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Match Day: The Roadblocks International Medical Graduates Face

Article In Brief

Non-US citizens who are international medical school graduates face an array of challenges to pursuing neurology residencies in the US, including extensive qualifying exams, visa problems, language barriers, financial impediments, and a lack of understanding of the American training system. Those who ultimately matched shared the strategies and sometimes winding pathways that led them to a neurology practice in the US.

Would-be neurologists experience great joy and disappointment on Match Day as they vie for a limited number of residency spots in the US. Among those hopeful candidates are non-US citizens who are graduates of medical schools outside of the US—international medical graduates (IMGs)—who share a relentless drive and a fierce passion to train to become a neurologist in the US.

But often their paths are beset with extraordinary challenges—including extensive qualifying exams, visa problems, language barriers, financial impediments, and a lack of understanding of the American training system. Indeed, 32.2 percent of non-US IMGs who ranked neurology as their only choice did not match in 2020.

In Zoom interviews, Neurology Today spoke to several IMGs who did ultimately match to neurology, but not always directly and immediately after finishing medical school programs abroad.

Sonika Agarwal, MD, for one, ultimately found her way into a neurology program more than 10 years after finishing medical school, but her story and pathway to get there was anything but direct. After graduating and training in Ob/Gyn at the Institute of Medical Sciences at Banaras Hindu University, Dr. Agarwal specialized in maternal-fetal medicine at All India Institute of Medical Sciences in Delhi, finishing in 1999. She served as faculty there for over five years until her husband was offered a transfer to Toronto. In Canada, while pursuing the process of recertification as a physician she learned that permanent residency was a prerequisite for training.

Her sister, also an Ob-Gyn, persuaded her to move to the US and Dr. Agarwal began taking her United States Medical Licensing Examination (USMLE) in 2006. “I had little knowledge of the match process but applied to about ten programs in Ob/Gyn in 2007,” she said. Over the subsequent two years she re-applied to consecutive matches, while doing clinical “observerships” and working in clinical research. Among other hurdles, she encountered insurmountable visa problems. In the year 2009 she applied to over 100 programs but discovered that by then, more than 15 years post-med school graduation, she was left out of most interview pools. [Stay tuned for more of her story later.]

Nishanth Kodumuri, MD, who graduated from Osmania Medical College in Hyderabad, India, in 2015, had had a lifelong interest in neurosciences. He decided to come to the US to pursue training in neurology after successfully completing USMLE steps 1, 2, and 3. He was excited when he succeeded in attaining an elective rotation in the laboratory of Argye Hillis, MD, professor of neurology at Johns Hopkins University.

“I was 24, had never traveled to the West, and did not know a soul in the United States,” Dr. Kodumuri said, acknowledging that the odds for succeeding were slim. In 2016 when he ultimately entered the match, he fully expected to fail.

When Brian C. Mac Grory, MBBCh, BAO, MRCPD, was half-way through medical school at the University College of Dublin, he was granted a scholarship to do a two-month elective at the University of Pennsylvania. “Participating in basic pharmacological research was eye-opening,” Dr. Mac Grory said. “I was enthralled with the fact that one could do both clinical work and research in a career.”

The following summer he did sub-internships at the Albert Einstein College of Medicine and the Massachusetts General Hospital in general neurology. “By then, neurology was an easy decision for me,” he said. Dr. Mac Grory had taken step 1 and step 2 CK (clinical knowledge) of the USMLE, while in medical school and took two days off from his 2011-2012 combined medicine/surgery internship year in Ireland, to travel to the US to take step 2 CS (clinical skills). [The Federation of State Medical Boards and National Board of Medical Examiners, the organizations that oversee the USMLE, announced the discontinuation of Step 2 CS on January 26 of this year.]

“I took a full day of tests jet-lagged but felt fortunate that I was able to schedule the examination months in advance and navigate the economic burden, challenges that many students were unable to overcome,” Dr. Mac Grory said. “The costs of interviews for a neurology residency—both in terms of money and time—were so prohibitive that I was only able to come back for three interviews later that year in order to apply for the match, as I was also working full-time as an intern in surgery in Ireland during the interview season. Realistically, I gave myself less than a 20 percent chance of succeeding,” he said.

Nimit Desai, MD, had not had much clinical exposure to neurology while attending the MGM Medical College in Mumbai, India, so he traveled to the US to do his first clinical rotation in neurology in 2015 just prior to graduating. Over the next two years, he completed step 1 and 2 and ultimately got a rotation in critical care at Jackson Memorial Hospital in Miami where he completed step 2 CS.

