by Joseph M. Firriolo, MD (@jomarkf)
Plastic Surgery Resident, University of California, Davis
Plastic Surgery (Integrated) continues to be one of the most competitive specialties in the National Residency Matching Program (NRMP) Main Residency Match. In the 2018 match, a total of 229 applicants vied for 168 available positions in 77 programs. 
It is especially tough to match as an international medical graduate (IMG); very few IMGs match into Plastic Surgery each year. A total of four IMGs matched in 2018: one was a US citizen, and three were non-US citizens (the applicants matched in programs based in California, North Carolina, Oregon, and Rhode Island). 
Although difficult, IMGs can maximize their chances of matching by following the tips below.
1. Set goals, establish a timeline, and maintain a realistic attitude.
For IMGs, the process of matching into Plastic Surgery will typically take a minimum of 2-3 years. It is important to keep focused and to maintain motivation. The best way to achieve this is to create a series of small, specific goals, with strict deadlines.
First, determine the application cycle in which you would like to participate. The residency application season begins in September each year; candidates match the following March.  By the September of your application year, you must pass the necessary licensing examinations (see Tip #2), optimize you CV, and obtain at least three letters of recommendation (see Tip #7).
For perspective, I have included my own personal timeline below. 2015 was my final year of medical school, 2016 and 2017 were dedicated research years, and I matched in March 2018.
Maintaining a positive and realistic attitude is key. It is very easy to get discouraged during this process. Years of consistent hard work combined with frequent travel, visa demands (for non-citizens), navigating foreign systems, financial stress, and isolation from your closest supporters can take a mental toll. If living in the US, make friends (medical and non-medical) and surround yourself with positive people. Reflect on constructive criticism from mentors and peers, but ignore statements that claim it is impossible for IMGs to match into Plastic Surgery. IMGs match into Plastic Surgery every year; official match results and data are publicly reported by the NRMP. 
2. Obtain ECFMG Certification.
Certification by the Education Commission of Foreign Medical Graduates (ECFMG) is necessary to participate in the match and must be obtained prior to the rank order list deadline (typically mid-February). ECFMG certification requires an online application  and passing grades for the United States Medical Licensing Examinations (USMLE) Step 1, Step 2 Clinical Knowledge (CK), and Step 2 Clinical Skills (CS).  While not a strict rule, it is advisable that IMGs pass all three of these examinations by the beginning of the application season in September.
There are important timing considerations for the USMLE. Firstly, as a foreign graduate you will need to take additional steps to verify your identity and credentials with the ECFMG before proceeding to schedule examinations. This process normally takes three weeks once all documents have been submitted.
Results for Step 1 and Step 2 CK are usually available within 3-4 weeks of the examination date. However, results for Step 2 CS are released according to a ‘Reporting Schedule’ and may take up to 3-4 months.  In addition, Step 2 CS examinations are conducted in only five US cities (Philadelphia, Chicago, Houston, Atlanta, and Los Angeles) meaning that most applicants will have to make travel and accommodation arrangements for this test. Step 2 CS testing centers can book out 6 months in advance (or earlier) so be sure to schedule your examination date early.
Although only passing scores are required for ECFMG certification, applicants should aim to score as well as they possibly can on Step 1 and 2 CK. USMLE Step 1 scores are consistently cited as one of the most important factors when selecting candidates for interviews and when ranking applicants. [8, 9] Also consider that you will likely need to dedicate more time than American students for USMLE preparation to account for differences in medical school curricula.
3. Get US clinical experience.
US clinical experience in Plastic and Reconstructive Surgery is advantageous for the IMG. It is even a prerequisite for some residency programs. Research programs ahead of time; a complete list can be found on the ACAPS website. 
US clinical rotations are best completed in medical school, as many programs will not accept medical school graduates. These are often referred to as ‘sub-internships’, ‘externships’, or ‘clerkships’. Sub-internships provide you with the opportunity to demonstrate your clinical, academic, and technical skills. These rotations may also help establish you as a culturally competent individual, capable of working effectively within the US healthcare system. On a personal level, US clinical rotations allow IMGs to determine if the American medical system is compatible with their own individual needs and expectations.
