Essential Guide for US Citizen IMGs: Researching EM-IM Residency Programs

Understanding the Landscape: EM-IM Combined Programs as a US Citizen IMG

Emergency Medicine-Internal Medicine (EM-IM) combined programs are small, competitive, and very different from applying to categorical Emergency Medicine or Internal Medicine alone. As a US citizen IMG or American studying abroad, you face additional layers: visa policies may not apply to you, but program bias, exam expectations, and limited spots all still matter.

Before you can build a program research strategy, you need a realistic view of:

• What EM-IM is

  • A 5-year combined residency that leads to board eligibility in both Emergency Medicine and Internal Medicine.
  • Often based at academic, tertiary-care centers with strong critical care, ultrasound, and hospitalist exposure.
  • Cohort sizes are small—often 2–4 spots per year or fewer.

• How many programs exist
  Numbers change slightly year to year, but there are only a few dozen EM-IM combined programs in the US, compared with hundreds of categorical IM or EM programs. This alone makes selective, data-driven research essential.

• What it means to be a US citizen IMG in this context
  As a US citizen IMG:

  • You do not need visa sponsorship, which removes one major barrier that affects many non–US citizen IMGs.
  • However, you are still an IMG in the eyes of programs. They may scrutinize your:
    • USMLE performance (especially Step 2 CK)
    • Clinical experience in the US
    • Letters of recommendation from US faculty
    • School reputation and rigor
  • Some EM-IM programs rarely interview IMGs, while others are IMG-friendly but expect strong metrics and multiple US clinical rotations.

Your goal is to identify where your profile aligns best with specific programs’ priorities. That’s where systematic program research comes in.

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Building a Program Research Strategy Specifically for EM-IM

A systematic program research strategy helps you avoid emotional, random searching and instead make deliberate, high-yield choices. Think of this like preparing for a major procedure: you need a clear workflow and checklists.

Step 1: Clarify Your Personal “Filters”

Before you look outward at programs, look inward:

1. Geographic preferences and constraints

   • Family or partner location needs?
   • Willing to move anywhere for 5 years, or only certain regions?
   • Comfortable with Midwest winters or prefer coasts/warmer climates?
   • As an American studying abroad, consider where you have support networks in the US; that can matter during a long, demanding combined residency.

2. Academic profile and competitiveness Reflect honestly on:

   • USMLE Step 1 (if scored) and Step 2 CK (critically important for IMGs).
   • Any exam failures or leaves.
   • Class rank or transcript patterns (consistent performance vs. upward trajectory).
   • Extent of US clinical experience (USCE) and EM/IM rotations.

   This will guide how broadly you should apply and help you prioritize which programs to research more deeply.

3. Career goals and training style EM-IM attracts people who:

   • Like complex, multi-system disease and resuscitation.
   • May aim for critical care, hospital medicine, academic careers, or ED-based internal medicine/observation units.
   • Often want flexibility (e.g., working in ED and on inpatient wards after training).

   Decide what matters most to you:

   • Strong critical care and ICU exposure?
   • Global health? Rural vs. urban? Academic vs. community?
   • Level 1 trauma center vs. more IM-heavy training?

Write down your top 5–7 “non-negotiables” and 5–7 “nice-to-haves.” These will become your reference when evaluating residency programs.

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Step 2: Identify the Full List of EM-IM Programs

To research effectively, you must start from a complete list:

• ERAS and NRMP databases

  • Use ERAS to filter for “Emergency Medicine-Internal Medicine” combined programs.
  • Cross-check with NRMP’s program directory to confirm active participation in the Match.

• Specialty and organizational websites

  • Look at:
    • The Society for Academic Emergency Medicine (SAEM) combined programs listings.
    • American College of Emergency Physicians (ACEP) and American College of Physicians (ACP) resources, which sometimes reference combined training options.
  • Some EM-IM programs are also linked on their institution’s EM or IM department pages, even if EM-IM isn’t easily searchable from the main GME page.

• Medical school advising and alumni networks

  • Ask your international med school if they have graduates in EM-IM.
  • Join Facebook, WhatsApp, or Discord groups for “US citizen IMG” or “American studying abroad” where people often share up-to-date program lists.

Create a master spreadsheet (Excel, Google Sheets, or Notion) with:

• Program name
• Institution and city/state
• Number of EM-IM spots/year
• Application ACGME/ERAS codes
• Categorical EM and IM program links
• Program website URLs for EM-IM, EM, and IM

This becomes the backbone of your program research.

