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15 Resident Integration: Orientation andOnboarding
151
cant negative impact on learner wellness and also patient
safety.
Planning New Resident Integration
Planning for the orientation and onboarding processes should
start with reecting on the scope and available time frame—
a “feasibility check.” If the residency’s commitments to services (inpatient, outpatient, specialty) require 24×7, 365-day
coverage, having time to devote to a dedicated integration
experience may be challenging and require additional
resources.
Preparation for integration should start several months
prior to the start of the academic year. The components may
include a preassessment of knowledge and skills, required
reading, and onboarding modules from the institution or program. This preparation may shorten, streamline or eliminate
parts of the actual orientation experience. Reviewing evaluation data from previous integration programming may indicate that some components may be too advanced, focusing
on skills that the residents did not adequately acquire in
medical school. Sample items to assess new resident preparation and experience are included later in this chapter.
It is recommended to start drafting the integration activity
timeline during the period between the Rank Order List
(ROL) due date and Match Day. Remember to be realistic
with the timeline to allow sufcient time after sending and
receiving the preassessment materials to digest the data and
use it to consider onboarding changes if necessary. Consider
the “feasibility check”—what activities are possible within
the allotted time frame? What works with the current structure of faculty and curriculum? One concept to consider is
the principle of incrementalism. Medical school graduates
have learned aspects of medical care, such as history taking,
physical examination, problem representation, and basic
management. Since clinical experiences are divided into
rotations, learners practice skills as appropriate in each
patient encounter, learning incrementally. Similarly, integration over time facilitates incremental preparation for residency. Draft a plan for the entire integration process, not just
the initial phase. It may be helpful to include a review of the
entire academic year to consider including more longitudinal
(incremental) elements. This is particularly useful when the
time allotted for onboarding is limited.
What follows is a sample timeline for orientation planning (see Table15.2). This is one approach, not intended to
represent the “gold standard.” Approaches to integration pro-
Table 15.2 Sample timeline for orientation/onboarding planning
Early February:
Identify members of the integration team
Review feedback from previous orientation/onboarding (if applicable)
Schedule the rst team meeting
Identify options for document sharing platform
Mid-February: First planning meeting, after Rank Order List submitted to National Resident Matching Program
Determine document sharing platform that works best/is accessible in the institution
Draft the components of the orientation/onboarding
Create a tentative schedule
Clarify and delegate responsibility to team members and how follow up will occur
Determine components of preassessment
March: Second planning meeting, after Match Week
Send welcome email and preassessment tools to new resident class
Develop rst draft of schedule
Check in with team members on their delegated tasks
April: Third planning meeting
Review preassessment results
Review ERAS applications of incoming resident class
Based on those reviews, adjust the schedule to add, revise or remove components.
May: Fourth planning meeting
Finalize draft schedule
Focus on developing the content and align with organizational standards
Orient/introduce clinical and administrative teams to new residents
Design implementation to include all key stakeholders
June: Final planning meeting
Disseminate the nal schedule to all stakeholders with enough time to receive feedback and make any last-minute adjustments
Disseminate nal schedule prior to or on the rst week of the start of the academic year.
July: Start of the academic year
152
B. Gopal and T. Kenyon
cesses vary across Family Medicine residencies in different
settings with different resources.
Most residency programs are community-based or nonnancially university-based. Regardless of the type of program, resources are often constrained and must be used
judiciously. A key rst step before signicant planning is
done is to identify who will be involved. Which faculty will
be participating in providing parts of the orientation/onboarding? Which residents will be participating and in what way?
There are advantages to having the current First Year class
and/or senior residents participate in the planning, as they
bring a unique perspective. What administrative support is
needed? It is important to clarify roles and responsibilities
for team leaders and participants. In addition, who are all the
people the new residents will need to meet? These people
will also need to be part of the planning process, if not centrally, at least peripherally.
