Choosing a residency program regardless of the specialty requires time and patience. In order to effectively research programs and decide if you could be a good fit for the program involves understanding the program classification or program type. 

Some programs begin in the PGY-1 year and are of one-year duration, some begin in PGY-1 and are of three, four, or five years duration according to the specialty, while others may start in PGY-2 and may be of two, three, four years according to specialty. 

Let us review the three main types of programs in detail: 

1. Categorical
2. Preliminary 
3. Advanced ​

Categorical Program:​​​

Categorical programs are those programs that provide COMPLETE training required to attain board certification in that specialty. The duration is dependent on the specialty.​​​

Image source: NRMP

Examples of categorical programs:
​Internal Medicine: 3 years 
Pediatrics: 3 years 
Family Medicine: 3 years 
Emergency medicine: 3 years to 4 years 
Pathology: 4 years 
Categorical Neurology: 4 years 
Categorical Diagnostic Radiology: 5 years 
General surgery: 5 years
Neurological Surgery: 7 years
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During this time, the applicant will have to meet the basic requirements for board certification in that specialty. Traditionally, this requires proficiency in the 7 ACGME core competencies (more details on the ACGME website), which include patient care, and professionalism, which are constantly evaluated and are required to be eligible for board certification. ​

Preliminary programs:​​​

For the purpose of discussion, these are four types:​​​

1. Preliminary Internal Medicine: Starts in PGY-1, a one-year program in various rotations within Internal Medicine. Preliminary Medicine provides the prerequisite training for advanced specialties like Radiology, Ophthalmology, Anesthesiology, Dermatology, and Neurology.
2. Preliminary Surgery: Starts in PGY-1, and it is a one-year program in various rotations within General surgery. Preliminary Surgery also provides the prerequisite training for advanced specialties like Anesthesiology, often Radiology and Ophthalmology, and even a pathway to categorical General surgery subsequently. 
3. Preliminary Pediatrics: Starts in PGY-1, it is a one-two year program which is very rare, and offered only by fewer than five programs in the country. They provide tracks to get into Neurodevelopmental disorders and Child Neurology. Needless to say, these are not feasible options for IMGs. 
4. Transitional year: This is a class of preliminary PGY-1 programs, which is also of a one-year duration that has various rotations in internal medicine, surgery, and other subspecialties. This also provides prerequisite training for advanced specialties like Radiology, Ophthalmology, Anesthesiology, Dermatology, and Neurology. ​

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Advanced programs:​​​

These typically begin at the PGY-2 level. Applicants must have completed the required preliminary training to be eligible for advanced programs. Examples: ​​​

Image source: NRMP

Match process for Prelim-Advanced programs: ​​​

Applicants must apply to BOTH the preliminary program as well as the advanced program for a successful complete match.​​​

Let us consider an example:​​​

An IMG is interested in becoming a neurologist. He/She has to apply to Preliminary Internal Medicine programs/Transitional year programs (PGY-1) and advanced (PGY-2 onwards) Neurology programs. The other option is to apply for Neurology programs that provide all four years of training at the same program.

The simplest way to think about this is: 
4 (Categorical) is also equal to 1+3 (Prelim IM + Advanced) 

Similarly, for Diagnostic Radiology 
5 (Categorical) is also equal to 1 + 4 (Prelim IM or Surgery + Advanced)

Now, this is a much harder process, because you have to match in both the Preliminary year and Advanced programs to have a complete match. 

Now, what if you don’t? Here are two scenarios (called Partially Matched) 

A. The applicant matches in a preliminary year but fails to secure a match in the advanced Neurology program that year. He/She has two options: 

• Apply to open advanced Neurology positions in SOAP (scramble) after the Match 
• Go ahead and start the Preliminary program and apply again for the Match the following year and apply to the ‘Physician Reserved’ Neurology positions.  

B. The applicant matches in the advanced Neurology program but fails to secure a match in a Preliminary year. He/She has two options: 

• Apply to open preliminary/transitional year positions in SOAP (scramble) after the Match. 
• If they do not find a PGY-1 position before the start of the academic session, the applicant will have to leave that advanced Neurology and will have to try again the following year. ​​​

Common pitfalls:​​​

Backup specialty: Many students use Preliminary year (prelim IM/surgery/transitional) as back up applications in case they do not immediately match the specialty of their choice. This gives the applicant a false feeling of safety in the event they go unmatched. 

• However, Preliminary positions, despite the clear abundance of these positions, are extremely competitive and are not meant to be backed up.
• These are meant for applicants pursuing Neurology and ROAD specialties and therefore, those who are interested in Categorical Internal Medicine will not be preferred for these positions. 

Applying both Categorical Internal Medicine and Preliminary Internal Medicine in the same program: Never a good idea. This gives a conflicting interest in specialties. This might result in the program rejecting your application altogether. However, applicants applying to Categorical General Surgery can also apply to Prelim Surgery, because it is a common track pursued here in the US. But for Internal Medicine, it is never a good idea.
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Matching into a Preliminary year/Transitional year without a plan for PGY-2: 

1. Try for advanced specialties the following year (through the ‘Physician Reserved’ spots). If you don’t have a competitive profile for advanced specialties, you will need to outline a plan in the limited time you have to create a profile in that direction. Our team at USMLESarthi can help you discuss your options. 
2. Moving to a Categorical Internal Medicine or Family Medicine program (from PGY-1 again). The problem with this is two-fold:
   1. ​Medicare funding is capped at a number of years for a particular specialty. For example, for Internal Medicine at 3 years, for Neurology at 4 years and so on. The clock starts as soon as you get into a PGY-1 program. So if you get into a prelim program, and then move to a PGY-1 Internal Medicine program, you are not eligible for full funding for the three years of IM training. You are eligible for only 2 more years of full pay (as you used one year for Prelim). So it is up to the discretion of the program whether or not to negotiate that funding issue. One way the programs have been known to deal with this is to split pay:   PGY-1: full pay PGY-2: half pay PGY-3: half pay
   2. In visa-requiring applicants, there is an additional obstacle, as ECFMG has explicitly specified in recent years, that they will not sponsor a repeat of the PGY-1 year. They encourage applicants to find a PGY-2 open position. 
3. There is yet another, albeit much less common pathway, that is to apply to open PGY-2 categorical internal medicine/family medicine positions, should they open up in the middle of the year when someone leaves the position or transfers elsewhere. This works mostly via contacts and word of mouth. Some forums have been known to provide this information. 

However, we at USMLESarthi, do not recommend applying to Preliminary programs without a clear idea of a plan of action for PGY-2. 

Visit our website or contact us for more information on how to create a specialty-specific CV and realize your dream specialty in the NRMP Match in the US.
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We wish you the very best in your residency journey!