Essential IMG Residency Guide: Researching EM-IM Programs Effectively

Choosing where to apply for an Emergency Medicine–Internal Medicine (EM-IM) combined residency is one of the most strategic decisions you’ll make as an international medical graduate (IMG). There are relatively few EM-IM combined programs, each with distinct strengths, cultures, and expectations. Thoughtful program research is essential—not only to maximize your chances of matching, but also to ensure the program truly fits your goals and situation as an IMG.

Below is a detailed IMG residency guide specifically focused on how to research residency programs in EM-IM and build a deliberate, organized program research strategy.

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Understanding the EM-IM Combined Pathway as an IMG

Before diving into individual programs, you need a clear understanding of what Emergency Medicine-Internal Medicine means in training and in long-term career options.

What is an EM-IM combined residency?

EM-IM combined programs are typically 5-year integrated residencies that lead to board eligibility in both Emergency Medicine and Internal Medicine. Graduates can:

• Work clinically in both the ED and inpatient/clinic settings
• Pursue fellowships in either EM (e.g., ultrasound, EMS, toxicology) or IM (e.g., cardiology, critical care, pulmonary, ID)
• Build careers in critical care, hospital leadership, academic medicine, or global health where dual training is highly valued

For IMGs, these programs can be especially attractive if you:

• Enjoy managing both acute, undifferentiated emergencies and complex chronic disease
• Are considering critical care or academic leadership where dual certification is an asset
• Want flexibility to work in diverse practice environments, including internationally

Why EM-IM is unique for IMGs

As an international medical graduate, pursuing EM-IM has specific implications:

1. Small number of programs:
   There are far fewer EM-IM programs than categorical EM or IM programs. That means:

   • Every application matters
   • You must be highly organized in how you research and prioritize programs

2. Competitiveness:
   Many EM-IM programs are located at large academic centers. These programs:

   • Often expect strong USMLE/COMLEX scores
   • May favor applicants with US clinical experience (USCE) and strong letters
   • Typically look for evidence of resilience, adaptability, and strong communication—key issues sometimes scrutinized more closely for IMGs

3. Dual identity, dual expectations:
   You must fit into both EM and IM cultures:

   • EM values rapid decision-making, teamwork, and procedural skill
   • IM values diagnostic reasoning, continuity, and detailed longitudinal care
   • Programs will assess if you are genuinely committed to both specialties

Understanding this context will help you ask the right questions and evaluate whether specific EM-IM programs are aligned with your strengths and trajectory.

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Step 1: Build a Clear Personal Profile Before You Research Programs

Effective program research starts with understanding your own profile and priorities as an IMG. This will guide where and how you research.

Clarify your “non-negotiables”

Before searching databases and websites, list your top non-negotiables:

• Visa requirements:

  • Do you need J-1 or H-1B sponsorship?
  • Are you open to programs that only sponsor J-1?
  • Are you already a permanent resident/green card holder?

• Geographic constraints:

  • Do you need to be near family/support in a specific region?
  • Are there states where you cannot be licensed due to exam attempts or time since graduation?

• Time since graduation and attempts:

  • How long since you graduated?
  • Any USMLE attempts (especially Step 1/2CK failures)?
  • Some programs have explicit or informal cutoffs (e.g., graduation within 5–7 years, no failures).

• Type of training environment:

  • Strong preference for academic medical centers vs community-based academic affiliates
  • Desire for exposure to high-volume trauma centers, quaternary care environments, or underserved populations

Writing these down will prevent you from wasting time on programs that are unlikely to consider your application or that would not be a good personal fit.