The second area to determine is how to communicate and
share documents. The use of an online platform for document sharing and scheduling helps to prevent multiple versions as items are updated. There are several electronic
platforms, and your organization might have a preference
depending on their internet security protocols. Some platforms to consider are Google Drive®, Microsoft OneDrive®
and OneNote®, and BaseCamp®.
The process for organizing the integration planning team
starts many months before the beginning of the academic
year (see Table15.2). Having identied the planning team
members and communication tool(s), clarify the meeting/
check-in points and steps for the rest of the integration planning period. Consider whether meetings will be in-person
and/or virtual, and what will be accomplished asynchronously through electronic mail, shared documents, etc.
How much content to include in the orientation/onboarding is not only relevant to the new residents, but also to
resource needs and everyone involved. Consider how much
time will be needed for leaders, faculty, residents, and administrative staff. The resource constraints will help determine
what is possible to include in the integration process as a
whole.
Integration should not be limited to one discrete timebased experience, regardless of length. It is helpful to consider integration along a continuum from Match through
developing practice. There are activities that prepare residents for the transition, the orientation/onboarding itself, and
the experiences that reinforce the most salient points. In
planning, one must give careful consideration for how much
time to spend on each of these phases.
Initial resident integration, like all other residency experiences, is time limited. Most Family Medicine residencies
have 3years to prepare medical school graduates to become
Family Physicians. Thus, a month-long integration represents a scaled 1:36 representation of residency. Given the
complexity of the specialty, residency cannot teach everything needed for autonomous practice in 3 years, just like
everything necessary for residency cannot be taught within
1month.
When considering the length of the initial introductory
phase of integration, as mentioned, the incrementalist
approach is helpful. What experiences are important before
beginning rotations, and what can be incorporated into
upcoming rotations and longitudinal experiences? Given
time constraints, it is important to dene critical elements of
learner integration and determine how much time is adequate. The efciency of integrating an entire class of residents simultaneously is weighed against the organization’s
stance on getting individual learners “on service” early to
focus on individual just-in-time learning. The overall goal is
preparation. In a study by Wiese and Bennett using the
“Ready-Set-Go” model, “Consultants’ central concern when
introduced to a new cohort of trainees was that they had the
required knowledge and skills (ready), were adapted and
integrated into the new workplace and clinical team (steady),
and safely participating in practice (go)” [9].
When identifying important components to include, there
are categories of topics such as described by McGrath etal.
for Emergency Medicine residents [10]. In their survey of
Emergency Medicine residency programs, the breakdown of
integration time spent by programs was 27% lectures, 23%
clinical work, 16% skills training, 10% administrative activities, 9% socialization, and 15% other activities. Most
included activities to promote socialization among interns
(98%) and with other members of the department (91%).
Many programs (87%) included special certication courses
(ACLS, ATLS, PALS, NRP) and specic procedural skills
courses (varied depending on the procedure). Course content
included the following: use of electronic medical records
(90%), physician wellness (75%), and chief complaint-based
lectures (72%).
The core skills and knowledge will vary by specialty, and
each program can collaborate with their interprofessional
faculty and staff to set priorities. Enlisting senior resident
participation in planning, delivering, and evaluating the integration process for the incoming class can increase engagement and effectiveness [11–13].
Baseline Assessment
Medical school graduates enter residency with various levels
of medical knowledge, clinical skills, experience and attitudes. Because the specialty of Family Medicine has such
wide scope, it is important to obtain a baseline assessment of
performance across this range of practice. Baseline assessment methods can come from various subjective and objective measures, which will be discussed later in the chapter.
15 Resident Integration: Orientation andOnboarding
153
The ACGME assumes that all medical school graduates are
under direct supervision until the program obtains this baseline assessment.
Individual Learning Plan
The ACGME denes the individual learning plan (ILP) as:
… a critically important tool for all residents and fellows and
takes into account individual strengths, professional goals, and
specialty requirements, and helps them identify what is needed
in terms of personal adjustments and resources to progress. [8]
Developing the ILP starts at the beginning and continues
longitudinally throughout residency training. The ILP provides the ability for the residents to assess their performance
and reect in a safe manner with their faculty advisor/mentor/coach.