“Just getting a rotation in any specialty is very difficult and time-consuming,” he said. There, he was introduced to the field of palliative care, which was revelatory, as it was not a well-established field in India. During that three-month shadowing experience, he was exposed to the neuro-ICU and stroke service. He applied to the 2019 match but was unsuccessful, having not known that he needed to start the process months earlier. He was accepted to a neuro-ICU rotation at Henry Ford Hospital in April of 2019, followed it up with a rotation in stroke at Marshall University in Huntington, WV, and neuroradiology and neuropalliative care at the University of Kentucky. This enabled him to qualify for a one-year research position under the mentorship of William “Bill” Tatum, MD, FAAN, at the Mayo Clinic in Jacksonville in 2019.

Mentorship Matters

Dr. Kodumuri also benefitted from a mentor. Working with Dr. Hillis, Dr. Kodumuri conducted research on the neuroimaging pattern of insular stroke and published a manuscript. The executive vice chair of the department of neurology and director of the cerebrovascular division of neurology at Johns Hopkins then introduced him to several colleagues. Based on her recommendation, he was able to secure a voluntary research position with vascular neurologist Souvik Sen, MD, MS, MPH, chair of neurology at Palmetto Health-USC Medical Group and member of the Prisma Health Stroke Center team. While spending five months in his laboratory, Dr. Kodumuri worked on several stroke epidemiology projects while attending interviews for a neurology residency, and ultimately matching in neurology at Prisma Health in 2016.

Dr. Mac Grory, who ultimately matched at Yale-New Haven Hospital in neurology in April of 2012, attributes his success in his early years to two Irish neurologists who had trained in the US: Professor Peter Kelly, MD, a stroke neurologist and the current president of the European Stroke Organization, who supported his application for the sub-internship at MGH between his fourth and fifth years of medical school, and Daniel J. Costello, MD, an epileptologist, who wrote him a very strong reference letter for residency, which he believes was instrumental in his getting accepted.

During Dr. Mac Grory's residency, David M. Greer, MD, FAAN, his program director, supported him through his applications for a fellowship at Yale-New Haven Hospital and his first attending job. “He has provided remarkable advice and support at all stages,” said Dr. Mac Grory, who also credits Joseph Schindler, MD, his program director during his subsequent stroke fellowship at Yale, and Lauren H. Sansing, MD, the academic division chief of stroke at Yale who encouraged and buoyed his aspirations to pursue clinical research, for their sponsorship.

When Dr. Desai was offered to work as a research trainee with Dr. Tatum at Mayo, he expected the position to primarily involve data collection and compilation. However, under Dr. Tatum's mentorship, he was given the opportunity to participate in clinical trials, surgical case conferences, poster presentations, and feel like a member of the team.

“As much as I gained from him professionally, I gained on a personal level. Dr. Tatum was always welcoming and approachable,” said Dr. Desai. “No matter how busy he was with his clinical and research responsibilities, Dr. Tatum would always make time to listen to my concerns and provide help when needed,” he added. “Under his auspices, I was able to learn about epilepsy, a career in neurology, clinical practice, and life in general. In retrospect, Dr. Tatum's support and counsel was crucial in keeping me motivated and pushing me towards my goals.”

Visa Problems

In 2019 while a third-year resident, Dr. Kodumuri returned to India to visit his fiancée and family and found himself unable to return to the US due to J-1 visa delays. (The J-1 visa is a non-immigrant exchange visitor visa often used by non-US citizen IMGs pursuing residency or fellowship training in the US. It allows holders to remain in the US normally for up to seven years, until they complete their training.) Although he had been invited to interview at 17 of 22 stroke fellowship programs, he missed those opportunities due to four months of visa delays. Fortunately, he was offered a fellowship at Prisma Health/ University of South Carolina School of Medicine upon his return.

Dr. Kodumuri spoke to Neurology Today by video link from Hyderabad where he was once again in India while awaiting J-1 visa review. He had traveled there to get married in December after a four-year long-distance relationship with his wife, who graduated from medical school in his class. When he returns, he will complete his final eight fellowship blocks and has accepted a position as an attending physician at Prisma.

Figure

“The costs of interviews for a neurology residency—both in terms of money and time—were so prohibitive that I was only able to come back for three interviews later that year in order to apply for the match, as I was also working full-time as an intern in surgery in Ireland during the interview season. Realistically, I gave myself less than a 20 percent chance of succeeding.”—DR. BRIAN C. MAC GRORY

Figure

“I realize now that becoming a child neurologist was my destiny all along. My journey was not an easy one, but it gave me perspective on the value of the American dream and reinforced my belief in the Indian philosophy of karma.”—DR. SONIKA AGARWAL

“[Getting] a J-1 visa is very challenging,” Dr. Mac Grory said, explaining that it needs to be renewed annually and one of its conditions is that the holder will return to their country for two years after training before applying for an H-1B visa to re-enter and work in the US. “One way around that is through the Conrad 30 waiver program, which allows each state's health department to request J-1 visa waivers for up to 30 foreign physicians per year.”