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How to Research Residency Programs in Depth as a US Citizen IMG

Once you have the list, the real work begins: how to research residency programs in detail and interpret what you find through the lens of a US citizen IMG targeting EM-IM.

1. Start with Official Sources: Program Websites & Institutional Pages

Read each program’s:

• EM-IM specific page

  • Curriculum overview (5-year schedule, rotations distribution).
  • Sample block diagrams.
  • Combined conferences, didactics, or scholar tracks.
  • Rotations unique to EM-IM vs. categorical EM or IM.

• Emergency Medicine and Internal Medicine categorical pages

  • Resident profiles.
  • Department strengths (e.g., ultrasound, toxicology, cardiology, heme/onc).
  • Research infrastructure, fellowship offerings.
  • Hospital systems served (university hospital, VA, county, community sites).

As you read, log information in your spreadsheet:

• Number of combined positions offered yearly.
• Main hospital type: county, academic, community-based university.
• EM case mix (trauma, peds, high acuity vs. lower volume).
• IM strengths (subspecialties, academic reputation, research output).

For a US citizen IMG, pay special attention to:

• Whether any current or recent residents are IMGs (even in categorical programs).
• Statements about:
  • “We welcome international medical graduates…”
  • “Experience with J-1 or H-1B visas…” (Even if you don’t need a visa, this often correlates with general IMG-friendliness and familiarity with non-US schools.)

2. Use Data Sources for Objective Comparison

To move beyond marketing language, use structured data to evaluate residency programs:

• FREIDA (AMA Residency & Fellowship Database)
  On FREIDA, look at:

  • Program size and type.
  • Number of EM-IM positions.
  • USMLE requirements and score cutoffs.
  • Whether they accept IMGs and historic percent of IMGs.
  • Gender and diversity breakdown (if listed).

• Doximity Residency Navigator (with caution)

  • Check for:
    • Reputation rankings in EM and IM.
    • Program alumni career paths (critical care, academic positions, etc.).
  • Don’t over-interpret rank numbers; instead, note recurring themes: “strong in critical care,” “urban underserved,” etc.

• Program-specific statistics

  • Some programs post:
    • Average board scores for matriculants.
    • Match lists for fellowship.
    • Board pass rates in EM and IM.
  • Use these data points to compare your own metrics and risk tolerance.

Combine this with your academic profile to categorize programs roughly as:

• Reach: Higher than your metrics, IMG-light or very competitive.
• Target: Roughly consistent with your scores and profile, some IMG presence.
• Safety: Historically more IMG-friendly, lower stated cutoffs or more holistic review.

You will later adjust this based on subjective fit.

3. Evaluate IMG-Friendliness and US Citizen Advantages

As a US citizen IMG, you sit in a specific niche. When evaluating residency programs:

Look for evidence of IMG-friendliness:

• Current or past EM-IM residents who trained at international schools.
• IM or EM categorical rosters that include IMGs.
• Program descriptions that explicitly mention IMGs in a positive, inclusive way.
• Clear statements of what they look for from IMGs:
  • US clinical experience (e.g., “We require at least 3 months of US clinical rotations.”)
  • USMLE thresholds (“We typically interview applicants with Step 2 CK > 240.”)

Leverage your US citizenship:

• Visa requirements may not filter you out.
• Programs that say “We do not sponsor visas” might still be open to you as a US citizen IMG.
• When you email programs with questions, you can emphasize:
  • Your US citizenship.
  • Your familiarity with the US healthcare system through rotations or personal background.

In your spreadsheet, add columns such as:

• “Current IMGs?” (Yes/No/Unknown)
• “IMG statement on website?”
• “Visa policy” (for context, even if you don’t need one)
• “Level of comfort with IMGs” (your subjective rating 1–5 based on evidence)

These help you systematically compare how IMG-friendly each program is.

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4. Analyze Curriculum and Training Focus for EM-IM

When evaluating residency programs, particularly EM-IM, curriculum is not just a list of rotations; it’s a window into how you’ll train and what kind of physician you’ll become.

Focus on:

1. Balance between EM and IM

   • How many months in:
     • Emergency Department (adult and pediatric)?
     • Inpatient wards, ICU, subspecialty rotations?
   • Is one side clearly stronger or more emphasized?
   • Are you integrated with EM and IM residents, or siloed?

