate on that case. But in reality, although exciting, these cases take up less than .01 percent of the radiologist’s work. You have to expect to pick up thousands of normals, normal variants, and common findings before picking up one of these rare zebras. When I hear that an applicant is choosing radiology for the one fascinating case, it does not show a good understanding of our day to day work!

The Family Member Saved By A Radiology Finding

Sure, every once in a while, the radiologist is the hero. We discover an occult aneurysm, unexpected appendicitis, or early breast cancer. Maybe the radiologist has picked something up in your relative to save the day and has been credited. But in reality, how often does that occur? Not that often! In reality, it is pretty darn unusual. If you want to save lives daily and get the credit, go into trauma surgery!!!

In general, radiologists have to be pretty humble because rarely are we showcased as an example of the medical profession for all to see. Usually, the doctors on display are the surgeons, internists, ob/gynecologists, or almost every other medical specialty. Don’t go into radiology to expect the glory of saving patients. We are usually behind the scenes!!!

The Diagnostic Dilemma

Many personal statements will describe when a radiologist went through a case and came up with an incredible on-target well thought out differential diagnosis. And, the applicant will point out that they want to go into radiology to make incredible interpretations. In reality, I also love a well thought out differential diagnosis in a compelling case. Unfortunately, most studies are not in the category of the intriguing differential diagnosis. Final interpretations are usually mundane and limited. Don’t expect to go into radiology to become the next House, MD, every hour of every day!

The Isolated Radiologist

What is the last thing that we want to hear as radiologists? That we spend an excessive amount of time in an isolated dark room, not speaking to others for hours. Yet, many personal statements assume that we rarely come in contact with others and only plug away at the films. Although there are probably a few radiologists out there like that, it is usually the opposite. I can’t tell you how many days, there is a constant bombardment with technologist questions, physician consults, nursing issues, and more. Please get your facts straight before putting it in writing a personal statement!!!

Busting Myths And The Final Truth About The Personal Statement

The good news: After all these false assumptions in many of these personal statements and the thousands of personal essays that have come across my desk, very rarely does one spur me to change a radiology residency applicant’s disposition on the final rank list. I usually give these personal statements a pass because I understand it isn’t easy to comprehend what a radiologist does without stepping in our shoes.

On the other hand, if I had to give you one piece of advice as one of the leading players in the application process at our institution, make sure you are not one of the chosen few who write a personal statement that influences our final decision. These are the personal statements with bizarre and sometimes scary thought processes and conclusions. The outcome of these weird personal statements is not usually positive! (meaning DO NOT RANK) So, stay away from the impulse to write something too unusual/different. We typically use the personal statement to weed out potentially psychotic behavior, not as a tool to make the final rank list.

So, as long as you don’t write something overly bizarre, I wouldn’t worry about this part of the application too much. Just make sure to avoid the basic grammatical and spelling errors. And, most importantly, don’t try to rock the boat!!!

 

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The Post Interview Second Look – Is It Worth My Time?

second look

Every year after interview season ends, there is a brief interlude until the rank selection list is submitted. And now, during the life and times of covid, it may be more challenging to arrange a second look. However, with vaccines available to health care team members, students, and attendings alike, you may be able to schedule one. 

So, you may wonder at this time- Does it make sense to go back to a radiology program to take a second look? It may be a complicated decision and can depend on numerous factors. Therefore, I am going to take a look at this issue from a program director’s perspective. We will approach the problem by tackling a series of questions that will help you make this critical decision. Hopefully, it will be of some benefit to those of you that are involved in this process.

Who Is Most Likely To Benefit From a Second Look?

From a residency director’s perspective, the ideal candidate for a second look at a residency program is a student that has already interviewed, for which the admissions committee was unsure of its final disposition. For example, every once in a while, an application/prospective resident interview causes a stir among the committee. The interview may have gone well, but the application quality didn’t sync with the interview. Or, the application was excellent, but the applicant’s personality was questionable on interview day. Usually, it is some conflict in the committee evaluation process. These applicants can benefit the most from a second look because it may sway the admissions committee one way or another after the candidate returns.

Second, the marginal/below average candidate that has been ranked but did not have many interviews would also be an ideal candidate to return for a second look. Some programs will rank their returning applicants slightly higher for just showing interest by returning to the program. Usually, candidates don’t return unless they are earnest about a program. A slight increase in the rank list can make the difference between matching and not matching.

