TABLE OF CONTENTS

INTRODUCTION.

PART I: THE STEPS....

- STEP I....
- STEP 2 CK.
- STEP 2 CS..
- STEP 3....

3
4
7
8
13

PART II: THE AMERICAN EXPERIENCE.

- ELECTIVES
- RECOMMENDATION LETTERS.

14
15
16

PART III: THE MATCHING PROCESS

- WHERE TO APPLY
- INTERVIEWING.
- CONTACTS.
- VISA ISSUES..
- FINAL ADVICES....

27
28
31
35
39
41

CONLUSION..

42

INTRODUCTION
This book is written for the people who intend to pursue their residency in the
United States. When we first started preparing for the steps, we had no clue that we
were engaging in the longest and most difficult path in medicine. Many times we felt
we were not being guided, even worse, sometimes we felt we were being misguided.
That is because most people talk a lot without having a single clue of what they are
saying, and how they could be affecting those around them. We had to filter a huge
load of information, choose between the right and wrong, and eventually come up
with our own conclusions concerning what to study and how to study it. Six of us
began the journey: Salah Aoun, Remy Daou, Serge Harb, Rudy Rahme, Tarek Toubia
and my self. Some of us changed their mind during the 7th year, but all of us ended up
having excellent results.

I am writing this book because I want the students to benefit from our
experience. I want to level the ground between them and make sure that no one will do
the wrong things just because he listened to the wrong people. Throughout this book, I
will be summarizing each and every one of our steps. From Step 1 till match day, it
will all be recorded.

If you are reading this, then you are probably about to take the most exhausting
ride in your life. So be patient, and good luck! Its going to be a LONG LONG year

PART I: THE STEPS

STEP 1
This is probably the toughest exam you will ever do: thats because its your first experience with
the American system, plus you feel that you have about 500 books to study and everyone is telling
you what to do and how to do it. These are the most common sayings:
Statement 1
Step 1??? You need maximum 2-3 months to do it. I did it in 8 weeks and I got a 99.
Answer: WRONG! There is now way you can do it in less than 5-6 months. This genius boy
is probably talking about his fifth revision, and there is no need to say that unless you SEE
the 99 with your own eyes, you should not believe it. So please, know that you wont be
taking this exam before end of December beginning of February.

Statement 2
I studied all the books. They are extremely helpful and I wouldnt have gotten a good grade if
I hadnt memorized them. The most important are physiology, pathology and microbiology.
There is no way you can present this exam if you havent at least memorized these 3 books.
Answer: WRONG! Thats the most common mistake done by students: beginning of August,
the student is feeling fresh and enthusiastic. So the first thing hell do is grab the
physiology book, and swallow it. By the end of the month, he would start the
Pathology book, and again swallow it. If hes perseverant, hell do the same with
microbiology made easy. But then, hell wake up realizing that he has spent 2 to 3 months
on 3 books that dont even represent 1/3 of the first aid. So hell drop the books and start
studying the first aid bala wa3e. By doing so, he will be failing to properly understand
biochemistry, genetics and embryology. Again, this is WRONG, and the right thing to do
will be explained further down.
Statement 3
The first aid is THE BIBLE. If you know it all by heart, you are guaranteed to have over 90
on the step 1.
Answer: wrong again! Unfortunately, there is no such thing as a bible for step 1. The first aid
is certainly a VERY VALUABLE tool, but you dont need to act as if it were the course of
Dr. Chahoud one night before the exam. This book only provides RELEVANT TOPICS,
most being taken from previous USMLE questions. So while it is very important to study it,
dont focus TOO MUCH on the details like you would do for a regular FM course. The only
way you can actually learn the details is by doing USMLE world. Again, this will all be
detailed later on.
Statement 4
When I finish my second revision (or even 3rd), I will leave two weeks from the Q-bank, and
if I have enough time, I might even do the Q-book.
Answer: wrong and DANGEROUS!!!!!! We all made this mistake and please believe me
when I tell you: the results could have been DISASTROUS. The most important part of
4

studying for step 1 is doing the exams. And when I say exams, I dont mean Q-bank. This Qbank is OUT DATED and provides simple direct questions. This is not the way the USMLE
does it. The questions of the actual exams are ALWAYS indirect, long and accompanied by a
clinical case. The Q-book is even worse because most of the times, the topics are
IRRELEVANT. What you should do is go to www.usmleworld.com and register. This is the
ONLY WAY you can guarantee a good grade. One of the top students in our class ended up
with a 92 because no one told her about this website. Had she known about it, I am sure she
would have gotten a 99. Please dont make the same mistake. Again, this website is the
ONLY thing that can guarantee your results.
So what do I do?
First, start by understanding the first aid. Why do I say understand? Because the first aid is the
summary of the summary of the actual information; So unless you are genius boy (like the one on
the top of the page), you probably wont understand it.
How to proceed then? Start with the tough material: biochemistry, embryology Read the first aid
in parallel with the book, but read ONLY the parts of the book which are concordant with the first
aid. Add ONLY what is EXTREMELY relevant for your understanding. Remember that the first aid
contains more information than you can assimilate, so dont make it a compilation of endless lists.
Make your own mnemonics and photocopy the good pictures and diagrams. Again, you will have a
ton of information to assimilate, and pictures will make it much easier!
What books to use? It doesnt matter. Sometimes, I just went to the library and got an English
colored book. So as long as you are referring to the first aid, it doesnt matter. By the way, the High
Yield series are actually the worst!! I used it only in the embryology, and even there it wasnt all that
good. I would recommend you to buy the following:
- Physiology (BRS): relatively good
- Pathology (BRS): least important
- Microbiology made easy: pictures are funny and easy to assimilate
- Biochemistry (Lipincott): very important
- Pharmacology (Lipincott): very important
Remember, as USJ students, our base in physiology and pathology is actually good so we dont need
to study the books. Just focus on the first aid and let USMLE world fill the gaps.
Second, after you finished understanding all the first aid, study it. By the end of this second step,
be sure that you still wont know much: you are NOT ready yet to take the exam.
Third, go to www.uslmeworld.com and register. You will pay around 100$, but believe me, its
worth every cent. Dont forget that you have paid the exam about 800$, and you really dont want to
fail it. You should plan at least 3-5 weeks to do it all. Haram a2all!!!! This is the most important
step. We didnt hear about usmleworld.com until we did step 2, and it was only then that we
understood HOW IMPORTANT it was. So please, again, this is your TOP PRIORITY. I tell you this
a posteriori. So if you dont want to trust my judgment, please trust my experience.
Be advised: when you are doing usmleworld.com, you will discover that you dont know all that
much. Its OK! You are doing it to LEARN and not to test yourself! Your grades will get better after
10 sessions.
Whats the logic behind choosing USMLE world over books?

