In this study of 744 IMGs applying for the 2022 residency match, we found that younger age, higher USMLE scores, higher-income country of origin (including the United States), fewer match attempts, applying to fewer specialties, having parents with college degree or higher, and coming from higher-than-average or lower-than-average family income were associated with increased odds of matching. Gender, personal income, and visa status did not demonstrate significant associations with residency match.
According to the NRMP in the 2022 residency match 5,048 US IMGs and 7,864 non-US IMGs submitted rank lists [2]. Thus, surveys for this study were sent to 38% of all IMGs who applied to the 2022 match with 5% of all IMGs participating in 2022 residency match responding. To our knowledge, only a limited number of studies focusing on IMGs residency match exist. Most of the data comes from the annual NRMP report.. This information is limited to data such as USMLE scores, research publications, work and volunteer experiences, and number of specialties applied. There are, however, papers focusing on specific economic and cultural challenges of IMGs demonstrating that IMGs from more developed countries match to more competitive specialties and residency programs [13, 14].
Our study cohort had a higher proportion of successfully matched applicants (87.3% of US IMGs, 70.5% of non-US IMGs) compared to the total population of applicants per the NRMP which reported a match rate of 61.4% for US IMGs and 58.1% for non-US IMGs in the 2022 residency match. Similarly, our rate of match to the preferred specialty was higher with 68.9% of US IMGs and 63.8% of non-US IMGs matching to their preferred specialty compared to the 2022 match rate to preferred specialty which was 54.8% for US IMGs, 53.5% for non-US IMGs [2]. Despite these differences, we still had a substantial proportion of unmatched non-US IMGs which allowed us to perform a multivariable analysis of factors associated with matching. Other than a higher match rate in our cohort, the rest of the reported variables, including Step scores and percent of female applicants, were similar to national average based on the NRMP data. This suggests that the data likely can be generalized to the other residency programs in the US. Our analysis of US IMGs was limited due to the small number of unmatched applicants in our cohort. Findings demonstrated that graduates from countries with high or upper middle income were more likely to secure residency position, and applicants with at least one parent with a college degree or higher were more likely to match to a program listed in one of the top-3 spots on their rank list.. IMGs from higher income families were also more successful in residency match. This supports our theory that IMG applicants from higher socio-economic backgrounds were more likely to secure residency positions even when accounting for other variables. Higher socio-economic status is also associated with medical school matriculation among American medical students. A 2018 AAMC study of 126,856 1st year US medical students from 1988 through 2017, the top two household income quintiles contributed between 73 and 79% of all US medical school matriculants each year. Interestingly, matriculants in higher-income quintiles were also more likely to be children of parents with at least a bachelors degree [5]. Regarding parental education, there are similar findings among US medical students. In 2022 only 21.5% of US medical school matriculants had parents with less than a college degree [15].
Our study did also demonstrate an association between being from a lower-than-average income family with higher chances of matching. While this result seems to contradict another finding of our study, it is possible that both are true. Admittedly it is very difficult to compare between residents of different countries since family income is self-reported and potentially subjective. However, with an increasing focus on diversity, resilience and grit in the residency selection process, applicants from lower-income families may have an advantage in demonstrating these qualities. The true association between family income and residency match success requires further study.
Per our data, age was significantly associated with chances to match, match to preferred specialty, and top-3 programs. Younger applicants do better in all three outcomes. The average age of a first-year medical resident in the US is 29.8years [16], the average age of matched IMG in our dataset was similar (28.9years).
In addition to the finding of applicants from higher income countries being 66% more likely to secure residency position, there is another observation. Approximately 10% of the worlds population comes from low-income countries [17]. Among our non-US IMG respondents only 5.7% reported being from a country classified as low-income by the World Bank. This underrepresentation could be due to financial barriers faced by these applicants.
There are programs in the US medical education, such as VSLO (Visiting Student Learning Opportunities) which charge different annual fees depending on a countrys income level [18]. The ECFMGs fees, however, are the same for every IMG. The fees are lower for IMGs residing in the US because they do not pay an international surcharge for the USMLE exam administration. In addition, USMLE examinations are less likely to be available in low-income countries, requiring applicants from these countries to travel internationally to sit for each exam which further increases the relative cost of the match for them [17]. The COVID-19 pandemic likely widened the gap between IMG applicants from different countries even more, starting with economic damages disproportionally affecting low-income countries and ending with new regulations complicating international travel especially for nationals of countries where Western vaccines are not readily available and those requiring US visas [19, 20].
We found that the increased number of specialties applied to was associated with a decreased odd of matching. This finding is consistent with NRMP reports demonstrating that applicants applying to a higher number of specialties have lower chances of matching. This finding may be due to residency programs perceiving applicants with multi-specialty CVs as having lower commitment to any given specialty. Alternatively, applicants applying to more competitive specialties are more likely to use less competitive specialties as a secondary option. Further specialty-specific studies are needed to analyze these findings.
Visa status was not associated with odds of matching. This is likely because our institution sponsors all types of visas for IMGs, however, this finding may not be generalizable to other institutions where only particular types of visas are sponsored.
To improve access to US graduate medical education for international applicants from lower socio-economic backgrounds, consideration of a sliding scale payment system for the variety of fees associated with the entire process could be introduced. Additional studies are needed to survey larger number of international applicants regarding the financial barriers they experience to entering the US graduate medical education system prior to developing this type of system.
Based on our data, any IMG applying to the NRMP would be advised to put their absolute best application forward the first time rather than taking a shot and seeing how they fair. Age was also a significant predictor of match success so waiting many years to apply could offset some of the gains in other areas. For those applicants who are further out from their primary medical training, they may need to find additional ways to connect with or highlight their value to programs to demonstrate how their prior experience is an asset and not a liability, since our data suggests a preference for younger applicants. We acknowledge that this finding could be the result of older applicants having more attempts due to weaker applications within our data set. It is also possible that applicants from lower socio-economic backgrounds are not able to apply shortly after medical school graduation as they might need to work for several years to be able to afford the USMLE and NRMP cost.
This was a retrospective study in order to comply with ERAS policies. Our response rate was relatively low at 15.13% but does represent 5% of all IMGs applying for 2022 residency match. This is still a relatively small sample compared to the number of IMGs applying for residency match each year. An unmeasured confounding is a potential limitation of this study. Due to difficulties with comparing socio-economic characteristics of people from different countries, we had to use subjective variables such as personal perception of the participants of their level of income growing up in comparison to other families in the same city. The match rate of our respondents was higher compared to the total population of applicants per the NRMP which could represent self-selection bias. There is a small chance all associations identified were due to statistical error.
We used contact information provided by the applicants as a part of NRMP. Based on our sample, more than 1/3 of all IMGs applying that year applied to our institution, they also likely applied to hundreds of other programs, and therefore, we do not believe that competitiveness of our institution was a significant limiting factor of this study, although it is a possibility.
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Relationship between individual and country-level socio-economic background, USMLE step scores, and ... - BMC Medical Education
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