It is helpful to provide a structured template to guide the
process. One example of a template is provided by Hahn etal.
through the Society of Teachers of Family Medicine (https://
www.stfm.org/publicationsresearch/publications/educationcolumns/2017/september/) GOAL worksheet. The preassess-
ment and baseline data assembled for each new resident offers
a foundation for the ILP.When advisors meet with learners to
review the data, the conversation can include self-assessment
and coaching to populate the ILP.If there are patterns in areas
of growth among the new resident class, programs can build
time into the integration process to address common gaps.
Residencies need to decide how ILPs will be reviewed and
updated as the learner’s academic journey unfolds.
Integration Components
This section provides specic examples and tools for residencies to consider in the planning process.
Orientation: Introduction totheWorkplace
The orientation can be thought to dene what the institution
requires for entry into the new role of resident physician. The
components of orientation are:
Institutional Ofcial (DIO) and other key administrative
people.
(c) Facilities tour: initial meeting with Chief Residents, fac-
ulty, and administrative staff.
(d) Community tour.
(e) Certications: Such as advanced cardiovascular life
support (ACLS), advanced trauma life support (ATLS),
pediatric advanced life support (PALS) and neonatal
resuscitation (NRP).
(f) Basic clinical processes: Such as surgical scrub training,
and the donning and dofng of personal protective
equipment.
(g) Introduction to electronic resources: This includes elec-
tronic health record(s) (EHR), residency data manage-
ment system, methods of electronic communication.
[15, 16].
(h) Discussion of Human Resource topics: such as health
insurance and other benets.
(i) Introduction to contact people and their role: These peo-
ple and resources includes the program director, associ-
ate program director(s), behavioral health faculty,
residency coordinator and manager, faculty advisors,
nurse leader, practice manager, chief residents, etc.
(j) Baseline assessment: This may include learning style
inventories, emotional intelligence skills (such as https://
www.dcms.uscg.mil/Portals/10/CG- 1/cg111/docs/
HPM/OSC/Module%206/Emotional%20Intelligence
%20Questionnaire.docx?ver=vRA4iMoQHbYoXoZUS
xykng%3D%3D), surfacing “hopes and fears” new resi-
dents have for the year ahead [17], cultural competency
(such as this tool—https://www.proprofs.com/quizschool/
story.php?title=crosscultural- healthcare- quality- quiz),
and an inventory of resident experience with common
procedures in Family Medicine (e.g., frequency of
observation/assistance with/performance of suturing
skin laceration, obstetrical procedures, etc.).
(k) Key processes in the program: This includes introduc-
tion to resources for advising and mentorship within the
program, evaluation of residents through the ACGME
required Clinical Competency Committee (CCC), peri-
odic updates to the ILP.
(l) Local health care resources for resident self-care:
Finding a local and available family physician, dentist,
mental health professional, etc.
(a) Institutional training: such as familiarity with policies
such as re safety, condentiality, infection control,
variance reporting, risk management, etc. [14].
(b) The Graduate Medical Education (GME) Department
may provide their own GME-level orientation and
onboarding process to learners in several different specialties. This may include meeting the Designated
Components ofOnboarding: Assimilation into
theWorkplace
As residents become familiar with the foundational elements
of joining the organization, the onboarding process facilitates the next step in assimilation. For example:
154
B. Gopal and T. Kenyon
(a) Residency culture: Describing the norms of behavior
(e.g., sharing clinical desktop coverage for peers on
vacation, attendance at didactic sessions), program mission/vision and shared values of residents, faculty,
administrative and clinical staff, and community and
sponsoring institution. The program should be transparent and deliberate in this conversation to minimize the
development of a parallel and dissonant “hidden curriculum” [18]. In other words, the intentional curriculum
should align with the unspoken/operational values,
beliefs, norms and culture of the organization or department. It is helpful to enlist the current residents in the
conversation about these key cultural features.