The books are too heavy to study and there is no way you can learn them all. So instead of loosing
time focusing on irrelevant information, study the first aid and let USMLE world fill the gaps. By
the way, in the exam, there will be many questions from outside the first aid but be assured, you will
not find them in the books. So dont loose your time with books. Study the first aid, do the cessions
of usmleworld.com to better memorize the details and use it as LEARNING rather than a TESTING
tool.
The actual exam
This is probably the most painful and draining experience in the 7 years of medicine. You will go
through 7 extremely long hours but if you did usmleworld.com, it will be a piece of cake. Just bare
in mind that there is no WAY you will get out of the exam knowing that you had a 99. You will feel
lost, afraid and you will spend the next 3 weeks praying. Of the 6 of us, the only exception was
Serge Harb, but then again, Serge is Serge and he is certainly not the rule but the exception.
Just a few words about the grading system: 99 is a percentile, not a percentage. You will actually
take 350 questions, 50 of which are trial questions (not counted). If you score 235/300, mabrouk,
you got yourself a 99. So keep in mind that you can do 65 mistakes out of 300 questions and still
score a 99. That makes it a lot easier right?
Why am I saying the truth?
Because this is what the six of us did and these were our results in comparison with our rankings in
class:
- Serge Harb: 1st in class, scored 258 (99)
- Remy Daou: 3rd in class, scored 251 (99)
- Georges Nakhoul: 10th in class, scored 242 (99)
- Salah Aoun: 23rd in class, scored 254 (99)
- Tarek Toubia: 24th in class, scored 237 (99)
- Rudy Rahme: 22nd in class, scored 230 (96) because he had done some bachotage.
So you can clearly see that all of us got outstanding grades even though we were not all ranked top
in our class. If we did it, so can you! Just trust me and stick to the plan!

STEP 2 CK
This exam is relatively easy compared to step 1. Thats because as USJ students, our knowledge of
pathology is relatively strong. So if you did get a 99 on step 1, you shouldnt worry much about step
2. Here are a few tips on what to do:
1. Dont even look at the first aid. This time, it is COMPLETELY irrelevant. You would be
wasting your time.
2. There are probably no books that can accurately help you. We have a solid basis in all the
material. So directly register on usmleworld.com. You will get about 2300 questions, which
is more than you need.
3. While doing the usmleworld.com, take some notes. Thats the only thing you should review
before going to the exam.
4. You should plan about one and a half month for studying.
Also know that 99 still corresponds to 235, but you get to do one more block. If you count the trial
questions, you can make about 30 more mistakes than in step 1. So the odds are really good this
time.
P.S.: There are websites you should check while doing usmleworld.com. They are called USMLE
score estimators. They will let you know how much you will get approximately on the step exam
compared to your results on the usmle world.
Example: if on step 2, your average on the usmle world is greater than 69%, you are guaranteed to
have a 99.

STEP 2 CS
Again, let me tell you about the things you SHOULDNT believe. The exam is not very easy, it
takes more than a week, and its definitely not like the ECOS.
This is actually the most stressful exam you will ever do. Dont forget, you are a foreign student,
going to a foreign country possibly for the first time, and you will be presenting an oral exam in a
foreign language. You have paid about 1200$ for the exam, a minimum of 1700$ for the ticket +
hotel stay and Im not even mentioning the pocket money or the jet lag. In other words, the stakes
are high and you are not allowed to fail! That makes it a lot harder!
Lets first start by understanding why the exam was made, and what it consists of:
1. Purpose of the exam
American residency programs get a countless numbers of applicants each year. Many of these people
are from China, India, the Middle East, Africa and some countries we havent even heard of. The
programs need to make sure that they are considering people with a good grasp of English, not with
the Go make coffee to Madame type of English. They need to be sure that these people can make
themselves understood. They also need nice and polite people, people that will not hit a patient in the
face. Thats why the CS was created.
2. CS grading system
The CS exam is made of three parts: English skills, communication skills and medical skills. The
exam is not graded. It is a pass or fail exam. However, you need to pass each of the three parts in
order to pass the test.
I will go through the details of every part later on, but what you should know for now, is that the
ONLY parts that USJ students fail is the communication skill. So you should not worry about your
English or your medical knowledge.
What to do:
First of all, go to the official ECFMG website and download the free video on the CS. Its about 20
minutes long and it will show you the whole setting of the exam. Thats the same video that you will
see on the day of the exam, right before starting.
Second, go www.usmleworld.com and register. It will cost you about 50$ but believe me, it is worth
every cent. You will have approximately 90 cases and 20 videos (See data gathering).
Third, keep in mind that the first aid is NOT a must. If you have it, read the first part, i.e. the part
concerning the exam. You can skip the cases because they are not very relevant, but if you choose to
do them, wait until you have finished every case on the website.
Fourth, practice, practice and practice!!! Ideally, schedule your exam with one of your friends and
rehearse together.

