The move
I had just passed the gastroenterology exit examination and should have been busy searching for an associate consultant job. Instead, I found myself packing thirty years of existence into two large suitcases and trying my utmost to prioritise the most important items. I was moving to the US to join my husband who was in the middle of his residency training. Although it was a huge career sacrifice, the move felt natural as we really wanted to start living together and we had immense support from family about the decision.
The match
After extensive research of my options in the US, I realised that there were no shortcuts or special treatment for Singaporeans! A Singaporean doctor there is simply another International Medical Graduate (IMG). No matter how many years of experience you have had, or how "similar" Singapore's training system is to theirs, you will still have to go through multiple examinations and redo the basic residency training if you want to become a licenced US doctor.
Over the years, the number of US medical graduates has increased, but the number of available residency positions has largely maintained the same, which significantly increases the competition. Overall, most programmes tend to prioritise positions for the local medical graduates and many programmes do not offer interviews to applicants who had graduated for more than five years. Not many programmes offer J-1 or H1-B Visas, so IMGs who are not US citizens or permanent residents are hugely disadvantaged.
Examinations begin with the United States Medical Licensing Examination (USMLE) Step 1, which tests on subjects like biochemistry or genetics, and can be daunting to someone who had been immersed in clinical work for many years. This is followed by USMLE Step 2 CK (clinical knowledge), Step 2 CS (clinical skills) and the final USMLE Step 3. To apply for the national match, IMGs need to at least pass Step 2 CS (to be Educational Commission for Foreign Medical Graduates-certified) and submit all relevant paperwork on the National Resident Matching Program website by a set deadline. The application fee is hefty and increases with the number of programmes that you apply to.
For applications as IMGs, it is recommended to have strong USMLE scores, some US working experience, research publications and recommendation letters from US physicians. I managed to do observerships at both Emory University and Duke University to show that I had exposure to the US hospital system. I also sent emails to programme directors to explain that although I had graduated in 2010, I had not stopped clinical work since graduation. Even with these efforts, the residency match was not a picnic for me and I was not offered interviews at any top-notch training programmes like Mayo Clinic. The residency interview process spanned a few months and required me to fly to various states like Hawaii or Idaho. The overall expenses, including application, travel and accommodation, added up to the thousands.
My husband made sure to use all his vacation time to "escort" me to my interviews and I really could not have gone through them without his support. The best advice I could give to another Singaporean doctor pursuing this path would be to have realistic expectations about matching into an "equivalent" university-affiliated residency programme in the US and carefully consider the financial drawbacks.
The programme
I was elated to match into my current programme which I had ranked number one due to its major affiliation to Yale, its location in an affluent and safe town, and the welfare benefits that the programme provided. Although residency pay is very low, by Singapore standards, my programme provided corporate health insurance, daily lunches, free apartment accommodation within walking distance to the hospital, and additional "wellness" perks like laundry for my lab coats, residency outings and a monthly allowance for food, snacks or shopping at the hospital.
The hospital I worked in runs in a privatised manner with no C-class wards; patients are either in single rooms with private bathrooms or share a large room with one other patient. Residents in our programme have very little "scutwork" – a term used to describe jobs like drawing blood from patients, inserting urinary catheters or setting intravenous cannulas. There are dedicated respiratory therapists to draw blood gases, phlebotomists to draw blood and blood cultures, and intravenous nurses to set lines. Foley catheters are inserted by nurses for both male and female patients. However, because everything is electronic, the residents do end up with a lot of typing throughout the day – including the progress notes, transfer notes, discharge summaries, hospital courses and sign out notes.
However, as I have not worked in other US residency programmes, my experience may not be indicative of how all programmes are run here.
There are also numerous learning curves to navigate. Firstly, everybody here is conditioned to use brand names. At first, I was constantly checking Google to find out which medications my patients or colleagues were actually referring to. Glucose readings became a challenge for me because the unit was reported in mg/dL while I had been programmed to understand mmol/L. Common Singapore medications like nifedipine LA or oral acetylcysteine are rarely used, while aspirin dosages are in 81 mg or 325 mg for some reason. One has to be vigilant about prescribing medications that are on the "preferred" drug list for the patient's insurance or one will have to pursue a tedious process called "drug prior authorisation".
The epidemiology of diseases in the US is very different from that of Singapore too – with tick-borne diseases like babesia or Lyme disease, fungal infections like histoplasmosis, sickle cell disease, inflammatory bowel disease or sarcoidosis being much more commonplace. Dengue fever is almost non-existent in the mainland. Antibiotic guidelines are also distinctly different and most antibiotics that doctors could order by ourselves in Singapore actually require approval by an infectious disease attending before the pharmacy would even release it here.
Bottom-line
In summary, I would recommend careful consideration with a viable backup plan (or plans) before making the move to the US as a physician.