(b) Residency curriculum structure: This is an opportunity
to describe the sequence of rotation structure,
competency- based goals and objectives, ACGME competencies/sub-competencies/milestones, and methods of
providing and receiving feedback along the educational
journey. Assessing where learners are starting in relation
to the Entrustable Professional Activities (EPAs) and
Milestones helps contribute to the Individualized
Learning Plan (ILP) [19–21].
(c) Assessment of baseline clinical skills: To determine indi-
vidual comfort, skill, and ability as part of the ILP, programs can choose direct observation, an observed
structured clinical examination (OSCE) with a standardized patient, video recording of their clinical activities
with asynchronous feedback, or other methods. It is
important that this assessment of clinical activities be
structured, objective and consistent, with observations
shared with the resident regarding strengths and areas of
improvement.
(d) Clinical skills education: This may include procedure
workshops (suturing, Point-of-Care Ultrasound, dermatologic procedures, etc.). There are many adaptations of
the “boot camp” model to ensure consistency in new
learner capability [22–25]. The boot camp model provides a focused and time limited experience on a single
or set of topics (e.g., inpatient adult medicine, inpatient
pediatrics with newborn care, etc.)
(e) Reference tools: This may include a specic guide to
common EHR functions [26] or more general guides
like an “intern survival manual.”
(f) Team building: The goal is to build camaraderie through
a shared experience within the new class, with senior
residents, faculty, administrative, and clinical staff.
Team building provides an overt method of promoting
residency culture in multiple ways, from the content of
the session, to those who are included. Example activities include a picnic for the entire department, small
group problem solving, using a ropes course or escape
room. One program used a “passport” to orient new
learners to specialists and processes in the Emergency
Department [27].
(g) Integration into Family Medicine Practice: Providing a
structure that facilitates gradual integration into assum-
ing responsibility for a panel of patients is important.
New residents are learning how to manage patient visits,
use the EHR, collaborate effectively with their clinical
team to provide care, and desktop (“in-basket”) manage-
ment with direct supervision. Beginning with 1–2
patients per 4-hour clinical session and transitioning to 4
patients per session over a month (or longer) is one
approach. Another piece to consider is assisting resi-
dents with foundational time management skills. Starting
with the mental model that a 60-minute patient visit
includes only 30minutes with the patient, 15minutes to
precept, and 15minutes to complete required documen-
tation helps build time and task management skills.
Attention to strategies in this area can promote resident
wellness and feelings of preparedness [28].
(h) Variety of care settings: Residents will be learning to
care for patients across the life cycle and in many differ-
ent settings such as the outpatient clinic, emergency/
urgent care, long-term care facilities, patient homes, and
perhaps unsheltered people in the community. Early
observational exposure to these settings can reduce anxi-
ety and uncertainty for learners as they begin training.
(i) Introduction to community resource: This is a broadly
dened term that includes resources for a variety of con-
ditions in the patient population (e.g., addiction, home-
lessness, food insecurity, hospice care, etc.). While
learning about the resources, residents learn about social
determinants of health (SDoH) locally and how to con-
nect patients to appropriate resources [29]. Some pro-
grams include sensitizing learners to the patient
perspective as well [30, 31] to provide insight into how
clinician behavior can enhance the patient experience.
Longitudinal Integration
Assessment of individual level of supervision over time:
There are three levels of supervision as dened by the
ACGME: direct supervision, indirect supervision, and oversight. The ACGME assumes that medical school graduates
start residency needing direct supervision of all patient care
activities. Assessing learners allows tailoring supervision
based on demonstrated capabilities. Residencies can integrate measures of the appropriate level of supervision for
common tasks as learners progress through training.