DATA GATHERING:
The first principle to keep in mind is that CS is NOT the Ecos. The 2 exams are TOTALLY
different:

First, when you are doing the Ecos, you are standing in front of a very bad actor: the simulator
barely read the case once or twice.
Second, and to make things worse, the simulator is being backed by a doctor. So in other words, you
are expected to only ask intelligent and relevant questions. For example, if you ask the simulator to
tell you about his family history, the doctor may interrupt you and say: what are you asking about
specifically??
Third, the Ecos is mainly about differential diagnosis, i.e., if someone is complaining of headaches,
you will have to ask about migraine, cluster headaches, tension headaches and that includes
detailed questions such as relation to coffee and chocolate or whether the patient ate at a Chinese
restaurant 2 days ago.
The CS is completely different. First, the actors are professionals. They have seen thousands of
applicants like you, and they really know how to handle their cases. What makes it even easier is the
setting of the exam. In deed, even during the first case, you will feel that you are facing a real patient
and even though you are stressed at the beginning, you will forget about it very soon. Second, the
concept of the exam is different. It is not about getting the differentials, but more about gathering a
full history, like a real observation. So despite the fact that you should get the differentials, they do
not represent more than 20% of the questions you should ask. Third, the actors are usually nice and
compliant. If you ask about their family history, they will willingly tell you that their father is
diabetic, their mother hypertensive and that their older brother died of colon cancer. They will share
all these information whether or not it is relevant to the case.
How to study the cases:
Again, please keep in mind that the differentials barely represent 20% of the questions you should
ask. The bulk is mainly the ROS, PMH, FH, SxH..
The model you should follow is HRP ASS FM:
H: History (Hx)
This part varies according to the cases. The general rule is to always ask around 6-8 questions about
the main complaint, i.e. if the patient is C/O about cough, ask about its onset, presence of blood,
sputum, quantity, color Then have in mind about 4 differentials and ask 1-2 questions about each
one. This is pretty much ALL you have to do for this part.
R: Review of Systems (ROS)
Dont be extensive. Ask a total of 5-8 questions according to your time.
General: Weight loss, Apetite, fatigue. ALWAYS ASK THESE THREE QUESTIONS!!!!
Neurology: Numbness, headaches, vertigo
Cardiology/pneumology: Chest pain, heart racing, shortness of breath
GI: Change in stool pattern, abdominal pain, nausea
Urinary tract: Change in urine color, burning
P: Past Medical History (PMH): Health problems, previous hospital admissions
A: Allergies: in general and specifically to medication
S: Social History (SH): tobacco, alcohol (ask the CAGE questionnaire only in patient with high
alcohol consumption), drugs, job (always ask about it), travel

S: Sexual History (SxH): Are you sexually active How many sexual partners do you have Do
you use protection Have you (or your partner) ever had an STD
F: Family History (FH)
M: Medications: If the simulator told you about a drug and you didnt properly understand its name,
tell him to spell it. He will not penalize you for that.
So why will you NEVER fail the data gathering?? As you see, if you got a very difficult case and
missed the whole Hx part, but asked all the remaining questions (RP ASS FM), you will get over
70% of the case. There is no need to worry!
The physical exam:
Download the videos from usmleworld.com. You dont have to do everything the examiner does.
But according to the cases, you might have to be somewhat complete i.e. if you have a chest pain
case, you should do a complete heart/lung examination and that includes inspection-percussionpalpation-auscultation. Just try to be a bit more selective. Dont forget that you are racing against the
time. Always do the HEENT. It is useful in 90% of the cases. Keep in mind that in cases where you
have to do a neurological examination, you will not have the time to examine any other part of the
body. It will be good if you manage to put your stethoscope on the heart and lungs for 5 seconds.
Another important hint: the simulator is acting, and so should you! When you put the stethoscope on
the patient, you dont have to actually listen. You are being graded for the gesture only. I know that
the first aid says the actor may do sounds to simulate for ronchi or crackles but this never happened
with anyone I know. To tell you the truth, I think its just a stupid myth.
Writing down the history:
After each case, you are allowed 10 minutes to write down the history. Here are some hints
regarding what to do:
- You will be given the choice to either write it down, or type it on the computer. Even if you
are very fast at typing, I advise to go for the writing because it is much better for space
management. If you choose to type, you will have to use the available space given to you i.e.
the numbers of letters they allow you to use. But if you write, you could always make your
handwriting smaller to fit the last remaining words.
- You should definitely use abbreviations. However, use only the very well known
abbreviations. I suggest you view the ones used throughout the cases of the usmleworld.com.
- Practice by writing down at least 10 cases. The first aid offers blank pages similar the ones
youll get during the actual exam. Use them in order to learn proper space management. I
would also recommend you to use a chronometer. Time is really tight and the 10 allotted
minutes will be gone before you even notice.

ENGLISH SKILLS:
Rest assured. There is no way you fail this part either. As long as you can make yourself understood,
its fine. It will probably be better if you spend sometime in the States before doing the exam. But if

10

you dont, its not a problem. If you prepared yourself well, you should be speaking mechanically,
without even thinking about your sentences.

