On 15 September 2013, thousands of doctors and doctors-to-be will flock to the Electronic Residency Application Service (ERAS) website to apply for a residency position in the United States. As this date is approaching, I can see both excitement and apprehension on the faces of prospective candidates. Most of the candidates that I know are foreign medical graduates (FMGs). For them, the process to get into a residency programme in the US is different in many ways from the pathway for graduates from US medical schools. The application submission is only one step in the long process that begins years before it. At this juncture, I cannot help remembering my own journey through the process that landed me here in the US.

Most medical students in Nepal start to think about pursuing a career in the US when they are in the final years of their medical school. There are a lot of things to consider. What you wish to specialize in is probably one of the first things to consider. Radiology, dermatology, orthopedics, ophthalmology, ear, nose, and throat specialty, and any surgical specialty is difficult, if not impossible, to get into for most FMGs as these are usually filled by US graduates. Internal medicine, pediatrics, family medicine, and pathology are probably easier to get in to.

Another thing to consider is the cost of the process. The United States medical licensing examinations (USMLE) are expensive. Then there is the cost of travel to the United States, the cost of living here, and the cost of applications. I spent around $10 000 on the whole process. Many doctors in Nepal work for a year or two to earn this sum before considering coming to the US.  I worked for a year, but did not make enough and ended up asking my parents for help.

The most important thing to consider, in my opinion, is whether you are prepared to leave your friends and family to spend the next three years or more in a new country. When we are in the process of deciding, we are surrounded by our loved ones and it is easy to overlook this fact. I did not realise how much I would miss my family and friends until I came over here. I use Skype and Facebook, but there is nothing like spending time face to face.

After deciding to pursue a residency in the US, then comes extensive preparation for the USMLEs. In Nepal we are not used to taking tests like the USMLEs. Also, the epidemiology of diseases that we see in Nepal are very different from those in the US. Most of us in Nepal spend around six to eight months reading before taking the USMLEs. It is said that most US residency programs use USMLE scores to screen the applications from FMGs. Hence, all FMGs spend a great deal of time preparing for the exams to score as high as they can.

One of the most daunting exams for FMGs is the USMLE step 2 clinical skills examination. This examination, in addition to testing for competency in clinical skills, also tests for communication skills and spoken English. The real challenge for FMGs during this exam is to ditch their accents and pronounce words in a way that is understood by most Americans. This exam can only be taken in the US. For FMGs from countries like Nepal, obtaining a visa to come to the US is a challenge. Many prospective candidates have to terminate their US residency dreams because they cannot get a visa.

Finding a place to live in the US can be a challenge. It is expensive. Also, it is difficult to rent a place without a social security number. In addition, the application and interviews take months. Most applicants from Nepal board at the houses of their seniors from medical school who are already doing a residency in the US. It is a tradition that has continued for years. This saves a lot of money for the applicants and also makes them feel at home.

By the time the candidates apply for a residency position, usually a year or two has passed by since they began their journey to get into a US residency position. After this the process is more streamlined. Candidates are invited for interviews by programme directors and ranked accordingly. Match day is an important day for everyone. It is the day where candidates find out whether they have been matched into a residency position or not. For many, this is the day that ends in celebration of all the hard work and time put into the process. However, for almost 50% of the FMGs, this is not the case. Many of these FMGs decide to quit the US residency pathway at this point. Others will come back another year for another round of interviews.

The whole process of trying to get into US residency is long, expensive, and tiring for many FMGs. There are a lot of debates surrounding the issues of FMGs beginning with the issue of “brain drain.” I will discuss those issues on another day. For now, I would like to wish all the applicants the very best. For those who are considering embarking on this journey, I will leave you with what my mentor, Buddha Basnyat, said to me when I asked him about doing my residency training in the US: “Make sure this is what you really want to do, and this is not just a blind commitment to the goods of this world.”

Siddhartha Yadav is a former BMJ Clegg Scholar and a third year internal medicine resident at William Beaumont Hospital, Royal Oak, Michigan.