Honestly assess your competitiveness

For a realistic EM-IM program research strategy, categorize your profile:

• Academics:
  • USMLE/COMLEX scores and attempts
  • Class rank, honors, distinctions
• Clinical experience:
  • USCE in EM and/or IM (observerships, externships, sub-internships)
  • Performance in ED and IM rotations (evaluations, SLOEs if available)
• Research and scholarly work:
  • Any EM- or IM-related research, QI projects, or publications
• Communication and professionalism:
  • English fluency and comfort, especially for EM where rapid, clear communication is vital

You don’t need a "perfect" record to match EM-IM as an IMG, but you do need to know where you stand to tailor your list (e.g., more safety vs reach programs, emphasis on IMG-friendly institutions).

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Step 2: Map the EM-IM Landscape and Identify Candidate Programs

Now that you understand yourself, you can begin systematic exploration of EM-IM programs.

Use official directories and match data

Start with authoritative sources:

1. FREIDA (AMA Residency & Fellowship Database):

   • Filter for:
     • Specialty: Emergency Medicine–Internal Medicine (combined)
   • For each program, check:
     • Program type and length
     • Number of positions
     • Hospital type (academic, community)
     • Contact information and website links

2. NRMP and ERAS data:

   • Review NRMP match data for EM-IM if available, and for EM and IM in general
   • Pay attention to:
     • Match rates for IMGs in EM and IM
     • Average USMLE scores (for a sense of competitiveness)
   • This informs how competitive your application is relative to the field

3. Program websites:

   • Once you identify the EM-IM programs from FREIDA or other directories, go directly to their official websites.
   • Confirm:
     • Whether they still offer EM-IM combined training (programs can open/close)
     • Number of EM-IM spots per year
     • Affiliated categorical EM and IM programs

Build a master list and spreadsheet

Create a structured spreadsheet to manage your program research strategy. Include columns such as:

• Program name
• City, state, and region
• Hospital/university affiliation
• Number of EM-IM positions
• IMG friendliness indicators:
  • Percent of current residents who are IMGs (in EM-IM, EM, and IM)
  • Visa sponsorship (J-1, H-1B, both, or none)
  • Time since graduation cutoff (if any)
• USMLE minimums (if listed)
• Application requirements and deadlines
• Notes on:
  • EM curriculum style (e.g., trauma level, EM volume)
  • IM curriculum emphasis (e.g., subspecialty exposure, research)
  • Combined program culture and strengths

This spreadsheet becomes your central command for evaluating residency programs and tracking updates throughout the application season.

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Step 3: Evaluate IMG-Friendliness and Program Fit

Once you know where EM-IM programs are located, the next step in evaluating residency programs is determining which are realistically attainable and a good match for you as an IMG.

Assessing IMG-friendliness

Since EM-IM programs are small, look beyond the combined track alone and examine the broader institution:

1. Resident composition:

   • Check current EM-IM, EM, and IM resident lists on program websites.
   • Look for:
     • Percentage of IMGs in the department
     • Diversity of medical schools represented
   • If you see no IMGs at all in EM or IM over several years, consider that a warning sign.

2. Visa sponsorship:

   • Most IMGs need J-1, some seek H-1B.
   • Program websites or FREIDA often list:
     • “J-1 only”, “J-1 and H-1B”, or “Do not sponsor visas”
   • If not clear, email the coordinator with a short, professional inquiry asking:
     • “Does your EM-IM program sponsor J-1 and/or H-1B visas?”

3. Eligibility criteria:

   • Look for explicit criteria:
     • Graduation within X years (e.g., 5–7 years)
     • USMLE score thresholds (e.g., Step 1 ≥ 220, Step 2 CK ≥ 230)
     • Requirements for US clinical experience
   • Programs with flexible criteria and historical IMG presence tend to be more welcoming.

Evaluating clinical and educational fit

As you research residency programs, look beyond IMG-friendliness. You need the training to match your career goals.

Key aspects to examine:

1. Emergency Medicine environment:

   • ED volume and acuity:
     • Level I trauma center vs community ED
     • Annual visit volume
   • EM curriculum:
     • How many EM months per year and how they’re structured across 5 years
     • Exposure to pediatrics, trauma, ultrasound, toxicology, EMS
   • Procedures and resuscitation:
     • Does the ED run the majority of codes and critical resuscitations?