COMMUNICATION SKILLS:
This is certainly not the hardest part of the exam. But paradoxically, this is the only part our students
fail. The reason for that is because they are MISINFORMED. If you do what I tell you, you should
have no trouble at all!
What you should know is that the simulators also have a checklist. If you manage to fill it
appropriately, mabrouk! Youre done. These are the things you should do:
- Knock on the door.
- Say good morning.
- Call the patient by Mr./Ms followed by his/her last name.
- Introduce yourself. You can give your name or a false name, it doesnt really matter.
- Maintain eye contact.
- Place a drape on the patient. The drape is on your chair. So I would suggest you drape the
patient before sitting down. That way you are sure not to forget.
- Use 1-2 open ended questions at the beginning: Tell me Mr. X, what brings you here? Can
you tell me more about it?
- Then move to the HRP ASS FM. Beware however, you have to use a transition sentence
before moving to the next part, i.e. after you are done with the H, you tell the patient: Now I
am going to ask you a few general questions (ROS), do you mind? When youre done with
the ROS, youd tell the patient: Now I am going to ask you some questions about your past
medical history, do you mind? and so forth. Use a transition sentences before EACH part of
the RP ASS FM.
- Once you are done with the history taking, you should ask the patient: Is there anything you
wish to add? At this point, he will probably fill the missing gaps of the history if there are
any left i.e. he may tell you yes, I was also feeling a bit nauseated.
- Washing of the hands: before doing the physical exam, you are expected to wash your hands.
Now it is not the end of the world if you forget. After all, it is only ONE checkpoint on the
simulators check list. However, I would advise to add the following sentence at the end of
the history taking: If you would please excuse me while I go wash my hands. That way,
you are sure to remember.
- During the physical exam (PE), you have to ask the patients permission before each move.
I will untie your gown, do you mind? I am going to listen to your lungs, do you mind? I
am going to palpate your belly, do you mind?. Do so before EACH AND EVERY one of
your gestures.
- After you are done with the PE, sit down again and quickly summarize the case. You dont
have to be extensive. Just do it in a couple of sentences. Dont forget that the simulator has a
checklist, so it does not matter whether you say all the information or half of it. If you only
said lets summarize, you will get the point.
- After the summary, expose the possible differentials. Dont be specific. Just give a vague
discussion and tell him you will have to wait for the test results: From what you have told
me Mr. X, I am considering 3 possibilities (Name them). Well have to run some blood tests
before we can be sure about the diagnosis. I will get back to you with the results.

11

Then counsel the patient. If hes a smoker, advise him to stop smoking. If hes got EBV
tonsillitis, advise him to avoid contact sports.
- Finally, ask another open ended question: Is there anything you wish to ask me?
- Say a nice word i.e. well Mr. X, it was really nice to meet you. Shake hands and leave the
room.
At one point in each of the cases, you will be asked a challenging question such as Do I have
cancer? Am I going to die When will I be able to walk again Dont panic. A single answer
can be used for all challenging questions It is certainly a possibility. But before we can be sure, we
should run some blood tests The concept is not to give any drastic answer or false reassurance
such as Rest assured! You dont have cancer! You have to remain vague. The usmleworld.com
and the first aid will give many examples of challenging questions. Take a look on them. They can
be very handy.
-

GENERAL HINTS:
For each of the cases, have a small plan i.e. a list of 3-6 points containing the differentials. For
instance, if a woman is C/O fatigue, the plan you should have is: depression hypothyroidism
cancer chronic infection. During the CS exam, when you are standing at the door in preparation for
the case, take 30-40 seconds to write it down. That way, when you go inside the room, you will be
ready to face the patient.
You are allotted 15 minutes for each patient encounter. Take 8 minutes for the history taking. You
should be doing the physical examination when the first bell rings (at 10 minutes). The physical
examination must not take more than 3-5 minutes. Practice with a partner, and have the cases timed.
You will receive your step score 8 weeks after the exam. However, beware of one detail. After the
middle of June, it will take up to 3 months before you receive the grade. So go the ECFMG website
and look for a score report calendar. It will tell you when you should expect your score according to
the timeframe during which you did your exam. For example, if you did your exam between June
27th and July the 31st, you will get your score report after September the 15th. Why am I telling you
about this? Because you should try to have your score before September!!!! Or else, you will be
disadvantaged during the interview season.

12

STEP 3
This exam is not a must. It will not affect the matching process in any away, especially the residency
matching. Up till now, it is not even considered important for the fellowship. The reason is simple:
residents apply for the fellowship match around the middle of the PGY2 (R2) year and most of them
take the step 3 during the PGY3 (R3) year. This means that when they match for fellowship, they
havent even done the step 3 yet. This is why the test is considered almost as a pass or fail test.
Why should you take it? The only reason that would push you to take this exam before going to the
States is the VISA. You cannot go on an H-1 VISA if you dont have a valid step 3 score. The VISA
issues will be discussed later on.
If I decide to take it, what should I do?
As you have seen, the answer is always: usmleworld.com. You dont need to buy or even look at any
book.
The exam is divided into two parts. The first part is made of questions quite similar to that of step 2.
The second part is made of clinical cases. Usmleworld.com offers both questions and cases.
The questions of the exam (both usmleworld and the actual step 3 exam) are extremely difficult. No
matter how good you are, you will still find it hard to get a high percentage of accurate answer. So
the key to getting a good grade is to focus on the cases. Prepare ALL the cases, and prepare them
well. It will really make a big difference. My performance during the exam was slightly above
average for the questions, but excellent for the cases. I ended up with a 96 (226).
My final advice to you is to take it before going to the States regardless of the VISA. I personally
found that it is better to take it not too far from step 1 and step 2. The type of questions is not very
different. If you wait till PGY3, you would have probably forgotten most of the relevant information.