Dr. Mac Grory's mentor, Dr. Greer, had introduced him to Karen L. Furie, MD, MPH, the chair of neurology at Brown, who provided him with his first job out of training. Because he was working under the terms of a Conrad 30 waiver, he was only permitted to submit his H1-B visa application in April 2017, a visa that takes about nine months to process by US Customs and Immigration and would have not allowed him to work until January 2018, a full six months after completing his training.

“This was a well-established problem, so physicians used a provision within the law called ‘expedited processing’ in which the visa could be processed in three months,” Dr. Mac Grory said. But after he had accepted the position, a change in immigration law created difficulties for him and other IMGs: the provision was suspended in early 2017.

“In order for me to start my job at Brown on time, Dr. Furie and her team reached out to the office of Senator Jack Reed in Rhode Island, and he wrote a letter requesting a specific exemption be provided to me so that I didn't go through the full nine-month waiting period,” he explained.

As he was scheduled to get married in Ireland two months after fellowship, this would have meant leaving his wife in America in June (she is a US citizen, a psychiatrist and a current MBA student), getting married in August. and then not seeing her again until the immigration situation was resolved.

“I consider myself very, very, lucky to have met such supportive people who have helped me along the way,” said Dr. Mac Grory, who began working on the faculty at Duke University in 2020.

Paying It Forward

“It is getting harder and harder for IMGs to secure residency spots in neurology, especially so due to the longer lag between application and medical school graduation,” explained Dr. Kodumuri, who believes it is his responsibility to now mentor other IMGs on the process including what to expect during interviews. “I advise them on how to write a compelling personal statement and how to search for experience in the US that will help with networking and making personal connections,” he said.

That is how Sruthi Konduru, MD, was introduced to him in 2019. Both physicians had sought the help of USMLE Sarthi, a professional organization that guides residency applicants from over 32 countries and introduces new candidates to mentors who succeeded in the process. Dr. Konduru, who graduated from JJM Medical College in Davagere, India, in 2014, moved to Madison, WI, two years later after completing step 1 and step 2 CK.

“It was very hard to find neurology rotations, so I found a research position at the University of Maryland studying diabetic neuropathy for eight months,” she said. She applied to the match in 2018 and was only asked to one interview. In 2019, she reapplied, and although she went on four interviews, failed to match again. The following year, Dr. Kodumuri helped review her applications and personal statement, and did several mock interviews with her.

Finally, Success

By the time Dr. Desai applied to the match again eight months into his research year, he had secured 19 interviews at neurology programs. He is now completing his first-year internship in the Medical University of South Carolina in Charleston. “Perseverance was key,” Dr. Desai said, adding, it is critical to keep working towards a goal.”

Dr. Konduru, who is currently, a PGY-1 at Wayne State University, successfully matched in neurology last year. She credits Dr. Kodumuri's coaching as well as her research mentor, Rama Maganti, MD, for his support which included a mock interview session. “I wish I had spent time before graduating getting hands-on experience or later securing observerships,” she said, “but I was grateful that I succeeded because of having done research.”

Ultimately, the research also paid off for Dr. Agarwal as well. In 2009, Dr. Agarwal was hired to manage large multicenter research trials at the MD Anderson Cancer Center. All along she had also been spending time raising her son who had been born with cerebral palsy and hypoxic brain injury. Having established care for him in the developmental and pediatric divisions at Texas Children's Hospital, Dr. Agarwal was impressed by the faculty there who encouraged her to look at the child neurology and developmental disabilities program at Baylor. In 2010, she accepted an NIH-funded post-doc fellowship in health services research and policymaking at Rochester University and resigned herself to a research career track.

“I promised my family that 2010 would be the last year I applied,” recalled Dr. Agarwal, adding, “I applied to three specialties, including child neurology, sending out 80 applications.” That year she successfully matched at the Texas Children's Hospital neurology/pediatrics program. Her visa problems had been solved by 2009 when she worked with an immigration attorney to file for a green card in the EB1A (extraordinary ability in science category) and ultimately became a US permanent resident later that year.

At Baylor, she was mentored to develop a niche in fetal and neonatal neurology and served as faculty after training. She has been on faculty at the Children's Hospital of Philadelphia for the past two and a half years.

“I realize now that becoming a child neurologist was my destiny all along,” she said. “My journey was not an easy one, but it gave me perspective on the value of the American dream and reinforced my belief in the Indian philosophy of karma.”