Otolaryngology is a small surgical specialty that consistently attracts very bright and dedicated doctors. As a result, the residency positions are very competitive. It’s no secret that being a foreign medical graduate (FMG; also known as international medical graduate or IMG) and pursuing a match in a surgical specialty such as otolaryngology-head and neck surgery can be quite a challenge. Just look at the numbers reported by the National Residency Matching Program (NRMP) in their last annual report. In the last two matches (2013 and 2014) only 13 FMG applicants matched in otolaryngology. In 2014, only 7 of the 295 positions (2.4%) offered on the match were filled by FMGs—and these numbers did not even differentiate between US FMGs (who are US citizens with foreign MD degrees and hence have no visa issues) and non-US FMGs.

It is a well-known fact that FMGs are more prone to apply to “FMG friendly” specialties such as internal medicine or family medicine. So for all of you against these odds, congratulations. A lot of people drop out of the race before it even begins. However, if you truly feel that this specialty is what you want, there is no reason why you should not give it your best shot. Here are my two cents as one of those lucky few that made it:

1. The sooner the better
This means, basically, the sooner you realize in med school that you want to come to the US for training, the best you can prepare yourself to be a competitive candidate.

2. The work starts at home
Doing well in your medical school course is the first step to becoming a competitive candidate. Try to be on the top 10% of your class. But if it is too late for this, do not worry. One of the beauties of this process is that if you were not a rock star at your med school, you have a second chance: doing well on the USMLE steps scores. This is actually going to be the real measuring stick that reviewers will go by. Nevertheless, it helps to have good scores in your clinical rotations at home, as it will also make the USMLE easier.

3. Doing an away rotation, or at least an observership in a US program
An away rotation is a good reason to start working on your goal early. Go to the program websites, where you can find information about how to apply for an away rotation, just as a US med student would do. Keep in mind that some programs will not accept foreign medical students. You will probably have to pay some fees such as a malpractice insurance fee among others and fill out some paperwork. Some medical school will not have an official block during your curriculum for these rotations, so you may have to sacrifice 4 or more weeks of your vacation time for this experience. One of the reasons why doing an away rotation is so important is that as a visiting med student on an away rotation you will have the complete experience. You will see patients in the clinics, scrub in the OR, and help the residents. In contrast to an away rotation, an observership is something that you can do once you are already an MD. During an observership, you cannot have any direct patient contact. If you are at this point of your career, email the programs directly to try to set up an observership. Although not as good as an actual student rotation, it is the second best thing to do. The observership will give you a general idea about the environment and structure of a residency in the US and will also help you get a couple of letters of recommendations (LORs) from the chairman and/or program director. During your time there be sure to schedule a sit down with the program director and/or chairman of the department. It is good to get some advice from them and ask any questions that you may have. Since you are going to need at least 3 LORs for your applications, it would be ideal to actually set up 2 or 3 of these meetings/rotations if possible.

4. Letters of recommendations
Very strong letters of recommendation are crucial, especially for FMGs. It is one more tool to demonstrate that you are reliable, intelligent, and capable of becoming an excellent resident in otolaryngology. The challenge is to get good letters of recommendations from otolaryngologists from the US. These are the letters that you want in your application because the letter is not only proof that you are a good candidate, but it also shows that you have participated in otolaryngology in the US. This demonstrates that you understand the US medical system by having been exposed to it and having done a great job by acquiring a recommendation. It also shows that you were already able to adapt to their system! Of course, to get a recommendation you have to first meet people and participate. FMGs in the past have spent time in the US doing clinical or basic science research, participating in clinical electives or observerships, and/or volunteering on surgical mission trips. If you have already graduated or are late in pursuing an elective in otolaryngology, seek research opportunities or a surgical mission trip. Personally, I think that clinical research can ultimately be more helpful for residency application purposes because it allows you to interact with patients, which can add to show your ability to establish good rapport to the writer of the letter of recommendation you hope to obtain. Clinical research can also facilitate meaningful publications in a shorter period of time. Overall, research allows you to become part of the team and sets the environment for you to be able to meet more people in your department. If, on the other hand, basic science projects seem more attractive to you, my only suggestion is to not spend all your time in the corner of the lab running your experiments; be sure to know your lab mates, know about their projects, assist them whenever possible, and make sure people know about your projects. If you can wear ‘the team’s t-shirt’ and represent your lab proudly, then your experience will be very rich and fruitful – both for your publications and your application.

5. Ace the Boards
The mean USMLE step 1 and step 2 CK scores for US seniors who matched in otolaryngology in 2014 were 248 and 252, respectively. That means you also have to ace those exams. One difference is that most US applicants apply only with the USMLE step 1 score; they will usually take USMLE step 2 CK and CS after or during the interview period. While this works for them, it will not necessarily work for you for these two reasons: (1) Programs prefer (some even request) that by the time you apply you will already have (or will soon have) your ECFMG certificate. That means having passed USMLE steps 1 and both step 2 CK and CS. Passing all these exams shows residency programs that you are already ECFMG certified and can start your training on day one of your residency if you are to match in their program. (2) If by any chance you did not ace your USMLE step 1 score, getting a high score on USMLE step 2 CK will help a lot, since most programs will take into account the best of the two scores. So, be ready to hit those books.