Consider clinical rotations an ‘audition’. Making a good impression may later earn you an interview invitation or even encourage programs to rank you highly for the match. Additionally, the surgeons you meet during sub-internships are great resources; they may turn out to be your future letter writers, research supervisors, or mentors.
4. Find a mentor.
Most applicants are aware of the benefits of mentorship; a supportive mentor will provide ongoing advice, assist with the match process, and write strong a letter of recommendation. I met my mentor, Dr. Brian Labow, during my sub-internship at Boston Children’s Hospital (BCH).  I returned to BCH a year later and completed a Research Fellowship under his supervision. I credit his mentorship and my research experience (see Tip #5) as two of the strongest factors that contributed to my success in matching.
Mentors can be found through clinical and research experiences as well as more formal mechanisms, such as the Plastic Surgery Research Council (PSRC) Mentor Program. 
Research and innovation are central to Plastic and Reconstructive Surgery and are especially important for foreign candidates. In 2016, successful non-US IMGs had an average of 55.7 abstracts, presentations and publications.  There are numerous Plastic Surgery Research Fellowships available in the US. You may ask programs directly about available research opportunities, or look at job postings on the PSRC 13] and ACAPS  websites.
Publish your research. Plastic and Reconstructive Surgery remains the number one journal in our specialty; it is always an excellent choice for manuscript submission.
Present your research. Make a calendar of the various academic meetings and their abstract submission deadlines. Academic meetings provide valuable networking opportunities and also contribute to your CV. There are many quality national (AAPS, PSRC, and ASPS), [15-17] regional (NESPS, CSPS), [18, 19] and local meetings throughout the academic year. You can find a meeting calendar on the ASPS website. 
6. Prepare for the application season ahead of time.
Start working on the following tasks ahead of application season in September:
- Maintain an updated CV.
- Draft a personal statement.
- Request your medical school transcripts (have them translated if necessary).
- Request a Medical Student Performance Evaluation (MPSE) from your medical school; provide your medical school with a guide. 
- Apply for the Postgraduate Training Authorization Letter (PTAL) if you are interested in Californian programs. 
- Take an application photo. You do not need to spend a lot of money on this. Wear professional clothing, go outside, and have a friend take a photo (iPhone photos will suffice). You can touch up the photo with an app such as Facetune. 
7. Obtain letters of recommendation (LOR) and ACAPS evaluation forms.
Request at least three LORs from US Plastic Surgeons who know you well and have supervised you clinically and/or academically. Start requesting letters at least 3 months before applying. Provide your letter writers with a copy of your CV and an ACAPS evaluation form (which they will need to upload to ERAS with your LOR).  While you may include letters from non-US physicians, they should be in addition to your three US letters. There is no substitute for letters written by US Plastic Surgeons.
8. Apply to as many programs as possible.
IMGs cannot afford to be picky! Apply to all programs where you would be willing to work for 6-7 years. It is important to note that matching at an institution contractually obligates you to work there, so do not apply for and rank programs that you have no interest in.
9. Prepare for interviews.
IMGs typically receive far fewer interview invitations than their American counterparts, so it is important to prepare well and make the most of every opportunity. I highly recommend practicing with a friend to refine your interview techniques.
Prepare for the predictable ‘IMG questions’. All of my interviews featured some combination of the questions below.
- “Why do you want to complete your residency in the United States?”
- “Why do you not want to do residency in [your country of origin]?”
- “What’s wrong with [your country of origin]?”
- “Why should we choose you over an American candidate?”
Be aware that most interviewers are not necessarily familiar with the many advantages of matching foreign graduates. Use your interview to highlight your strengths as an IMG. Reflect on the following points:
- You have seen another healthcare system.
- You may know more than one language.
- You may have additional postgraduate experience, e.g. research or clinical work.
- The challenges of moving to a new country, obtaining a visa, and establishing a new social and academic life are evidence of your interpersonal and organizational skills.
10. Plan for Match Week.
Match Week can be stressful. Have a plan in place in case you fail to match.
If you do not match:
- This is not a reflection on you. Every year many capable American and foreign applicants fail to match. Take some time to relax, review your application, find areas for improvement, and try again next year!