15 Resident Integration: Orientation andOnboarding
155
Integration Observations andFeedback:
AMeans forContinuous Improvement
There are several perspectives which can inform planning for
integration in subsequent years. Since newly arrived learners
have a unique perspective, it is helpful to gather their impressions and observations during this initial period. Invite new
residents to assess integration activities by measuring satisfaction, utility, and effectiveness for engaging in the role of a
resident. Consider asking learners to list their individual
learning points gleaned from the process. Immediately after
onboarding, asking what worked well, what didn’t work
well, what should be changed and what was missing provides important data for future planning.
Faculty and leaders can use new residents’ baseline
assessment data and observations to consider changes to the
current integration process in real time. For example, if it is
discovered that several new residents are less comfortable
with core physical examination skills, faculty can incorporate a session to coach residents on those skills. This data can
also be disseminated to faculty rotation coordinators, such as
a summary of new resident experience with obstetrical skills
and procedures. The faculty can utilize the data to inform
faculty preceptors, helping them to tailor their approach
based on resident needs.
This data is also helpful in identifying potential changes
to the onboarding process in the future. To determine appropriate content and length of orientation/onboarding, consider
measuring levels of learner preparedness in the following
3–6 months. Are most learners demonstrating adequate
knowledge and skills in key areas (e.g., use of the electronic
health record, relationships with patients and interprofessional team members, using resources to address knowledge
gaps, etc.)? What level of comfort do learners report, both
immediately after onboarding activities, and in the rst
3–6 months of residency, with these activities? Inviting
observations from physician preceptors, clinical team members and senior residents can yield robust data about individual residents and the cohort. If after 3 months, several
new residents are struggling with a particular process (e.g.,
timely documentation in the electronic health record), it may
be helpful to increase the amount of coaching new residents
receive in that skill in future years.
Additional Concepts toConsider
Advantages ofOrganized Integration
The Coalition for Physician Accountability UGRC’s
Executive Summary states that:
Solutions that bring the components of the (UME-to-GME) tran-
sition into better alignment could have many positive outcomes
and will likely decrease student costs, reduce work, enhance
wellness, address inequities, better prepare new physicians, and
enhance patient care. [4]
Among the advantages of an organized integration process for an entire class of residents are streamlining core
skill training, enhancing a sense of camaraderie, and reinforcing the support of the education team. It can also
address anxiety and fear related to this signicant increase
in patient care responsibilities, lack of experience with
variation in health conditions, urgent/emergent situations
and building longitudinal relationships with patients and
families.
Learner/Residency/Institutional Goal Alignment
It can be illuminating to ask new residents to reect on what
they were told about the culture and function of the department/organization, compared to what they experience as
newcomers (e.g., the “hidden curriculum”). This can help
identify areas of alignment and dissonance and identify
potential changes to the onboarding process and/or the culture and function themselves.
Another aspect of the initial introduction of new medical
school graduates into training is the dichotomy between
being learners AND being salaried employees of an organization simultaneously. Since learners have different career
trajectories, this may be one of their rst experiences as
employees. At times, this change requires a shift in the resident’s mental model of their role and responsibilities. For
example, if residents opted to watch medical school lectures
on video vs attending in person, they may see didactic sessions as optional to attend unless expectations are claried. It
may be benecial to surface this dynamic and discuss it in an
open manner during onboarding to enhance resident understanding of expectations.
The other dynamic to consider exploring is that of the
shift in mental models from being a student (reliant on
didactics/information transmission, shelf exams, etc.) to
being an apprentice physician (consistent experiential learn-
ing opportunities in addition to receiving didactics). Are residents being taught what they need to know (one way
responsibility of the program), and/or are they learning what
they need to know (shared responsibility)? In the UGRC’s
Recommendation #27:
Targeted coaching by qualied educators should begin in UME
and continue during GME, focused on professional identity for-
mation and moving from a performance to a growth mindset for
effective lifelong learning as a physician. Educators should be
astute to the needs of the learner and be equipped to provide
assistance to all backgrounds. [4]
Stanford psychologist Carol Dweck, PhD, has researched
the concepts of “growth mindset” extensively [32]. When
156
B. Gopal and T. Kenyon
learners display a growth mindset, they demonstrate a desire
to actively learn from others and from their own experiences,
embrace challenges as opportunities to grow, and work
toward personal mastery. This concept is directly applicable
to graduate medical education [33]. Again, making this a
topic of conversation early in training can help faculty understand resident perspectives and reframe the expectations for
this new stage of training.