How do you do well on the USMLE? Without a doubt you need to study hard. Some people start with USMLE 1 and others start with USMLE 2. This decision is merely a matter of personal preference. Most find that it works best to stick to no more than two books and prioritize answering question banks such as USMLE World QBank. Question banks not only help you refresh your memory, but also show you how questions and answers are phrased. Set a timeline and be sure to establish a plan of attack that includes a mock test at least 10 days prior to the date of your exam. Be open to the indications of the mock test result. If you don’t like the outcome, I strongly suggest you take your time and re-schedule your exam so that it will give you more time to raise your score. While you will hear stories of people being able to raise their score >10 points in a week, this is severely optimistic. The reality is that you may want to invest more time to get this step of the process done right.

6. Research, research, research
...research, research. If you have the opportunity to take part in a meaningful research project during your medical school years, take it. It does not matter if it is otolaryngology related or not, or if it is clinical or basic science (although the latter is generally preferable). According to the NRMP the mean number of abstract, presentations, or publications by US seniors who matched in otolaryngology in 2007 was four. For better or worse, research has more weight if presented at US meetings compared to national meetings in your country, or if published in a US journal. Consider investing one year after medical school doing a research fellowship in an otolaryngology program at the US. Doing a year of research is extremely important not only for the educational experience, but also because it gives you a chance to get yourself known, get some abstracts at some national meetings, or even produce some publications to improve your CV. One way to find these research spots is by emailing programs and asking if they have any positions available. A warning to keep in mind is that most of these positions come with small or no salary, but it is definitely going to boost your chances of matching in the future. In my case, I e-mailed about 60 people and ultimately received one reply back with an offer. So do not be discouraged; be persistent. Suffice to say if you get a research spot, work extremely hard on your project from day one. But don't stop there; you also have a great opportunity to become known by the program. One way you can do this is by going to grand rounds every week, journal clubs, or any other departmental activity. Besides being a great learning experience you will get to know the residents and faculty, and they will get to know you. Also make sure that one of your letters of recommendation comes from the principal investigator of your project.

7. Getting your application ready
Programs receive hundreds of applications every year and they only give around 10 or so interviews per spot. Once they are done choosing those lucky few, they close the gate. So send in your applications as early as possible. This means no more than 1 or 2 weeks after the initial application date starts. Another thing, and again this is my personal view: I know most of you would like to train in a "cosmopolitan" city such as New York, Chicago, Miami, or San Francisco, or in the so-called "top tier" programs. In order to increase your chances I would highly recommend applying everywhere you can. Applying to many programs is a big expense, but if you made it this far, don’t take any chances and think of the money you are spending as an investment. Be assured that standards of training are so high in surgical specialties such as otolaryngology that there really are no bad programs out there. You are going to get a solid training nearly anywhere you go.

8. Interview time
All the work you have put in over the past few years has been for this, the dreaded interviews. It is a scary feeling knowing that your first job interview is going to be in a foreign language. The key is to prepare yourself. One way to do this is to set up some mock interviews with your US mentor or research principal investigator (if you have one). This experience will make you feel more confident of your interviewing skills. As an FMG there are a couple of questions that are going to come up frequently during the interview trail. The most common one is about your plans after residency and if you want to eventually go back to your country or stay here in the US. Another common topic is questions about your medical school and if there are otolaryngology residency programs in your country and why you do not want to do your training there. So be ready to answer these types of questions since there are sure to come up at any point during an interview. Also keep in mind that this is your moment to shine. As an FMG, you have a unique background that may help you stand out from the rest. For example, you may have had to work as a general medicine doctor in the middle of the jungle for one year. So make sure to find a way to bring out these unique backgrounds in the interview.

9. Know the visa paperwork
Another thing to keep in mind is the visa options available for you. Again, you can find detailed information in the ECFMG website, but the standard visa is the J-1. People will ask you about this, especially regarding timeframes for when you would be able to get the visa (since the concern is that your visa won’t be approved, and then the residency spot is not filled). Ensure that the university/residency program works together with you to complete all the required information. While there are not many otolaryngology residency programs that have trained FMGs in the past, you can take a look at what other specialties within the university do to help FMGs secure visa and bring this up with the program if necessary. Usually there is a single international department that assists with all the visa related processes within a university, so it is good for people to learn that the path has been walked successfully by the university in the past.

Remember that otolaryngology programs are not used to dealing with visas and all the associated paperwork. They may ask you what your visa situations/options are. Be ready to explain this in a straightforward and simple manner. They may have the idea that is a complicated process but in reality it is not.

10. And last but not least
Try to enjoy the process. The positions are indeed limited, but someone has to fill the spots, so why not you?! In 2013, 6 FMGs matched into otolaryngology out of 290 available positions and in 2014, 7 of the 295 positions were filled by FMGs. As with everything in life, luck plays a big part of all this -- being in the right place at the right time. Stay positive, try your best, and good luck!