13

PART II:
THE AMERICAN
EXPERIENCE

14

ELECTIVES
Before applying to the match, you must have some kind of experience in the United States. Many
programs consider this as a requirement, but even when they dont, your application will certainly
look much more appealing if you did at least one elective in the states. The more electives you do,
the better it is!
Why is the elective so important?
1. Because you need TWO letters of recommendation from the States. A section of this booklet will
be dedicated to the letters of recommendation.
2. Because you need to establish a contact. The importance of contacts will also be discussed later
on. Here is what you should know for now: it is extremely important for the program to put a face on
the applicants name. In other words, you have a lot more chances to get accepted in a program in
which you did an elective than in a program that has never heard of you. This is why you have to
pick TARGETED electives i.e. do the elective in a place that is foreigner friendly, a place that is
willing to accept foreigners.
Many people would find it tempting to do the elective in a very well known program such as Johns
Hopkins or Harvard. The idea is not bad because a good recommendation letter from such a program
is a big asset no matter where you are applying. However, keep in mind that programs such as these
will NEVER accept a foreigner. So while it may be justified to do one elective there, it will certainly
be stupid to do more.
Keep in mind that when you first go to the States, you might not be able to get an excellent
recommendation letter. After all, you are new to the system; you are probably doing your 6 th year
which means you dont have a big in hospital experience and you havent studied the steps yet. It
is still important to go! That way, you will be ready for your second elective and you will be sure to
get excellent recommendation letters.
As I was saying, you should try to do your elective in a place willing to take foreigners such as
Cleveland Clinic. I cannot name all these programs but as a general rule, try to find where you
predecessors got accepted. You can check the contact list at the end of to booklet to get a proper
idea on where to apply.

15

RECOMMENDATION LETTERS
You will be asked to provide the programs with 4 letters of recommendation (LOR). Keep in mind
that it is important to get letters from Lebanon and the USA. If you send 4 LORs from the States, it
will sound suspicious, i.e. the programs will think that you are not in good terms with USJ. Dont
forget that people in the States worked with you for a month. They cant possibly know more about
you than your own school. Bottom line: you have to get 2 LORs from Lebanon and 2 from the
States.

How to recognize a good LOR

A good recommendation letter has many characteristics. I will quickly expose them then Ill try to
dissect some of the LORs we were able to get so you can have proper picture.
The writer of the letter should start by introducing himself. Then he should introduce the applicant
and describe how their paths crossed. The subjects that should be mentioned are the following:
- Relationship with pears: team player, ethical, liked and respected
- Medical skills: analysis, clinical judgment If the doctor really likes you, he might compare
your skills to that of a resident.
- Academic skills (If applicable): someone writing from USJ could mention your behavior in
class, your academic achievements (scholarships).
- Special kills: speaks three languages, elected class representative, first in his class
- Personality: hard worker, serious, dedicated, enthusiastic, avid learner
- Length of the letter: should fill at least a full page.
- Personal experience: the doctor could write about a specific event i.e. something you did
really well such as a presentation, a clever behavior to avoid a confrontation with an unhappy
patient
Hidden messages
Keep in mind that the letters are written in a special way, almost like a code. Good means average,
excellent means good, and outstanding well if you get an outstanding, you certainly are
outstanding because this is the best word you can get. Also keep in mind that if a subject is skipped,
it COULD imply that this particular point is negative. For example, if a doctor does not mention
your relationship with your pears, it COULD imply that the relationship wasnt very good.
Waiving your letters
When you send the LORs to MyEras, you can either send letters you saw, or you can waive your
right to see your letters. If you waive your right, the letter will be sent directly by the doctor and you
will NOT get to see it. Theoretically, it is better to waive your letters. It will show that you are
confident and sure about the impact you had on the doctor. However, it is also a double edged sword
because the doctor may write something bad about you and that will surely ruin your plans. So no
matter how confident you feel about yourself, unless you personally know the doctor, dont waive
the letters. I know people who were able to see their letters and waive them still. Apparently, they
were nice to the secretary and she showed them the LOR before waiving it. If you manage to do it,
its excellent. I didnt. Thats why I did not waive my letters.

16

Presentation
Be advised that Americans give a particular attention to organization. The LOR should contain NO
typing errors and NO grammatical mistakes. It should be written on an official hospital paper. So
please, make sure that the Lebanese doctor writing your LOR prints it on an OFFICIAL paper i.e. a
paper with the HDF sign on top of it.
Samples
I will now provide you with five samples, two of which I wrote. The other three are LORs Serge
Harb and I got from Cleveland Clinic. I will also be commenting each of the LORs.

17

Sample 1
July 31st, 2009
RE: Georges Nakhoul
Dear colleague,
I am writing this letter in support of the application of Dr. Georges NAKHOUL to a
residency position at your program. Georges graduated from Saint-Joseph University school of
Medicine (Beirut, Lebanon) in June 2009. He is currently a first year resident in internal medicine at
Hotel-Dieu de France Hospital. I have had the chance to observe Georges during several levels of
his 7-year medical studies. I was also personally in charge of him during his rotation of internal
medicine.
Georges was an outstanding student. Throughout his academic years, he obtained excellent
results, and was ranked among the first ten students of his class. He was avid to learn and always
showed great interest and enthusiasm towards the various courses and medical cases. He was
always thoroughly prepared and genuinely engaged in the subject of his studies, raising the most
pertinent questions. His problem solving skills were remarkable.
As a medical trainee, he showed knowledge clearly superior to what is expected for his level
of training. He is smart, composed and cultured. He proved on several occasions that he has an
excellent clinical judgment and his suggestions were often welcomed and valued. I was impressed by
the depth and quality of his clinical decisions, and by his continuous interaction in conferences and
on clinical rounds.
Georges was also a team player and a pleasant, easy going young man. I was not surprised
when I learned that he was elected class representative for three consecutive years. His kindness and
polite behavior earned him the appreciation of his colleagues and the respect and esteem of all the
hospital staff.
I am also aware that he wrote a review on military injuries during the war that opposed the
Lebanese army and a terrorist faction in May 2007. The study aimed at estimating the mortality and
morbidity of the war on Lebanese soldiers. Georges actually did a gigantic effort and worked on the
files of more than 3000 army casualties. He even got to personally present the study to the
commander in chief of the Lebanese Armed Forces and received his full support. I hope the study
will be published soon.
Georges is also a very hard worker. He was always the first to arrive and the last to leave.
Throughout his clerkships, he was fully dedicated to his work and took care of his patients with
patience, concern and consideration. His approach was mature, confident and compassionate,
which was very comforting to the patients as well as to their families. In fact, Georges is very
devoted to humanitarian work in general. He is an honest and conscientious person and he
possesses all the qualities of a good physician, both from the medical as well as the moral and social
perspectives.

