Covid-Era Residency Hurdles for International Medical Graduate Physicians

By Michelle R. M. Warncke, MBBS, MPH

Edited by Sarah Pressman Lovinger, MA, MD

I am an international medical graduate (IMG) who was unable to participate in the residency match this year because of the Covid-19 outbreak. Although a US citizen, I received my MPH in the UK, and chose to stay in the UK for a medical program that had a hands-on approach to teaching. 

Unfortunately, when Covid-19 hit the US, my last practical exam before being eligible for a US residency – Step 2CS – was cancelled as testing was suspended for 2 months, and then for 12-18 months.  The governing board still has not yet determined when the opportunity to take Step 2CS will again become available. This hold up has had a huge impact on my life and on the lives of as many as 3000 IMG physicians trying to match in a US residency spot. I managed a Facebook group for IMGs caught up in these restrictions and have become very aware of the challenges our cohort is facing. 

What is the usual exam process that IMG physicians undergo in order to participate in the US residency match? As with American medical graduates (USMGs), the normal pathway to certification for IMGs is to pass the USMLE Steps 1, 2CK, and 2CS, thereby showing our equivalency to USMGs. The Step 2CS, specifically, must be done in person and is administered in only 5 centers in the US. Because of the infection risk and travel restrictions, it has been suspended until June 2021 at the earliest. 

In 2020, the governing board for USMGs (the AAMC) has allowed them to postpone the Step 2CS until during residency. The governing board for IMGs (the ECFMG) announced that they would continue to require Step 2CS before granting certification. They did, however, propose five preliminary alternative pathways for this year’s match cycle in light of the suspended testing. Restrictions to these pathways were designed to predict who would be most likely to pass Step 2CS. Instead, many of my peers and I found out that we were being excluded because of retroactively determined restrictions on who would be deemed eligible to apply. The fee for this temporary certification is $900, alienating even more applicants.

What has happened to IMG physicians who could not take the exam and apply for residency in 2020? Many physicians have been left without a clear career pathway. Many IMGs are now living in the US and are waiting to figure out their next steps. Some IMG physicians are returning to their previous country and are leaving behind partners, spouses, and children. The alternative would be to spend another year losing clinical skills and falling behind in training, making the prospect of a residency even more remote.  Covid-related travel restrictions made the prospect of international travel even more difficult. Almost all of my colleagues are experiencing career and relationship stress. 

Many residency programs rely on the IMG physician workforce.  How do you think these restrictions will affect US residency programs While there are individuals that do not match this year, what I have seen of the candidates left out of this year’s match is that residency programs will be missing out on several qualified if untraditional candidates with a true passion for patient and colleague advocacy. At this point, program directors whom I have spoken to have many applications, but this seems to stem from applicants applying to an increased number of programs rather than an increase in unique applicants. 

Can you tell us a little about your plans? I am one of the lucky ones. I am planning on returning to the UK in July for foundation programme training (similar to a US internship year). I hope to return to the US for a residency so that I can give back to my community. Happily, my husband received permission from his graduate program to join me in the UK.  Even our cat (Mac and Cheeks) will travel with us! I will continue to advocate for improved IMG residency opportunities.