What I know now that I wish I knew then

Jens Urs Berli, MD, is an International Medical Graduate from Switzerland who trained at the Johns Hopkins School of Medicine in Baltimore. He's an associate professor as well as Residency Program director at Oregon Health & Science University. His clinical focus is Gender Surgery.

As an International Medical Graduate (IMG) and program director in a U.S. plastic surgery training program, I've had personal experience finding my path into a U.S. residency and I've witnessed the journey of many of my IMG colleagues. It's fair to say the road to becoming a successful plastic surgeon in the United States is not straightforward – and can be long, winding and lined with obstacles. Here are the things I learned along the way that may prove helpful to other IMGs.

Mentorship

Find an IMG mentor who's gone through the same process and is well-connected. Even though every international student has a unique story, an IMG mentor can help highlight the aspects of the application process that are the most important and pertinent to foreign graduates. Sometimes the answer you may get is not what you want, but it's important to be realistic about your chances and havea backup plan. While perseverance and hard work has led many IMG to their dream career, it also has led some to a long and disappointing detour.

As program director, I review many national and international graduate medical student applications. Some of the most important things for IMGs to focus on are:

• A U.S. mentor who's genuinely advocating on your behalf is probably the single-most important factor in a successful application.Trying to apply remotely for a U.S. residency will most likely not be successful. The U.S experience can mean observerships, clinical elective rotations, as well as research and conferences. Be aware that you may be allowed to do elective rotations as a medical student, but not after you graduate. Further, some programs require completion of at least USMLE Step 1 prior to your rotations. When deciding upon the laboratory at which to undertake your research, do your due diligence and evaluate the faculty's track record, funding, prior students' experiences and the fate of prior IMGs.
• When applying for residency, evaluate which programs have previously interviewed and matched IMGs and are therefore "IMG friendly."
• A letter of recommendation alone won't be sufficient. Ideally, the letters you submit will offer comments on both your academic and clinical abilities.

Keep an open mind

As an IMG, your most important feature should be an open mind – and be flexible when it comes to planning. If you've determined that you want to take a certain path, you have to understand that achieving your goal may take some luck and may require you to take a couple of unexpected turns prior to arriving at your final destination. Many roads lead to becoming a plastic surgeon in the United States; plastic surgery is one of the most competitive specialties to match, and very few IMGs match directly into a categorical integrated plastic surgery residency.

However, there are other tracks to consider. You could complete general surgery and match into an independent plastic surgery program. This route often involves a preliminary general surgery position for one to two years, with the hope of finding a categorical general surgery position. During that time there's also a chance that a categorical plastic surgery position may open up as programs expand (this happened to me). If you do match into a categorical general surgery residency and apply for the independent track, you do need to be aware that programs are currently downsizing the number of independent residents they match every year. Therefore, it's unclear how many positions will be available by the time you're eligible to apply. It's also a very long road. Here's the advice I would give anyone going that route: They should be willing and motivated to pursue other surgical specialties should they not match into an independent position. You don't want to spend a long, difficult residency in general surgery if you don't find joy in that specialty. General surgery should not be a means to an end – otherwise, you most certainly will not perform to the best of your abilities, and you will face a very difficult time.

As noted, preliminary general surgery positions will help you start your training in the United States and allow you to later pivot to plastic surgery. It also gives you a good foundation in surgical patient management and a skillset that you can use wherever your journey takes you. For preliminary general surgery positions, find a program that's invested in preliminary residents and work hard. Ideally, the institution you choose has a plastic surgery program, and you can always work to find a mentor in that program during your time on general surgery. You're also most likely to stay at the institution where you complete your preliminary year, so choose wisely.

Lastly, make sure you have a backup plan, in case you cannot train in the United States. You may consider doing an internship in your home country prior to leaving for America, in order to stay plugged-in and connected.

Understanding visas

The importance of understanding visas prior to accepting a position in research or residency as an international medical student cannot be stressed enough. Many students – and even residents – have been forced to end their U.S journey early due to visa-related issues that might have been avoided with careful planning. Contact your local embassy and an immigration lawyer to understand the exact rules your home country requires you to follow.

Be aware that a J-1 has a homecoming requirement of two years. (Before a J-1 person with a two-year home residency requirement can change to nonimmigrant status or adjust to U.S. permanent resident status, he or she must either return to the country of last residence for two years or obtain a waiver of the two-year home residency requirement.) Waivers for this exist, but you may be required to work with an underserved population after you complete your residency – which can have geographical implications for you and your family. Be sure to ask about these points prior to accepting a visa.

Final thoughts

The decision to immigrate to the United States for surgical training has been the best professional decision I've made. Yes, it came with a lot of uncertainty and there was always a door that opened – but in my case, and in many other IMG's cases, it wasn't the door I expected. Keep an open mind, have a backup plan, work hard and, most of all, have fun while doing it. Make friendships.

Dr. Berli and Dr. Gfrerer are both international medical graduates.