Resident Self-Care andWellness Strategies
According to the UGRC’s nal report, recommendation #31
states:
Anticipating the challenges of the UME-GME transition,
schools and programs should ensure that time is protected, and
systems are in place, to guarantee that individualized wellness
resources—including health care, psychosocial supports, and
communities of belonging—are available for each learner. [4]
Most often, learners are transitioning to a new community, where options for important personal care resources are
unfamiliar. It is important to share a list of primary care practitioners, dentists, and mental health professionals who can
take new patients. There are also models of allowing residents time in orientation/onboarding to attend appointments
[34] and providing a week of orientation free of clinical
responsibilities [35] to promote self-care. One program
insightfully expanded this dissemination of resources to the
families and loved ones of new residents [36], and another
used a virtual museum tour as a tool for discussing transition
to residency [37].
Looking Through aTrauma-Informed Lens
With the COVID-19 pandemic, we have all been through a
signicant traumatic period. It is important to note that even
before the pandemic, medical education has passively
accepted a certain level of “generational trauma” as part of
the learning process. Attending physicians in medical
schools and residencies pass on long hours and traumatic
experiences as part of the “rigor” of medical education,
something implied to build resiliency and clinical capability. People shaped by this method of “learning” are often
left with fear and shame as their motivation toward
perfectionism.
When considering the culture of the program and how to
integrate medical school graduates, it is important to consider looking through a trauma-informed lens. Consider the
residents’ lived experiences from medical school and life.
Consider how fear and shame may cause residents to hide
their areas of improvement and how the residency culture
may unintentionally compound this. Trauma-informed medical education (TIME) is a concept that considers the trauma
that medical students and residents experience prior to starting their medical education and/or within their learning environment. Traumatic experiences can inuence how residents
interpret and work with their patients’ trauma background
[38].
TIME is based on the eight concepts of trauma-informed
teaching (see Table15.3) [39]. Concepts of shame, vulnerability, and power are transparent with alignment between the
overt and hidden curricula. Approaching resident integration
with a trauma-informed lens enhances an equity, inclusivity,
and diversity (EID) approach.
When considering how to introduce TIME into resident
integration, consider that the “earlier, the better.” First-year
residents are looking at the program through the lens of their
experiences in medical school, so consider how the preassessment may help you to understand their context. One
approach is to start the rst week of residency with interactive sessions that cover the concepts vulnerability, empathy,
shame, and trauma-informed care [40–48]. For example,
residents describe what a culture looks like when it repeatedly rewards vulnerability as opposed to implicitly or explicitly punishing vulnerability. While it is important to provide
these sessions early, there must be complete buy-in from the
faculty to support these concepts.
Table 15.3 Eight principles of trauma-informed teaching
1. Work to ensure your residents’ emotional, cognitive, physical, and interpersonal safety.
2. Foster trustworthiness and transparency through connection and communication among residents.
3. Intentionally facilitate peer support and self-help.
4. Promote collaboration and mutuality by sharing power and decision making with your residents.
5. Empower voice and choice by identifying and helping build on resident strengths.
6. Empower your residents to self-regulate by teaching them about the biology of learning.
7. Impart the importance of having a sense of purpose.
8. Pay attention to cultural, historical, and gender issues.
Adapted from: Trauma Informed Pedagogies eds. Thompson and Carello
15 Resident Integration: Orientation andOnboarding
157
Conclusion
As referenced in the UGRC report, residencies have a
responsibility to facilitate a smooth transition for learners
from medical school graduate to new resident physician.