2. Internal Medicine environment:

   • Breadth of subspecialties:
     • Cardiology, pulmonary/critical care, ID, nephrology, hem/onc, GI
   • ICU and inpatient exposure:
     • Number and type of ICU rotations
     • Opportunities to manage complex inpatients
   • Outpatient continuity:
     • Structure of continuity clinics
     • Population served (urban underserved, VA, academic faculty practice)

3. Combined program philosophy:

   • How integrated is the EM-IM experience?
   • Is there dedicated combined program leadership?
   • Do EM-IM residents have:
     • Specific combined conferences or retreats
     • Tailored mentorship and advising
   • How do they handle scheduling conflicts between EM and IM obligations?

Culture and support for IMGs

Some institutions are particularly supportive of IMGs and international backgrounds:

• Look for:
  • Mentions of diversity, equity, and inclusion (DEI) on the website
  • Faculty with international training history
  • Formal support for visa, relocation, and onboarding
• During outreach or interviews, discreetly ask existing residents (especially IMGs):
  • How supported they felt during visa processing
  • Whether there are challenges specific to IMGs at that institution

This deeper evaluation helps ensure you are not just able to enter a program, but able to thrive there.

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Step 4: Go Beyond Websites – Deep Dive Research Methods

Public websites give only part of the story. To truly understand EM-IM programs as an IMG, use multiple information sources and strategies.

1. Connect with current and recent residents

Nothing replaces speaking directly with those inside the program.

• Find contacts:
  • Most EM-IM websites list current residents with emails or social media
  • Look for IMGs across EM-IM, EM, and IM
• Reach out professionally:
  • Send short, respectful emails:
    • Introduce yourself (IMG, interested in EM-IM)
    • Ask 2–3 specific questions about training, culture, and IMG support
• Helpful questions to ask:
  • How integrated is the EM-IM curriculum day-to-day?
  • How balanced is the workload between EM and IM?
  • What kind of career paths have EM-IM graduates pursued from your program?
  • Are there unique challenges for IMGs here (visa, communication, evaluation)?
  • Would you choose this same EM-IM program again?

Keep communications concise; residents are busy. Express genuine interest and appreciation.

2. Attend virtual open houses and webinars

Since COVID-19, many EM and IM programs host virtual open houses and Q&A sessions.

• Monitor:
  • Program websites
  • Social media (Twitter/X, Instagram, LinkedIn)
  • EM/IM interest groups and societies
• Use these sessions to:
  • Hear program leadership describe their philosophy
  • Observe how they discuss IMGs and diversity
  • Ask thoughtful questions about:
    • EM-IM curriculum structure
    • EM vs IM culture integration
    • Support for international graduates

Take notes immediately afterward to add to your spreadsheet.

3. Use alumni networks and mentors

Leverage connections from:

• Your medical school alumni network
• Prior observership or externship sites
• International or national EM/IM organizations

Identify people who:

• Matched into EM-IM
• Trained in EM or IM at institutions that also have EM-IM tracks
• Have experience advising IMGs on specialty choice

Ask them:

• Which EM-IM programs are known to be more IMG-friendly?
• Where do EM-IM graduates tend to go after training (fellowships, jobs)?
• Are there programs with a particularly strong or weak reputation for combined training?

4. Analyze scholarly output and niche strengths

If academic medicine, global health, or critical care interest you, examine a program’s scholarly and clinical strengths:

• Search for:
  • Publications by EM-IM faculty or residents
  • Research focuses (e.g., resuscitation science, sepsis, health systems, global EM/IM)
• Look for:
  • Presence of EM or IM fellowships (especially critical care, ultrasound, global health, education)
  • Opportunities for:
    • Protected research time
    • Quality improvement (QI) projects
    • Education or leadership tracks

Choose programs that match your long-term goals—especially if you envision a career that leverages dual training beyond pure clinical work.