18

In summary, I would say Georges is definitely one of our FINEST residents. He is clever,
competent, zealous, but EQUALLY humble, trustworthy and compassionate. I am sure he will be a
great addition to any program. If I can be of further assistance, please feel free to contact me at 00961-3-### ###.
Sincerely,

SIGNATURE

NAME, MD
Associate Professor in Internal Medicine,,
Htel- Dieu de France Hospital, Saint- Joseph University
Beirut, Lebanon

As you see, the first paragraph introduces the student as well as the relationship the doctor had with
him. The second mentions the academic performance, the third the medical skills. The fourth and the
sixth describe the personality and the relationship with pears and the fifth highlights the work I did
on my thesis (special feature).
The letter is slightly over a page long and the words used are very strong.

19

Sample 2
July 24th, 2009
Re: Serge Harb

Dear Colleagues,
I am very pleased to provide a letter of support for Dr. Serge Harb. I have worked with him
during his XXXXX rotation in September 2007 and as a medical student, and I have found him to be
a very talented physician with creative and innovative approaches to problem-solving in neurology
and internal medicine.

He was an A plus medical student at Saint Joseph University- Faculty of Medicine. He

graduated in June 2009 with honors and was ranked top of his class. He was also granted
scholarships as a reward for his brilliant results. His perfect academic record was complemented by
a research he did on a new marker of acute myocardial infarction, the CD 40 ligand. I know he
worked really hard on that study: he used to go the hospital at night in order to enroll patients, and
managed to collect more than 200 patients in a very short time. Dr. Harb also wrote a textbook
providing algorithms on ECG interpretation. I personally found the book very useful since it
provides simple and concise hints placing ECG interpretation under the grasp of all medical
students.

Serge is currently an intern at Htel - Dieu de France Hospital where I get to discuss with
him cases on the medical ward. I have been impressed on numerous occasions by the depth of his
clinical judgment and by the power of his analyzing capacities. He always showed enthusiasm and
interest during the conferences and on the clinical rounds He is smart, hard working and reliable,
but also kind and compassionate which was very comforting for patients.

During his residency, he is demonstrating exceptional self-motivation for research. He is

currently conducting a study on the effects of ezetimibe on small dense LDL and on oxidized LDL.

On a personal note, Serge has been a pleasure to work with in the inpatient services. He is
kind and polite, and he was liked and respected by his colleagues as well as by the hospital staff.

In summary, Dr Harb is an exceptional student. He possesses a tremendous potential and is

certainly well qualified to become a superb academic internist. His conscientious concern for
patients, his interest and aptitude for clinical research, and his teaching ability will make him an

20

asset to any institution with which he affiliates. I therefore strongly recommend him for your
program.
Sincerely,

SIGNATURE

NAME, MD
American Board of XXXXX and XXXXX
Ass. Professor of XXXXXXX
Htel- Dieu de France Hospital, Saint- Joseph University
Beirut, Lebanon
Tel: 961 1615300, ext. ####
Email: XXXXXXXXXXXXXX@hdf.usj.edu.lb
Again, all the relevant subjects are mentioned but in a different order. The LOR is large enough and
the words used are very strong.

21

Sample 3

Note that this letter is written on an official CCF paper. The doctor mentioned a specific incident: I
felt somewhat embarrassed

22

Sample 4

23

As you probably noted, what makes this LOR unique is the strength of the words used. The word
outstanding is written THREE times in the last paragraph. The word superb is written twice and
the sentence extremely well is used twice. If you get a letter like that from a program, you are
certain to get in!!!
I know this might not be relevant to you, but I want you to know that this guy got his LOR after
working with the doctor for 10 days only! This is just to tell you how impressive you can be if you
are motivated enough!

24

Sample 5

25

Note that in this LOR, the doctor mentioned that I refused to waive my right to see the letter. Of
course, this is certainly not ideal. Despite the fact that this LOR was good, I only sent it to the
program I got it from. I preferred not to send it to other programs and to tell you the truth, I was
lucky because I had another LOR from a different program, so it didnt really matter. You might not
have the choice. It is still OK. I know a friend that sent a LOR with a similar sentence. She still got
accepted in an excellent program.

26

PART III:
THE MATCHING
PROCESS

27

WHERE TO APPLY
As IMGs (international medical graduates), we have to apply to no less than 60 programs. Some
even chose to apply for a hundred. The process of forming the list of programs is really draining.
Each program has a website with specific requirements regarding the application i.e. some require a
year of experience in the states, others will ask for step scores over 90 If you plan to consult each
and every website to see whether or not you fill the requirements, you will need at least a month to
form your list. To tell you the truth, I dont think its worth it. The only thing you will gain by NOT
applying to a program is a few dollars. So you might as well apply for a program and if you dont fill
its requirements, well get a rejection! So what? It will save you a lot of time. Remember that no
matter what you do, and unless you apply for really bad programs, you probably wont get more than
12-15 interviews. So you are getting around 60 rejections anyway right?
I will now give you a list of the programs my friends and I applied to. To make things easier, I will
divide them into three categories. Category I includes the most competitive programs. Usually, these
programs are affiliated with big universities and they attract the best students in America. Most of
them dont take foreigners by POLICY. So in order to get in, you need either a very big WASTA
(for programs such as Johns Hopkins, MGH) or at least a decent contact (for programs such as
University of Iowa, University of Indiana). The issue regarding the contacts will be discussed
separately. Category II includes good to average programs. Of course, a good contact is always
welcome; however, you can expect to get an interview if you have an excellent file. Category III
includes ordinary programs; many of these are community programs, but some are university
programs. With a decent file, you will probably get an interview in these programs.
LIST OF PROGRAMS
Category I
- Cleveland Clinic Foundation - Ohio
- University Hospitals Case Medical Center program (Case western) Ohio
- University of Michigan program, Ann Arbor Michigan
- Duke University North Carolina
- Vanderbilt University program Tenessee
- Emory University Program Atlanta
- Johns Hopkins University program (main program not Bayview) Maryland
- Beth Israel (Albert Einstein) New York
- New York University Medical Center New York
- New York Presbyterian Hospital; Columbia New York
- New York Downtown hospital; Weil Cornell New York
- University of Chicago Chicago
- Mayo Clinic, Rochester MN
- Indiana University Indiana
- University of Iowa Hospitals and Clinics program Iowa
- University of Kansas school of Medicine program Kansas
- University of Pennsylvania - Philadelphia
- University of Pittsburg Philadelphia
- Yale-New Haven Medical Center Connecticut