2. Critical care training

   • How many ICU rotations (MICU, CCU, SICU, Neuro ICU)?
   • Are EM-IM residents favored for ICU spots or leadership roles?
   • Any dedicated critical care tracks or fellowship paths?

3. Procedural exposure

   • Central lines, intubations, chest tubes, ultrasound-guided procedures.
   • Is ultrasound teaching robust and formalized?
   • Are you able to do ED bedside procedures frequently?

4. Schedules and wellness

   • EM shift scheduling: 8 vs. 12-hour shifts, frequency of nights.
   • IM ward structure: q4 call vs. night float systems.
   • Vacation policies, protected educational time.

5. Mentorship and identity as a combined resident

   • Dedicated EM-IM program director and assistant director?
   • EM-IM resident retreat, interest groups, or scholarly tracks?
   • Formal advising structure for dual-board eligibility and career planning?

Add columns like:

• “ICU-heavy? (Y/N)”
• “US/Global health opportunities?”
• “Strong ultrasound?”
• “EM-IM leadership/mentorship rating (1–5)”

This tells you not just if the program is good, but whether it aligns with your vision of an EM-IM physician.

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Practical Tactics for Evaluating Residency Programs Beyond the Website

Some of your most important insights will come from informal or semi-formal sources: residents, advisors, and program social media.

Talk to Current and Former Residents

This is particularly valuable for a US citizen IMG.

Ways to connect:

• Program emails
  Many EM-IM sites list a chief resident or program coordinator contact. You can ask:

  • Whether they have current or recent EM-IM or categorical residents who are IMGs.
  • If any residents would be open to speaking with you as a prospective applicant.

• Alumni networks and social media

  • LinkedIn: Search “[Program Name] Emergency Medicine” or “[Program Name] Internal Medicine” plus “MD.”
  • Instagram/Twitter/X: Many EM or EM-IM programs have accounts showcasing resident life.

When you talk to residents, ask targeted questions:

• “Are there any US citizen IMG residents, or have there been in the last 5 years?”
• “How supportive is the combined program leadership?”
• “How do EM-IM residents integrate with categorical EM and IM residents?”
• “What are the main strengths and biggest challenges of this EM-IM program?”
• “Would you choose this program again and why?”

Record their responses in a notes column in your spreadsheet. Two or three such conversations can drastically refine your “evaluating residency programs” judgment.

Use Social Media and Online Forums Strategically

• Program Instagram/Twitter/X

  • Look at:
    • Resident diversity.
    • What they highlight (wellness, academics, global health, ultrasound).
    • EM-IM spotlights or combined program content.

• Student Doctor Network (SDN), Reddit, specialty forums

  • Read with skepticism, but:
    • Note recurring themes (e.g., “brutal call schedule but amazing training”).
    • Screen for posts tagged with IMG or EM-IM experiences.
  • Avoid getting trapped in negativity; use these platforms as one data point among many.

Consult Advisors Who Understand IMGs and Combined Programs

You need at least one advisor who:

• Understands EM and IM competitiveness.
• Has insight about IMGs in US GME.
• Ideally knows something about EM-IM combined training.

Options:

• Your medical school’s international advising office or dean of students.
• US faculty you worked with on rotations (ED or wards attendings).
• Alumni from your school who matched into EM, IM, or EM-IM.

With your spreadsheet in hand, ask:

• “Looking at my scores and experiences, which programs seem realistic vs. reach?”
• “Do you see any red flags with my target list?”
• “Are there EM-IM programs you think are particularly IMG-friendly or IMG-averse?”

Advisors can save you from over- or under-shooting your list.

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Putting It All Together: Building and Refining Your EM-IM Program List

Once your research is reasonably complete, you need to turn data into decisions.

Categorize and Prioritize Programs

Using your spreadsheet, give each program a simple composite rating based on:

1. Objective Fit

   • USMLE alignment.
   • IMG-friendliness.
   • Curriculum fit (EM-heavy vs. IM-heavy based on your preference).

2. Subjective Fit

   • Geography and lifestyle.
   • Culture you sensed from residents and social media.
   • Your interest in their unique strengths (e.g., global health, critical care, ultrasound fellowship pipeline).

3. Risk Level vs. Application Strategy

   • Label programs as Reach / Target / Safety.
   • For EM-IM, you may not have many true “safety” programs because of small numbers of positions, but some programs are more historically open to IMGs or have less national name recognition.

