By Tarek Haykal, MD
Hematology and medical oncology has become, in recent years, one of the most competitive internal medicine subspecialties in the United States. And while it became competitive overall, it has become more specifically so for international medical graduates (IMGs).
My journey started when I graduated as an MD in Lebanon, my home country, a few years ago. Like many IMGs, I matched in a community program in the US, and was quite content. It was what they call an “IMG-friendly” program. But since my arrival to the US, my ultimate goal was always to match in hematology and medical oncology.
Unfortunately, in the current day, it is no longer an easy process for an internal medicine resident to match in their desired specialty, especially in competitive ones, without a list of qualifications and requirements that need to be met before you even attempt to apply. A great love, respect, commitment, and desire for the wanted specialty is surely not enough.
I have increasingly known that hematology and medical oncology has become competitive, but not to the level that I have seen when I first started training in the US. Learning that applicants must fulfill all of the requirements on increasingly long checklists when applying for specialties was quite a shock for a foreign medical graduate.
Many of my co-residents in the classes ahead of me did not match in hematology and medical oncology; those who did match in the specialty almost never matched in their desired programs. The only match success stories I saw were in less competitive specialties. I have seen, over and over, many IMGs compromising on their desired specialty and settling for a less competitive one because of the tremendous barriers in the way of reaching their goals.
Many things are required nowadays to make your application stand out. I personally believe that the first and foremost important thing is research, research, and more research. Unfortunately, this is a challenge for many IMG residents—for some, research is not the type of work they are interested in doing, or the extra effort required to be involved in research activities is an obstacle. Other IMGs don’t have the opportunity presented to them, and some lack the skills and knowledge needed to achieve a strong research portfolio.
While research is one of the main determinants that reflects an applicant’s potential and competitiveness, other factors definitely play an important role as well, such as volunteer experiences (which are always limited in community programs) and letters of recommendations from prominent faculty in the field (which are often absent in smaller residency programs). To compensate for these deficiencies, foreign graduates may seek away electives in larger university institutions or try to join various committees, if any exist in their program or hospital.
Another important factor is visa status. An IMG cannot apply for the majority of grants in the US. Most foreign graduates who match in the US today are on J1 visas (a form of exchange student visa) and don’t qualify to receive any payments outside of their program’s salary, which makes IMG candidates unattractive to top-tier programs that mostly depend on grant funding. I was told by many programs that I can’t moonlight like the rest of my colleagues because I am on a visa, I can’t be on an institutional T32 because I am on a visa, I can’t have the easy liberty of applying for jobs post-fellowship, especially in academic institutions, because of the visa…
Another major problem for IMGs in community programs is that they are often overlooked or filtered out by many fellowship programs. That can be hard for some foreign graduates, especially the ones that have worked hard to achieve their career goals. For IMGs applying for a competitive specialty, their main goal is to first match—it does not matter where. If you are lucky and have enough interviews to have an actual choice, then you could maybe consider your options.
I, personally, have been lucky, and I have done a lot in the 2 years of residency prior to applying to one of the most competitive specialties. I had quite a few publications cited on PubMed and many abstracts selected and presented at ASH, ASCO, and NCCN annual conferences, in addition to many volunteer opportunities at my hospital. I also completed a 1-month elective in the Leukemia Department at M.D. Anderson Cancer Center, where I worked closely with world leaders in the field. I was lucky to have had a great letter of recommendation from them. My goal was to make sure I mastered all the requirements needed to become an appealing applicant, especially when I have many factors that I could not change about myself (visa and IMG status, my medical school, my residency program, country of origin…).
Learning from the prior experiences of colleagues in my program who have gone through the specialty match, I applied broadly. I had no idea how competitive I was as an applicant, nor how my application would be received, so I knew I needed to take a very wide and open-minded approach. I applied to almost all combined hematology and medical oncology programs in the US. I received a significant number of interviews and I was waitlisted in many more. I interviewed in all different places, from large university systems to small community programs. I interviewed in the pre-COVID era, when one had to travel in person, which took significant resources. I ended up almost bankrupt and burnt out by the time I finished my last interview.
Unless you have been in our shoes, it is hard to relate to the paranoia of an IMG going through the process of applying to a highly competitive specialty. The feeling of imposter syndrome weighs on your shoulders and makes you feel unworthy of where you are, even though you know deep down that you have worked tirelessly to get there.
Now that I have matched at my dream program, in my dream specialty, I began to understand the process even more.
IMGs often see my name on the fellowship website and email me to ask about my experience and how I managed to accomplish what I have. My simple answer is always, “I am the second IMG to ever match in the program, and the only one to match in the last 20 years.” By simply saying those few words, they understand that I am a rare exception. I am grateful every day that my fellowship program has looked at my potential and capabilities, beyond my IMG status, residency program, and visa status; however, I continue to remain a rare exception among top university programs.
IMGs should be seen for who they are as doctors and as people, rather than as a visa status, a pedigree, or an application. The system needs to treat applicants more fairly and holistically, beyond a checklist that needs to be met. Until then, I tell all fellowship applicants, especially foreign graduates, to work hard, persevere, and never give up. While it is a rocky road ahead, your success will always be heard and you will always reach the path destined for you.
Dr. Haykal is a second-year hematology and medical oncology fellow at Duke University. He graduated from medical school in Lebanon and conducted his internal medicine residency at Hurley Medical Center/ Michigan State University. He aspires to become an academic clinical researcher and trialist, focused on the care of patients with solid tumors by studying and applying innovative immuno-oncology and targeted therapies. Disclosure.