28

Boston University Medical Center Program Boston

Beth Israel Deaconess Medical Center Program Boston
Massachusetts General Hospital (MGH = Harvard) program Boston
University of Massachusetts Medical Program Boston
Brigham and Womens Hospital Program - Boston
University of Texas Houston program Texas
Baylor University Medical Center Texas
Washington University (WSHU) Saint Louis MO
Georgetown University District of Columbia
George Washington University District of Columbia
University of Florida, Gainesville Florida
University of Florida, Jacksonville Florida
UCLA California
UCSF California
Brown University Program Rhode Island
Tufts Medical Center Program Boston

Category II
- University of Cincinnati Ohio
- Ohio State University program Ohio
- Case Western Reserve University (Metrohealth) Program Ohio
- University of North Carolina North Carolina
- Greater Baltimore Medical Center (GBMC) Maryland
- University of Maryland Maryland
- Saint Lukes-Roosevelt hospital program NY
- SUNY Upstate at Syracuse medical program NY
- SUNY Buffalo Graduate Medical Dental Education Program NY
- Albany Medical Center NY
- Caritas Saint Elizabeths Medical Center Boston
- University of Illinois Chicago Chicago
- Saint Louis University Group of Hospitals Program Missouri
- Tulane University Program Louisiana
- University of Connecticut Connecticut
Category III
- Henry Ford Hospital Program Michigan
- Wayne State University Michigan
- East Tennessee University Program Tennessee
- Good Samaritan Hospital of Maryland Program Maryland
- Union Memorial Hospital Program Maryland
- Staten Island Hospital Program New York
- John H. Stroger Jr. Hospital of Cook County Chicago
- University of Kansas (Wichita) Program Kansas

29

UMDNJ-Robert Wood Johnson medical School (Cooper) New Jersey

Hospital of Saint Raphael Program Connecticut
Saint Lukes hospital program Missouri

30

INTERVIEWING
Ok, so you did everything right so far, and you got invited to an interview. Now what? Well, here is
what you should know: first of all, the interview process is EXTREMELY draining. After your
second interview, you will start to feel really tired. You have to put on a nice face all the time, repeat
the same sentences, and spend the whole day looking interested. You will be probably getting very
similar presentation and you have to ask preformed questions over and over again. But what can you
do? There is no other choice but to follow the standard procedure.
I would recommend you to buy the book called first aid for the match. I would also recommend
the website: www.studentdoctors.net. They provide you with interesting hints and feedbacks on the
different programs.
During the interview day, you will be interviewing 1-4 doctors for 10-30 minutes depending on the
program. Each interviewer will ask you a few questions, and when hes done, you will be expected
to ask some questions as well. That shows how interested you are in the program. Keep in mind that
while you have to be prepared to some extent, the interview is NOT an oral exam. It will be
conducted just like a normal conversation. You dont have to feel stressed at all. Also be advised to
do your first two interviews in your least important programs. Consider them as mock interviews
and use them to get acquainted a little bit with the system.
You will also be allotted some time with the residents. You are supposed to ask them questions
about their opinion in the program, their experiences All these issues will be developed in the upcoming paragraph.
Questions asked by the programs:
I will give you now the most frequent questions thrown on the applicants during the interview. There
is no right and wrong answers. I am only giving you some examples. No matter what you do, keep it
simple and be as honest as possible.
- Q: Why did you choose internal medicine?
A: Because I like challenging medical cases, because of the vast diversity of cases, because I
like human contact with patients
-

Q: What are you looking for in a residency program

A: I expect from the program to:
o Have a high board pass rate
o Give priority to education
o Have a great continuity clinic (if applying to the primary care field)
o Offer research opportunities

Q: Why did you choose our program?

A: The answer is similar to the one above. However, try to make it a bit more specific. Go to
the programs website and find something particular about it. You can even mention its
location; for example: I always wanted to live in New York.

Q: What are your strengths and your weaknesses?

A: I believe I am:

31

o Strong willed, hard working, smart, team player

o But the main disadvantage is that I will be alone, away from my family you can say
you are perfectionist, a bit obsessed. When you are naming a weakness, dont say
something that will scare the program, or make you look bad. For example, dont say
you have problems adjusting with change or that you hate calls
-

Q: Tell me about yourself

A: Name your strengths (see previous question). Also give some details on your academic
performance, highlight your special skills or hobbies: basketball player, writer, class
representative. Always remember that during the interview day, you are trying to promote
yourself so dont be shy or modest.

Q: Tell me about your plan

A: I am planning to be a cardiologist, oncologist I plan to return to my country/stay in the
States

Q: Describe an interesting case

A: Invent any case you want. Just memorize it well. Have two cases ready in your head.

Q: Why do you want to be a doctor?