There are many approaches to providing foundational experiences that contribute to high quality integration into graduate medical education. Enlisting input from current residents,
interprofessional faculty, leaders, clinical team members,
preceptors, and attending physicians helps dene the tenets
of a successful integration structure. New resident feedback
provides experience-based observations to guide programs
in planning for the future. The UGRC research highlights the
critical need to “get it right” when assisting residents to transition into this next phase of training. The authors hope the
concepts in this chapter offer ideas for re-examining the residency’s current approach to integration, and using their collective creativity to maximize the preparation, wellness, and
capabilities of new residents joining their program each year.
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International Medical Graduates
inFamily Medicine Education
RobertC.Langan
16
Key Points
• According to the Association of American Medical
Colleges, 25% of the total US physician workforce and
24.2% of all US family physicians are international medical graduates.
• International medical graduates may particularly benet
from a holistic review of their residency application,
which is dened by the AAMC as “exible, individualized ways of assessing an applicant’s capabilities by
which balanced consideration is given to experiences,
attributes, and academic metrics.”
• Flexible orientation and onboarding processes should
take into account the need for international medical graduates to acclimate to a new country and community, learn
the health system, and provide time for necessary but
nonresidency activities such as obtaining a driver’s
license. Faculty mentors, faculty education about international medical graduates, and awareness of the possibility
of bias and discrimination are key components to assuring
a smooth transition to residency training.
Introduction
International Medical Graduates (IMGs) form an integral
part of the physician community in the United States, working in ofces, emergency departments, hospitals, academic
settings, research, urgent care centers, and community medicine settings in urban, suburban, and rural locations.
According to the Association of American Medical Colleges
(AAMC), 25% of the total US physician workforce and
24.2% of all US family physicians are IMGs [1]. IMGs bring
a tremendous breadth and depth of experience and diversity
to the medical community, but there are also considerations
of which family medicine educators should be aware in the
recruitment, hiring, and onboarding processes.
Denitions
An IMG is any physician who has completed their medical
school training outside of the United States. An IMG may be
a US citizen (both individuals born in the United States and
naturalized citizens) or a non-US citizen. The term foreign
medical graduate is sometimes used to indicate an IMG who
is a non-US citizen.
Trends inFamily Medicine
According to the American Academy of Family Physicians
(AAFP), in 2023, 793 US citizen IMGs and 562 non-US citizen IMGs matched into Family Medicine, which together
represented 26.5% of all positions lled. In comparison,
graduates of US allopathic and osteopathic medical schools
lled 29.4% and 29.6% of Family Medicine positions,
respectively, in 2023. Overall, 23.6% of all US citizen IMGs
who matched and 11.2% of all non-US citizen IMGs who
matched entered Family Medicine programs in 2023 [2].
Since 2000, the number of Family Medicine positions
lled by US citizen IMGs has increased from 189 to 793, an
increase of over 300%. In comparison, non-US citizen IMGs
saw growth during the same period of time from 265 to 562,
an increase of over 100% [3].
History
R. C. Langan (*)
St. Luke’s Family Medicine Residency/Sacred Heart Campus,
Allentown, PA, USA
e-mail: Robert.Langan@sluhn.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_16
In the United States following World War II, the combination
of unprecedented growth in graduate medical education,
increased demand for physicians, and a robust economy led
159
160
R. C. Langan
to increasing numbers of non-US-trained physicians immigrating to continue or restart their medical careers. As a
result, the Evaluation Service for Foreign Medical Graduates
(ESFMG) (later renamed the Educational Council for
Foreign Medical Graduates (ECFMG)) was formed as a private, nonprot organization in 1956 [4].
The ECFMG developed processes to validate medical
credentials, conrm prociency in English, and assess medical knowledge for IMGs. In 1961, certication by the
ECFMG was required by the American Medical Association
and American Hospital Association for IMGs caring for
patients in US hospitals [4].