Sample Approach for a US Citizen IMG Targeting EM-IM

Imagine you are:

• US citizen IMG with Step 2 CK 238.
• Two US EM rotations, one IM sub-I, all with strong letters.
• No fail attempts, no major red flags.
• Solid but not exceptional research.

A reasonable program research strategy might be:

• Identify all active EM-IM programs (for example, ~20–30; number varies).
• After research:
  • 5–7 “Reach” EM-IM programs (top academic centers, high board scores, IMG-light).
  • 10–15 “Target” EM-IM programs (some IMG presence, board scores in your range).
  • 3–5 “More IMG-friendly” EM-IM programs (if available).

Because EM-IM is so small, most applicants also apply to:

• Categorical Emergency Medicine (EM)
• Categorical Internal Medicine (IM)

You should therefore:

• Run a parallel research process for EM and IM programs:
  • Identify IMG-friendly categorical EM and IM programs.
  • Treat them as your stability base if EM-IM spots don’t work out.

Keep Your List Dynamic

Program research is not static. As Match season unfolds:

• Update notes after:

  • Virtual open houses.
  • Email exchanges with coordinators.
  • Conversations with residents.

• Be ready to:

  • Remove programs that truly don’t fit (e.g., newly discovered IMG-unfriendly culture).
  • Add backup categorical programs if your profile appears less competitive than you expected.

The key is to avoid last-minute panic by doing most of this research early (ideally 6–9 months before ERAS submission).

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Common Pitfalls for US Citizen IMGs Researching EM-IM Programs

Being aware of frequent mistakes can protect your program research strategy:

1. Over-focusing on program name brand alone

   • A mid-tier academic EM-IM with strong mentorship may be better than a famous brand that rarely supports IMGs.

2. Ignoring IMG track record

   • If a program has never had an IMG in EM-IM or categorical EM/IM, you must be realistic about your chances.

3. Not diversifying with categorical EM and IM applications

   • EM-IM is extremely small. Most US citizen IMGs need a parallel plan.

4. Relying only on forums or word-of-mouth

   • Anecdotes can be biased. Always cross-check with official data and direct communication.

5. Underestimating the importance of US clinical experience and letters

   • Programs need evidence that you function well in US hospitals, especially in acute settings like the ED and wards.

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FAQs: Researching EM-IM Programs as a US Citizen IMG

1. As a US citizen IMG, do I still need to worry about visa policies when researching programs?

You don’t need visa sponsorship, but visa policy often serves as a proxy for IMG-friendliness. Programs that routinely sponsor J-1 or H-1B visas:

• Are familiar with international schools and credentialing.
• Tend to have processes for reviewing IMG applications thoroughly.

So while visa status doesn’t affect you directly, it still helps you evaluate residency programs’ openness to non–US-trained graduates.

2. How many EM-IM programs should I apply to as a US citizen IMG?

Because EM-IM has few total positions nationwide, many US citizen IMGs applying to EM-IM:

• Apply to every EM-IM program where they are remotely competitive, unless there’s a major geographic or personal constraint.
• Simultaneously apply to a robust number of categorical EM and IM programs (often 30–60+, depending on competitiveness and advisor guidance).

The exact number should be tailored by an advisor who knows your metrics, but casting a wide net among EM-IM programs is usually wise.

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

Look for combined evidence:

• Current or recent EM-IM or categorical EM/IM residents from international schools.
• Positive statements about IMGs on the website.
• Willingness of program staff or residents to engage with you via email or virtual meet-and-greets.
• Advising or guidance you receive from other IMGs who applied previously.

No single sign is definitive; instead, you’re looking for a pattern of openness and experience with IMGs.

4. Should I prioritize EM-IM over categorical EM or IM in my research?

Your research should center on EM-IM first if that’s your true goal, but remember:

• EM-IM programs are few and competitive.
• As a US citizen IMG, you’re still in a more scrutinized group.
• Having strong categorical EM and IM options is not a lack of commitment to EM-IM; it’s a smart risk management strategy.

Research EM-IM in depth, then build a parallel list of categorical EM and IM programs that align with your profile and interests, ensuring you have a realistic and balanced application plan.

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By approaching your EM-IM search with a structured, data-driven program research strategy, you’ll move beyond vague impressions and instead make deliberate, informed choices that reflect both your ambitions and your realities as a US citizen IMG.