Finally, the other ideal candidate would be the interviewee who felt he/she didn’t get the best impression of a program and wants to make a more informed decision on the day he/she will submit the rank list. Maybe the program director was absent. Perhaps you have a spouse that wants to remain in the area, and you didn’t get the best impression on the interview, but the location would be ideal. Or, maybe you like the people you met, but you felt you didn’t meet the residency program’s key players on the day you interviewed. Whatever the case may be, the second look can help to reinforce that decision.

How Do You Know You Should Come For a Second Look?

Let’s first begin by stating: The worst situation for the residency applicant and the program is to have an applicant that has already been placed into the “Do Not Rank” pile return for a second look. It wastes the applicant’s time and money and the resources of the program director and staff. Also, it may not make sense for the individual applicant to return depending upon other applicant factors. So, here are some criteria that may help you to decide if you are in either of these situations:

  1. Did the interviewer suggest you come back for a second look? The program director will usually recommend to return for a second look if he/she is potentially interested in a candidate and think it may be of some benefit.
  2. Did you get the cold shoulder during the interview process? Some interviews don’t go well for multiple reasons. That will happen from time to time. Your instinct is probably correct if you feel that is the case. In this situation, it is perhaps not worthwhile to return for the second look.
  3. How far down is the program on your rank list? If the program is very low on the order of your rank list and you are a reliable candidate, it is probably not worth the effort to return for the second look.
  4. Is it reasonable to travel to the interview site? Some candidates live very far away from the prospective residency program. Suppose it will be disruptive to return to the program due to travel costs or significant inconvenience (maybe you are amid your medicine sub-internship and can’t miss a few days). In that case, it is probably not worth your effort.

 

How Should You Behave/Present Yourself On The Day Of The Second Look?

The program director or interviewer that asks you to return for a second look will often tell the candidate, “we would love to have you return for an informal second look.” It is important to remember that there is no such thing as an “informal” second look. A second look is a second interview day, and you need to treat it as such. Wear your best interview clothes as you would have worn for your first interview. Be on your best behavior and be friendly to all staff members, just as you would have done for the initial interview. Remember, you still have not been admitted to the program, and you are certainly not yet “one of the residents.”

What Should You Tell The Program Director Before You Leave?

Certain buzz words have significance to the program director when meeting at the end of the second look day. The program directors and admissions committees take these words very seriously. So, be careful what you say. If you say the wrong thing, it may cause a different result than intended.

If you are genuinely interested in the program, you can say, “I will rank the program first.” This phrase is specific and demonstrates your genuine intention to the interviewers. The program can verify this fact on match day when you either match the program or do not match it. So, your action will back up the facts. This truth will follow you from this point forward. If you ever decide you want to return to the community as an attending and you did not abide by your word, the program can blacklist you!!!

On the other hand, the phrase “I will rank your program highly” is a buzzword that means your program is nowhere near their first choice, and you will probably match elsewhere. Some applicants do not realize this. So, be careful!

If you are still not sure after the interview day, it is appropriate to say, “I really enjoyed my second look at the program, but I am still considering my decisions.” The program director/interviewer will usually understand. When/if you decide to rank the program first, you can always contact the program and let them know.

Final Thoughts About The Second Look

The second look can be an essential part of the residency interview process. It can provide a slight edge to your candidacy and may be worthwhile if approached the right way. On the other hand, it may not be the right move for all applicants. So, weigh the facts and make a final decision. The interview process will be over before you know it!!!

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Radiology Residency And The SOAP Match

It’s the middle of March, and every 10 minutes, you are checking your email to see if you have matched in one of the most competitive specialties out there; maybe it was dermatology or radiation oncology. You can’t eat or drink. Your mouth is dry. Suddenly, you get the dreaded email- “You have not matched for the ‘blank’ specialty in the regular match.” All these years of work, and what do I have to show for it? A wave of depression sets in. You want to stick your head in the sand.

Unfortunately, every year this scenario plays out. Each year the dynamics of matching in competitive specialties becomes more challenging due to increasing numbers of medical schools/American MD graduates and stagnant American residency positions. (1) Not everyone gets their first choice of specialty during the standard NRMP initial match. Since this time of the year is about to arrive, I thought it was essential to give you some guidelines/tips on approaching the issue if you are one of these residents.