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Step 5: Build a Strategic, Tiered Application List

After deep research, you must narrow your options and create a structured list of programs with realistic expectations as an IMG.

Tier your programs: reach, target, and safety

Given the small number of EM-IM programs, you may also apply to some categorical EM and/or IM programs as part of a balanced strategy. Within EM-IM:

1. Reach programs:

   • Highly competitive institutions
   • Very strong academic reputation and limited IMG presence
   • You meet the minimum criteria but may be below average in scores or USCE

2. Target programs:

   • Programs where your profile matches or slightly exceeds averages
   • Some evidence of IMG inclusion (past or present)
   • Reasonable compatibility with your academic and career interests

3. Safety/realistic programs:

   • Known for IMG representation, flexible policies
   • Visa sponsorship clearly stated
   • Your profile is at or above their typical benchmark

As an IMG, aim for adequate numbers in each tier, given that EM-IM slots are limited. Many IMGs also include:

• Categorical Internal Medicine programs as a reliable foundation
• Select categorical Emergency Medicine programs that are IMG-friendly

This diversification protects you if the small EM-IM pool does not yield enough interviews.

Balance fit, location, and visa realities

Be honest about what matters most:

• If visa sponsorship is critical:
  • Prioritize programs explicitly supporting your required visa type
  • Eliminate those that do not sponsor at all
• If geography is important:
  • Prioritize specific regions but keep some flexibility to improve your odds
• If long-term career plans hinge on certain resources:
  • For example, if you are committed to pursuing critical care:
    • Favor EM-IM programs with strong ICU exposure, existing critical care fellowships, and dual-boarded intensivists

Keep a separate column in your spreadsheet for a personal “fit score” (e.g., 1–5 or low/medium/high), considering all factors: IMG-friendliness, academic interests, support systems, and program culture.

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Step 6: Use Your Research to Customize Applications and Prepare for Interviews

Thorough program research is not only about choosing where to apply. It also helps you tell a coherent story in your application and later during interviews.

Tailor your personal statement for EM-IM

Use what you’ve learned about EM-IM to write a focused personal statement:

• Explain:
  • Why dual training (EM + IM) specifically appeals to you
  • How your background as an IMG gives you a unique perspective on acute and chronic care
  • Your long-term vision (e.g., critical care, health systems leadership, global health)

For specific programs you are most interested in:

• Briefly reference:
  • Features that match your goals (e.g., “strong ultrasound training in the ED and robust ICU exposure in the IM department,” “commitment to underserved populations,” or “global health track aligned with my prior experience”)

Prepare program-specific talking points

As you receive interview invitations, revisit your spreadsheet:

• For each program, list:
  • 2–3 unique strengths that attracted you
  • 2–3 thoughtful questions to ask about EM-IM integration, EM culture vs IM culture, and IMG support
• Examples of strong questions:
  • “How does your program ensure that EM-IM residents are fully integrated and not perceived as outsiders in either department?”
  • “What kinds of career paths have your EM-IM graduates pursued, and how does the program support those goals?”
  • “How are EM-IM residents supported in navigating visa or licensure issues, particularly for IMGs?”

You will sound knowledgeable, sincere, and focused—often setting you apart from applicants who did not invest in serious program research.

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Common Mistakes IMGs Make When Researching EM-IM Programs

Avoid these pitfalls as you develop your IMG residency guide for EM-IM program research:

1. Relying only on program websites:
   Websites can be outdated or incomplete. Always verify details (e.g., visa sponsorship, number of EM-IM positions) by direct inquiry if needed.

2. Ignoring the EM and IM categorical environments:
   You are joining two full departments, not just a small EM-IM track. Investigate both the EM and IM cultures and training quality.

