by Pedram Mizani, Doctor, MHSA, family unit physician and chief clinical officer of the AmeriClerkships Medical Society

Published in Residency Programme Alert* on February 2018.

In the 2017 Primary Residency Match, almost 1 out of every four postgraduate year (PGY) one residency positions were filled by international medical graduates (IMG), more than one-half of whom required U.S. visa sponsorships (National Residency Matching Plan, 2017). The continued add-on of non-U.S. physicians to primal primary intendance and surgical fields is a positive sign that at to the lowest degree these residency specialties volition continue to diversify, a central element in providing culturally sensitive primary care in the U.S.

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Published with permission from HCPro/Residency Program Alert. Likewise published on HCPro.

* Virtually Residency Program Warning: Residency program managers in all specialties are challenged to finer manage their programs as accrediting agencies focus on effect measures, the core competencies, proper documentation, resident supervision, and plan, faculty, and resident evaluation. Add to those responsibilities the challenge to prepare for site visits, develop budgets for your program, and mitigate legal risks. Residency Program Warning is the source you need to confidently encounter these challenges. This monthly resources provides residency managers with essential tips, tools, and best practices from the most well-respected, in-the-trenches experts. Dr. Pedram Mizani, the AmeriClerkships' Main Clinical Officeholder, is a writer and contributors to Residency Program Alert.

In the 2017 Main Residency Lucifer, virtually i out of every four postgraduate year (PGY) 1 residency positions were filled by international medical graduates (IMG), more than half of whom required U.S. visa sponsorships (National Residency Matching Programme, 2017). The continued addition of non-U.South. physicians to key chief care and surgical fields is a positive sign that at least these residency specialties will continue to diversify, a key element in providing culturally sensitive chief intendance in the U.S.

However, the benefits of promoting a culturally diverse resident population come up with the challenging responsibility of judging all IMG applicants fairly. By properly identifying and aligning the skills and qualities they present in their Electronic Residency Application Service (ERAS) application packages with what your residency programs value near, you can find the all-time match. This challenge is typically greatest when evaluating non-U.Southward. citizen/resident IMGs, especially those who choose to back up their own candidacies with foreign messages of recommendation (LOR).

We must also take a moment to define "strange," as this term has not been clearly defined by residency programs. While to some, "foreign" may be a euphemism for third-world countries whose native languages are not English, I define it as any LOR generated by a non-U.Southward. licensed medico pertaining to a non-U.S. experience, and being submitted to U.S. medical residencies for consideration.

LORs take always been an important part of whatever U.S. medical residency application package, but perhaps are more so now because residency selection committees are nether pressure to visualize the type of resident an IMG may be outside of United States Medical Licensing Examination (USMLE) lath scores and small-scale application flaws. Withal, one medical school study found that 73% of directors of American residency programs considered LORs from a foreign country to be useless (Gayed, 1991).

With so much pressure mounting to invite the candidates who they think volition fit in and do the all-time, residency programs are putting greater value on LORs (or lack thereof) in each application. In fact, in the National Residency Matching Program'due south (NRMP) 2016 Program Director Survey, "messages of recommendation in the specialty" was ranked as the second most popular and of import criteria when offering residency interviews among all specialties, with only USMLE Step 1/COMLEX Level 1 score ranking higher (National Residency Matching Programme, 2016). Because this survey did not delineate if "messages of recommendation in the specialty" was purposefully stated this fashion to include strange LORs, the following pros and cons of foreign LORs pertain to their U.S. medical residency relevancy.

Pro: They tell a lot nearly what a candidate perceives as acceptable communication standards

A foreign LOR is most probable unwaived, and so the applicant has seen it, and by virtue of having submitted it to your program, is telling you that he or she approves of the content and writing style. This can be useful to come across if the candidate takes cracking pride and care to communicate accurately and in proper English, or if he or she sees nix wrong with a poorly written LOR (foreign, or from a U.S. clinical experience).

Pro: They give a glimpse into the type of healthcare environment the candidate is coming from

In nearly every non-English-speaking country, undergraduate, medical educational activity, and PGY-1 are combined every bit one Md program, virtually guaranteeing that the medical graduate will immediately give back to the community every bit a licensed general practitioner. Knowing this can assist you avoid erroneously concluding that six or seven years of medical education is abnormal and bold that there were unwanted gaps in an IMG's medical instruction.

Pro: They may assist explain gaps during (or more likely after graduating from) medical school abroad

If written objectively, a strange LOR can aid account for any perceived gaps, especially if a few years have passed since the candidate graduated from medical school. The all-time-case scenario is that the author was an IMG'south hospital or clinic employer.

Pro: They may come from a healthcare environment similar to that of the U.S.

This does not happen often, but some IMG candidates submit LORs from U.S. physicians whom they've worked with on U.Southward. military machine bases abroad. This is often the case if the non-U.S. citizen/resident was employed by a foreign physician employer contracted to provide local physicians who speak the native language of that land in our bases (e.g., Iraq). In Japan, the U.S. Air Force offers a ane-year unaccredited fellowship program to practicing Japanese-speaking physicians who wish to rotate through all core specialties, also as electives, in a U.S. healthcare environment in their own backyard.

Pro: They may testify that patient demographics treated past an IMG candidate may exist similar to those seen in your residency

Many programs encourage their residents to learn medical Spanish; therefore, a foreign LOR that emphasizes an IMG's power to speak with patients in both Spanish and English language may give an IMG candidate an border over similarly qualified candidates.