In 1974, the ECFMG merged with the Commission on
Foreign Medical Graduates and changed its name to the
Educational Commission on Foreign Medical Graduates
(while retaining the acronym ECFMG). In addition to its previous responsibilities, the newly constituted ECFMG
acquired responsibility for J-1 visa sponsorship of non-US
citizen IMGs [4]. Beginning in 2024, all IMG physicians
who apply through the ECFMG are required to graduate
from a medical school accredited by agencies recognized by
the World Federation for Medical Education [5].
Residency Application
IMG applicants to ACGME-accredited family medicine residency programs submit applications through the Electronic
Residency Application Service (ERAS) just like applicants
from US allopathic and osteopathic medical schools. As
mentioned previously, a candidate must receive certication
through the ECFMG in order to work as a physician in the
United States [4]. Many IMGs will have completed this certication prior to applying for training and it can be found in
the ERAS application under a separate heading.
Programs should review the need for non-US citizen
IMGs to obtain a work visa in order to start their residency
training as described in the onboarding section below. In
many countries, the degree “MBBS” (Bachelor of Medicine,
Bachelor of Surgery) is used in place of MD, but the degree
itself is equivalent. Many foreign medical schools are 6years
in length and start immediately after secondary school, so
there may not be an undergraduate school or degree listed on
the application. Many countries have a year of mandatory
medical practice in an underserved area following the completion of medical school, which can be found under the candidate’s employment history.
Graduates of Caribbean medical schools often rotate at
US hospitals during their third and fourth years, so the quality and verbiage of letters of recommendation should be
similar to those for US allopathic and osteopathic students.
However, letters from outside of the United States may be
written by individuals for whom English is a second lan-
guage, may be certied translations from the original language, and/or may be written by physicians who are not used
to the conventions of US letters of recommendation, including phrases such as “top 5% of all students I ever worked
with” or “this student will make an exceptional resident.”
This should be taken into consideration when these letters
are reviewed and compared to the more familiar format programs may be accustomed to using and seeing. Many of the
application characteristics that have been used to identify
desirable candidates, such as membership in Alpha Omega
Alpha or the Gold Humanism Honor Society, may not be
available at the candidate’s medical school.
Programs often request that IMG candidates have a set
number of US clinical experiences, either working or as an
observer, to include in their application. This requirement is
based on a premise that US clinical experiences will allow
IMG physicians to familiarize themselves with the US
healthcare system and practice English in a clinical environment. Although graduates of Caribbean medical schools
spend their clerkships in US hospitals, other IMGs may have
a difcult time obtaining these experiences due to availability and cost, particularly if the candidate is from a resourcepoor environment. The COVID-19 pandemic, with its
extensive restrictions on travel, also had a signicant impact
on US experience for many non-US citizen IMGs.
Previously, the United States Medical Licensing
Examination (USMLE) Clinical Skills Examination (CSE)
provided information to programs about the clinical and
communication abilities of candidates and was required for
all candidates prior to starting residency. However, with the
suspension and ultimate discontinuation of this examination
[6], programs are no longer able to rely on this evaluation.
The ECFMG now utilizes the Occupational English Test
(OET) to conrm English prociency and is a requirement
for ECFMG certication [7]. Written communication from
the personal statement and comments from letters of recommendation can be used for a preliminary assessment of
English prociency, but often these skills are best assessed
during the interview process. IMGs may be bilingual or trilingual, and these language skills may be invaluable in caring
for immigrant populations in a program’s community.
Many non-US citizen IMGs have experience working as a
physician in their home country. This experience, particularly if it involves delivering primary care in a resource-poor
setting, can be a valuable asset to candidates who are starting
residency training. Programs should look at the date of graduation, work experience, and volunteer experience to get a
clearer picture of an IMGs path to applying for residency,
realizing that gaps in their training and experience may be
due to immigration, obtaining nances, and other circumstances related to relocation.
As a result, IMG applications in particular may benet
from a holistic review more than their non-IMG colleagues.