- Read the NRMP website ahead of time to learn about the Supplemental Offer and Acceptance Program (SOAP). 
- Be prepared for SOAP interviews (usually telephone or video interviews). Make sure you have clean interview clothes, a Skype account, a computer with a webcam, an American cell phone, and a private space for interviews.
If you do match:
- Celebrate! Visit your home country if possible.
- Research your visa options (if applicable) and start the application process as soon as possible.
- National Resident Matching Program (NRMP). Results and Data: 2018 Main Residency Match. April 2018. http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf
- National Resident Matching Program (NRMP). 2018 Match Results by State, Specialty, and Applicant Type. April 2018. http://www.nrmp.org/wp-content/uploads/2018/04/Main-Match-Result-by-State-and-Specialty-2018.pdf
- Association of American Medical Colleges (AAMC). ERAS Timeline for IMG Residency. https://students-residents.aamc.org/applying-residency/article/eras-timeline-img-residency/
- National Resident Matching Program (NRMP). Main Residency Match Data and Reports. http://www.nrmp.org/main-residency-match-data/
- Educational Commission for Foreign Medical Graduates (ECFMG) On-line Services. Interactive Web Applications. https://secure2.ecfmg.org/emain.asp?app=iwa
- United States Medical Licensing Examination (USMLE). http://www.usmle.org/
- United States Medical Licensing Examination (USMLE). Step 2 CS: Score Reporting Schedule. http://www.usmle.org/step-2-cs/#reporting
- National Resident Matching Program (NRMP). Results of the 2016 NRMP Program Director Survey. June 2016. http://www.nrmp.org/wp-content/uploads/2016/09/NRMP-2016-Program-Director-Survey.pdf
- National Resident Matching Program (NRMP). Charting Outcomes in the Match for International Medical Graduates. September 2016. http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-IMGs-2016.pdf
- American Council of Academic Plastic Surgeons (ACAPS). Plastic Surgery Residency Programs. http://acaplasticsurgeons.org/residency-resources/fellowship-programs.cgi
- Boston Children’s Hospital. Department of Plastic and Oral Surgery: Research and Innovations. http://www.childrenshospital.org/centers-and-services/departments-and-divisions/department-of-plastic-and-oral-surgery/research-and-innovations
- Plastic Surgery Research Council (PSRC). Mentorship Program. http://ps-rc.org/about/mentorship-program.cgi#
- Plastic Surgery Research Council (PSRC). Opportunities Board. http://ps-rc.org/opportunities/
- American Council of Academic Plastic Surgeons (ACAPS). Job Search. http://acaplasticsurgeons.org/jobs/
- American Association of Plastic Surgeons (AAPS). Annual Meeting. http://meeting.aaps1921.org/
- Plastic Surgery Research Council (PSRC). Annual Meeting. http://ps-rc.org/meeting/
- American Society of Plastic Surgeons (ASPS). Plastic Surgery: The Meeting. https://www.plasticsurgerythemeeting.com/
- Northeastern Society of Plastic Surgeons (NESPS). Annual Meeting. http://meeting.nesps.org/
- California Society of Plastic Surgeons (CSPS). https://californiaplasticsurgeons.org/
- American Society of Plastic Surgeons (ASPS). International Clearinghouse of Meetings Calendar. https://www.plasticsurgery.org/for-medical-professionals/resources-and-education/events/international-clearinghouse-of-meetings-calendar
- Association of American Medical Colleges (AAMC). Recommendations for Revising the Medical Student Performance Evaluation (MSPE). https://www.aamc.org/download/470400/data/mspe-recommendations.pdf
- Medical Board of California. Physicians and Surgeons. http://www.mbc.ca.gov/Applicants/Physicians_and_Surgeons/
- Apple App Store. Facetune. https://itunes.apple.com/us/app/facetune/id606310581?mt=8
- American Council of Academic Plastic Surgeons (ACAPS). AAMC Letter of Recommendation Form. http://acaplasticsurgeons.org/multimedia/files/Letter-of-Recommendation-Form-for-AAMC.docx
- National Resident Matching Program (NRMP). Match Week & SOAP for Applicants. http://www.nrmp.org/match-week-soap-applicants/