Pathology FAQs for IMGs

Why is Pathology becoming easier for IMGs?

Pathology is getting more IMG friendly by the day. The job market for Pathology in the US is not that great. It is important here to understand that the definitions of a “good job market” differs between an AMG and an IMG. For an AMG, a good job market is defined as high-paying initial jobs (>300K) in tier 1 cities or near their hometown or any other location with temperatures above 700 F during most months of the year. Understandably, these locations are already saturated and more often than not the AMG pathologists have to relocate to places they do not want. In addition, Pathology is a high-end service and by its inherent nature requires one to subspecialize. It means that AMGs have to wait for one more year to start paying off their huge student loans.  AMGs are increasingly staying away from Pathology residency which is obvious from the recent NRMP stats that shows that 65% of Pathology residency positions are filled by IMGs (both US and non-US combined). Most IMGs are okay with the current job market and are having no problems in finding jobs because most of them are very flexible on geographic location as well as initial salaries.
In addition, the US programs have had very good experiences with IMG residents. Most places have one or two IMG “STAR” residents who had finished their residencies in their home country and are way ahead in the game compared to their peers. These positive experiences have opened new avenues for IMG applicants.

Why do Pathology programs do visa easily?

​On the contrary, there are only a few programs (15-20) that sponsor H1b visa. Like I mentioned, Pathology is a high-end service and most community hospitals are not well-equipped to start and maintain the infrastructure required for a Pathology residency program. This leaves mostly the big university programs that do not sponsor H1 visas even in other specialties. However, it seems like the J1 visa rejections for Pathology programs is much lower as most of these programs are well-known universities with great rapport. So most Pathology programs sponsor a J1 visa and this is problematic because the number of waiver jobs is limited in Pathology compared to the primary health care specialties.

Is Home country residency in Pathology a ticket to bucket-load of interviews and confirmed match?
Home country residency is the definitely the best credential to have in your profile if you are applying for Pathology residency match. The impact is almost equal to having three good USClinical Experiences (observerships are considered USCE in pathology). However, home country residency alone is not “a ticket” as such. It has to be complemented with either of these credentials:

1. Scores above 240, or
2. 3, 1-month observerships with good letters
3. Long-term research in Pathology + 1/2 observerships
4. Exceptional research background in Pathology
5. Rare, hands-on Pathology experiences in the US (available only to GC/citizens), like Pathology assistant positions, post-sophomore year fellowships that go empty could be filled by IMGs
6.  A related graduate degree from the US, like PhD. in Pathobiology, Immunology, microbiology, biochemistry etc.

Any of these combined to a home country residency increase your chances of the match. The more credentials you add, the more the numbers increase (apparently as high as 41 is documented  ) but it also depends on how many programs did you apply to. There are 150 odd Pathology programs and almost 120 of them sponsor J1/H1 visa. 70-80 is a safe number to apply to.
what about scores requirements. Is Step 3 almost a requirement like it has become in Psychiatry?
As I mentioned earlier, scores are not independent factors for the Pathology match. Neither is a longer YOG. Step 3 is an absolute requirement only at those 15-20 places that sponsor H1b for the simple reason that they feel safe to start the H1 process with already completed Step 3. A few programs even cancel the offered interviews if the Step 3 is not finished but they are few rare ones.  Finishing Step 3 before starting the residency is universally advised by all program directors as Pathology as a specialty is completely unrelated to the contents of the Step 3 examination and unlike an IM/Peds resident, it becomes tougher than easier for a Pathology resident to remember the clinical stuff as they progress in their residency programs.

​How important is USCE/Research to Match? How should an IMG WITHOUT home country Pathology experience or residency plan it?

I feel US Clinical Experience is more important than research.  USCE makes the students more acquainted with the practice of Pathology in the US compared to research which is mostly bench-work. Moreover, the letters of recommendation obtained from a daily sign-out session are more residency oriented while the research letter may make you sound more like a Ph.D. applicant. In pathology ( and in all other specialties IMO), research should only be sought after if you have finished at least 3 observerships of 4 weeks each and secured 3 US letters for the sign-out experience.
Most applicants are home country trained in Pathology but there are about 30-35% young graduates applying directly after medical school. Also, there are many applicants who apply to Pathology only as a backup to Internal Medicine. In addition to the IMG pathologists, even the other two categories can match if they get those above-mentioned 3 observerships and manage good letters. Compared to trained pathologists who usually do observerships as a colleague to the junior faculties and do really good in their rotations, the other two categories of students do not seem to match. However, this game is totally fair. There are many programs that prefer only young graduates with good scores. Also, there are many programs that entertain all kinds of applicants. In the words of one PD during the interview season, ” Do not think that because 3 out of the 6 of you are already trained pathologists, the rest of them are already out of the race. We have called you for an interview as we know that each one of you is special in your own way. While half of you are vastly experienced, the other half has great scores and are young and we need both kinds of residents to make our program rich”.
An inexperienced medical student in a Pathology rotation can still get a good letter of recommendation. They need to be sincere and show up in time. Dress well and behave well with the techs/residents/fellows/attending.  A golden tip is to accept that you know nothing and ask doubts. If an attending shows you angiosarcoma, for example, go home and read up about angiosarcoma at night, come back again with few genuine doubts and discuss with the resident/fellow (to make sure you are not asking something silly) and then ask them those questions. Not only does this show that you were attentive during sign-out but also that you were interested and went home to study all about that one topic and now are willing to share the information and ask doubts. You don’t have to be a good pathologist to be a pathology resident, you have to be a good and sincere student (this should apply to all specialties).
You have to try and understand what kind of people are they looking for and see if you fit. Pathologists are clichéd to be the doctors who do not interact with people but it is not true in reality. Although we do not talk to the patients usually, we do talk to the clinicians all the time. If you come across as someone who could express themselves well over a phone call, an academic discussion, or in a written format (for example this entire write up be me  ), you are a personality that would fit well in a Pathology department. Pathology is all about how well you communicate what you see to the clinicians. Communication skills are very important both to do good in a rotation as well as during your interviews.
Attempting to finish a Pathology residency in the home country in order to improve your chances for Pathology match is a bit too extreme step. Although it gives you a good backup, it takes away 3 precious years of GC application from you especially when you know that there are ways to match without home country residency too
Any other important trend that IMGs should be aware of?

1. A recent trend among non-visa requiring candidates is to look for Pathology assistant jobs. This is the strongest hands-on grossing experience that anyone can have in the US as an IMG. J2/L2 EADs can also be employed to these positions.
2. Doing all your Pathology USCE in one single institution or state may be considered as a lack of flexibility and it is preferable to do at least one rotation in IMG friendly places like NY so you seem more flexible
3. The job market is getting much better. This is reflected by increased numbers of job postings on websites like pathologyoutlines.com and sudden fellowship position openings in offseasons that show that people got a job and they left their second scheduled fellowship so that it shows up now.

The basic principles for Pathology match are similar to other residencies. It is a good time to enter into Pathology residency as it is not very competitive now. As the job market keeps getting better, the balance will shift to the other side in due time. I have met thousands of Pathologists during my 3 years of residency and 2 years of practice in India and my research stint at Mayo Clinic for one year and I am yet to meet a sad Pathologist. As you get to know more about the subject, you start loving it more. All the best!

Dr. Anurag Sharma, Pathology resident. Cleveland Clinic

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