Pro: They can indirectly tell you lot about an IMG's U.S. clinical experience and residency readiness

One or more foreign LORs with as well few or no recent U.S. LORs tin can be an indicator of an IMG candidate's lack of contempo U.S. clinical experience, which volition aid you decide if an invitation to interview is better suited for an IMG with a better U.Southward. clinical experience portfolio.

Con: Unfamiliar language or grammatically incorrect content tin can be distracting

Due to the sheer number of applications submitted past IMGs to chief care and surgical specialties, information technology'south nearly impossible to conduct the first circular of vetting by looking for positives. This is why nosotros look for negatives and cherry flags: The more nosotros come across, the more we tend to disqualify the candidate. Grammatically wrong LORs—mostly seen in foreign LORs but also not uncommon in U.S. LORs—can waste valuable seconds that we could be putting into assessing a candidate's residency readiness based on ACGME core competencies, non alphabetic character writing skills.

Con: Healthcare setting is most likely completely different than U.S. GME settings

Although information technology's nice to have a colleague abroad support an IMG candidate, the experience that led to the writing of the LOR was most likely not in a setting with patients from the U.S., being treated under U.South. healthcare policies, or following protocols commonly implemented in the U.South.

Con: Fact-checking is neither timely nor efficient, and downright incommunicable in most cases

Many LOR reviewers in the U.South. notice it quite discouraging when they are faced with challenges (eastward.yard., time differences, missing land codes for directly telephone numbers, generic email addresses that are checked infrequently, and outdated contact pages on medical school websites) when attempting to contact the alphabetic character writer about an IMG they are interested in. But like a poorly written LOR, these issues create a cerise flag, and plenty red flags can pb to a rejection.

Con: Most strange LOR writers have never been trained in a U.South. GME, so they lack immediate brownie when it comes to recommending someone to enter it

In that location is typically no indication that an LOR writer has any experience with U.S. GME, making information technology nearly impossible for him or her to make a recommendation to a U.S. program based on the writer's experiences. Therefore, it makes it difficult for an LOR reviewer in the U.Due south. to trust someone's recommendation who may not have trained in the same system for which they are recommending a candidate.

Con: References to ACGME core competencies are nearly nonexistent

This is understandable, since ACGME core competencies are unique to the U.Due south., which is the reason why some programs refuse to consider LORs from not-U.Southward. experiences. A seemingly strong foreign LOR (based on a candidate's medical noesis or loftier USMLE scores) is not truly relevant to U.S. medical residency programs if information technology fails to address all other ACGME core competencies as we would like to run into them be taught and carried out in this land.

Con: They rarely criticize or even point out weaknesses in IMG candidates

IMG candidates typically ask friends or professional colleagues from abroad to write LORs, and in general, friends and colleagues will not be disquisitional of an IMG's performance. In my 18 years of reviewing LORs, I take nevertheless to come across a foreign LOR that was critical of a candidate or objective of that candidate'southward functioning. If all LORs are positive and subjective, and so the value of an LOR rapidly diminishes.

Considerations for foreign LORs

With all of that existence said, foreign LORs deserve special consideration nether the following conditions:

i. The LOR is written by a U.S.–licensed doc outlining experiences that took place on U.S. military bases abroad, treating patients from the U.S., using the U.Due south. healthcare organization

2. The clinical experiences described took identify in whatever of seventy ACGME International–accredited residency programs in Singapore, Lebanon, Sultanate of oman, Qatar, United Arab Emirates, and Kingdom of saudi arabia

3. The experiences took place in non-military "American hospitals" abroad, especially if they are Joint Commission International–accredited

4. The LOR is written by a physician who supervised the IMG candidate who was responding to a humanitarian disaster

five. The LOR is written by an IMG who completed a U.S. ACGME–accredited residency program, is not licensed in the U.S., only is practicing abroad

6. The LOR is from a clinical experience in an English language-only speaking medical school with a supervising medical lath that has reciprocity agreements with your state medical board for purposes of licensure

7. The candidate is applying for a fellowship, avant-garde, or PGY-2 position in the exact aforementioned specialty every bit his or her field of do (eastward.yard., ophthalmology), and the U.S. residency or fellowship program requires the IMG'due south immediate supervisor to attest to his or her performance and specialty suitability

8. The position offered is a research track and the candidate has extensive residency relevant research experience abroad

I hope you find this information useful when faced with evaluating a foreign LOR in an ERAS application to your residency program. Consider sharing this information with your residency faculty and colleagues who review residency applications for interview consideration. By truly understanding all that is entailed in residency applications submitted by IMGs and taking proactive steps to address the unique aspects of such applicants, we can meliorate the suitability of those whom we invite for interviews, prior to extending offers.

References

Gayed, N. K. (1991). Residency directors' assessments of which selection criteria best predict the performances of strange-born foreign medical graduates during internal medicine residencies. Academic Medicine, 66 (xi), 699–701. Retrieved from http://journals.lww.com/academicmedicine/Abstract/1991/11000/Residency_directors__assessments_of_which.15.aspx

National Residency Matching Program. (2016). Results of the 2016 NRMP programme manager survey. Retrieved from www.nrmp.org/wp-content/uploads/2016/09/NRMP-2016-Program-Director-Survey.pdf

National Residency Matching Plan. (2017). Results and data: 2017 main residency lucifer. Retrieved from www.nrmp.org/wp-content/uploads/2017/06/Main-Friction match-Results-and-Data-2017.pdf