3. Underestimating location and lifestyle factors:
   Burnout risk is real. Consider:

   • Cost of living
   • Support systems (friends/family/community groups)
   • Weather and safety, especially if coming from a very different climate or culture

4. Not tracking information systematically:
   With limited EM-IM spots but a lot of details, lack of organization can lead to:

   • Missing deadlines
   • Misunderstanding requirements
   • Sending generic, unfocused applications

5. Over-focusing on “name prestige”:
   A famous institution does not always equal the best fit or best support for IMGs. Look at fit, culture, IMG track record, and your career goals.

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Putting It All Together: A Practical Program Research Workflow

To make this concrete, here’s a step-by-step program research strategy you can follow over several weeks:

1. Week 1–2: Self-assessment and groundwork

   • Clarify your non-negotiables (visa, geography, training environment)
   • Assess your competitiveness (scores, USCE, research)
   • Learn the basics of EM-IM training and career paths

2. Week 2–3: Create your master list

   • Use FREIDA and official directories to identify all EM-IM programs
   • Visit each program website; extract key data into a spreadsheet
   • Add columns for IMG-friendliness, visa type, and fit score

3. Week 3–4: Deep dive and outreach

   • Contact selected residents/faculty with brief, targeted questions
   • Attend virtual open houses and webinars
   • Explore research strengths and fellowship opportunities

4. Week 4–5: Tier and finalize your application list

   • Categorize EM-IM programs into reach/target/safety
   • Decide how many categorical EM and IM programs to include
   • Re-check eligibility criteria and visa policies

5. Week 5 onward: Customize and refine

   • Tailor your EM-IM personal statement with insights from research
   • Prepare program-specific talking points and interview questions
   • Continue updating your spreadsheet with new information (e.g., changes in program leadership, new open houses)

By following a structured workflow, you transform a vague, overwhelming process into a focused strategy aligned with your goals as an international medical graduate pursuing Emergency Medicine-Internal Medicine.

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FAQs: Researching EM-IM Programs as an IMG

1. How many EM-IM programs should an IMG apply to?

Because EM-IM programs are few and competitive, most IMGs:

• Apply to all EM-IM programs where they are eligible and reasonably competitive, and
• Complement this with a broader list of categorical EM and/or IM programs, particularly IMG-friendly IM programs.

The exact number depends on your profile, but the principle is:
cast a wide but strategic net within EM-IM and ensure a solid safety base in categorical IM (and possibly EM).

2. How can I tell if an EM-IM program is truly IMG-friendly?

Look for multiple converging signs:

• Current or recent IMGs among EM-IM, EM, and IM residents
• Clear statement of visa sponsorship (including your needed type)
• Responsive communication when you inquire about IMG issues
• Alumni or resident feedback indicating supportive culture for international graduates

If a program has never had IMGs, does not sponsor visas, or is vague/unresponsive about IMG-related questions, it is less likely to be IMG-friendly.

3. Should I prioritize EM-IM over categorical EM or IM as an IMG?

It depends on your long-term goals:

• If you are strongly committed to a dual-career identity (e.g., critical care, academic leadership, global health integrating acute and chronic care), EM-IM may be ideal.
• If your main goal is to practice primarily in the ED or in IM, a categorical path may:
  • Be more attainable as an IMG
  • Provide more flexibility in choosing locations and programs

Many IMGs apply to both EM-IM and categorical EM/IM to maintain options.

4. How important is US clinical experience for EM-IM programs?

US clinical experience (especially in EM and IM) is often very important:

• It demonstrates:
  • Familiarity with US healthcare systems and documentation
  • Proven ability to function in US clinical teams
  • Usually generates stronger letters of recommendation

If you lack USCE, prioritize obtaining observerships, externships, or sub-internships—particularly in EM and IM departments with EM-IM combined programs or strong academic reputations.

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By approaching your EM-IM residency search with clarity, structure, and persistence, you significantly improve your chances of matching into a program that values your background as an international medical graduate and equips you for a meaningful, versatile career in both Emergency Medicine and Internal Medicine.