Wash That Fit of Depression Away

It is crucial to get into game mode. The SOAP process can be time-consuming and exhaustive from both an applicant’s and a program director’s perspective. But, to be a viable applicant, you need to move on. As an associate radiology residency director, one of my biggest turnoffs in the SOAP process is interviewing miserable residents that do not show a bit of enthusiasm for their new specialty choice. It is not the end of the world, and it is a sign of mental toughness and grit if you can adapt to the unique circumstances. Things don’t always go our way!!!

If you are in this situation, it is also important to remember that you are not alone. Numerous qualified medical students don’t match. Often the overall quality of the applicants is better than the initial match. So, don’t take this as a sign that you are going to make a horrible resident. It’s just not true.

Think About Your Options

Residency is a long, arduous process. So, this decision should be well thought out, and all applicants need to step back. Don’t rush into applying to a specialty if you are not convinced that you have an interest. If you are not sure, there are other options, such as applying for a transitional or prelim year and then reassessing the application during the year of residency. Only apply for the specialty of radiology if you are genuinely interested!

Most Applications In The SOAP Are From Different Specialties

We often get former applicants from matches of the most competitive specialties. Presently, these would be radiation oncology, dermatology, and some of the surgical subspecialties. For many years these specialties are entirely matched with no slack. So, your two choices are to reapply another year after completing a year of preliminary medicine or surgical internship. Or, you can change specialties entirely. You take a risk either way. If you reapply, you may not match the following year unless there is a significant change in your credentials. On the other hand, if you decide to match in the SOAP for another specialty such as radiology, you may be matching in an area that you may or may not genuinely interest you. You will need to make that hard choice in a very brief amount of time.

Significant self-reflection and analysis are critical at this juncture. Sometimes, the right choice is to apply to another specialty. I believe that medical schools underexpose students to many different subspecialties. Frequently, the best fit for a prospective resident is different from the specialty he/she initially applies. So, think about the possibility of applying to another specialty than you initially chose.

Don’t Fret About Application Items Not Geared To Radiology

Don’t worry if some of your recommendations, personal statements, and application are not entirely “radiology-centric.” The program directors usually understand the predicaments of the applying residents at this point. However, the applicant should develop reasons for his/her newfound interest in radiology during the interview since enthusiasm for the specialty is critical. Make sure you have a logical argument prepared for the phone or “in-person” interview for why you would be interested in radiology. It will go a long way toward securing a spot in a radiology program.

The Early Bird Gets The Worm

Joining the SOAP right away is probably one of the most critical factors in the residency SOAP match process. If you are not early in the draw, you are going to miss out on the spot. Make sure your application is submitted to your SOAP specialty of interest as early as possible. Often, we find out about outstanding candidates only out after the SOAP match ends. Don’t let that be you!!!

Try To Schedule Onsite Interviews If Possible

In the SOAP process, it is a significant advantage to match the face to the application. Although it is not always possible due to distance or other circumstances, if you are interested in a position and want to maximize your chances of acceptance during the SOAP process, an onsite interview shows your interest and ups your chances of obtaining a spot. (although not as critical in the times of Covid!) I always would rather deal with the known vs. the unknown entity. You get a better feel for the applicant, usually when he/she is sitting in front of you (or on Zoom!) rather than in a phone interview conversation. We have accepted applicants over the phone, but your chance of acceptance “in person” is higher. Try to get to the interview if possible physically.

Use Your Connections

Any connection to the SOAP match program of interest is of significant help. We value the known vs. the unknown quantity when we are looking at SOAP applicants. So, if you have any connection to the program of interest, it will give you a leg up in the process. It could be a resident you met at some point earlier in your medical school training, a former mentor, or a friend of a relative. It doesn’t matter. Any connection is often better than no relationship. Use it!!!!

This Too Shall Pass

The SOAP process is short-lived but very stressful for all parties. Applicants and programs that did not match the first try will often find a happy end to this story. Be enthusiastic, get past your depression, put time and effort into the SOAP process, and, often, the SOAP process will handsomely reward you. Don’t take it seriously, be depressed about not matching into your initial specialty, or take a lazy approach and you won’t. Good luck with the match!!!

(1) http://www.usnews.com/education/best-graduate-schools/top-medical-schools/articles/2013/07/11/aspiring-med-students-face-growing-residency-competition