A: Because I love medicine; medicine allows me to help people, to make a difference

Q: What have you done in your life that shows that you are hard working and dedicated?
A: Ill let you think of something. Remember: the answer does not have to be restricted to
medicine.

Q: What are your hobbies?

A: Sports, writing, traveling, whatever crosses your mind

Q: Why should we pick you? What can you offer to the program?
A: Because (Review the part on strengths).

Q: Where else have you applied?

A: Many programs on the east cost, Midwest

Q: Do you see problems in managing both a professional and a personal life?

A: Of course not! I am very organized. I kept a good ranking in school and managed to keep
up with my hobbies: sports, music

Q: What is the one event you are proudest of in your life?

A: Ill let you think of something

Q: Why did you leave your country? Why did you choose America?
A: Because I want to get the best medical training possible and America is the place to be.
That way, when I return to my country, I will be able to spread the knowledge

32

Q: Describe yourself in three words.

A: Smart, dedicated, friendly, hard working, team player

Q: Most memorable patient encounter?

A: Think of case!

Q: Who are your heroes?

A: Cant say who yours are, but be prepared to answer the question.

Q: Which type of patient population do you have most trouble working with?
A: Pediatric population because the communication with children is hard.

Q: Would you have trouble working in a predominantly Catholic (or Jewish) hospital?
A: Of course not. We have 18 confessions in Lebanon and we know how to deal with
diversity.

Q: What books have you read recently?

A: Think of something!

Note 1: dont forget to read everything related to your thesis and your personal statement because
they may ask you a lot of questions about them.
Note 2: most of the programs will invite you to a dinner the night before the interview. Most of the
times, this is a complete waste of time, and your presence is not required. Only in one of my
interviews was the dinner actually being monitored. But since it is not possible to know, I would
advise you to go to all dinner. There is nothing to loose, and if you are lucky, the food might actually
be good.
Questions you should ask the program:
At the end of the interview, the interviewer will ask you whether or not you have questions. Even if
you feel you dont, you should ask at least 2 or 3 to look interested. I will give you a few samples to
choose from:
- Regarding fellowship: how easy is it to get a fellowship? What percentage of graduates
enters fellowships? Where do your residents match? Do you tend to favor your residents?
- Regarding research: what are the research opportunities? Is there any research protected
time? Does the program fund national/regional conferences?
- Regarding patient population: what type of patients do we deal with? Do we see a large
variety of cases?
- Regarding teaching: how many conferences do we have every week? Are all the rounds
teaching rounds
Of course, if you are interviewing in a small community hospital, then its probably not a great idea
to focus on research. No matter which program you are applying to dont ask your interviewers
questions regarding every days problems such as: where to live, how safe the area is, call
schedule If you do feel there is an issue that needs clarification, leave it to the residents.

33

Questions to ask to the residents:

Unlike the former part, there is no must/should in this paragraph. Residents are usually here to
help answer your most common questions but they are not monitoring you. Feel free to drop any
comment that crosses your mind and stay quiet if you dont feel like talking. Of course, this is true
with regular residents/interns, not with the chiefs.
Again, here are some samples, but keep in mind that this is the least important part:
- What do you like/dislike most about the program? What are its strengths/weaknesses?
- Which institution did you graduate from?
- How safe is the city?
- Ask about the call schedule; ask about the teaching/conferences.
- As about patient load; ask about supervision/autonomy.
- Where do you live?
- Do you have time to read?

34

CONCTACTS
If you think about the odds of matching in a good place, there is a good chance you may end up
feeling depressed. After all, you are one among the thousands of doctors applying. However, what
may seem impossible from outside the system will certainly be feasible if you have proper contacts.
Allow me to explain: as foreigners, our files get discarded even BEFORE reaching the hands of the
program directors. Many programs dont take foreigners by policy, and even those who do will give
priority to students from programs they know. Needless to say that in this particular matter we are a
thousand light years behind the students of AUB. Please understand that a contact does NOT always
mean a wasta the Lebanese way. It could simply be a resident willing to push your application. If
your file is good, then the program will be more than happy to send you an interview. I will now
relate a few of our experiences:
1. The interviews at Iowa: there are 2 USJ graduates in the internal medicine program; Georges
Hajj, a third year resident and Samer Badr, a second year resident. Serge Harb and I got in
touch with them when we got to the US. They mentioned us to the program, and when the
director saw our files, the interview was automatically sent to us. The other students from
USJ who had also applied to Iowa did not receive interviews. If you look at their files, I
believe they were certainly eligible of getting the interview. However, they lacked the
contact
2. Georgetown: Serge Harb and I had both applied to Georgetown. I can say without hesitation
that, whether we look at the grades, the letters of recommendation, the research
experience, Serges file is better than mine by far. However, I was the one who got the
interview. Why? I think you guessed by now: because of CONTACTS. I happened to know a
Lebanese GI attending there called Dr. Nadim Haddad. It was he who pushed my application.
3. Yale: Roland Assi got an interview at Yale and he later on matched in Preliminary Surgery.
Again, the equation is simple: he had a contact; Dr. Sabet El-Hachem, a Lebanese Surgeon
from Akoura. That same doctor also helped me to get an interview in internal medicine, but I
contacted him late in the interview season, so I was back to Lebanon before having the
chance of interviewing there.
4. Case Western: I got my interview at the family medicine program through a Lebanese
attending, Dr. Georges Kikano. Serge got his interview in internal medicine through a
Lebanese attending, former USJ grad Dr. Jihane Fares. Of course, keep in mind that unless
you have a good file, no one can help you.
5. University of Massachusetts: there is a former USJ grad now a PGY2 called Joe Fahed.
Unfortunately, we didnt find out until the end of the interview season. Joe tried to help us
but the program had already sent all its invitations, so we didnt get any. Why am I telling
you this? Because I would like to urge you to act fast. Even before submitting your file, get
in touch with your contacts.
6. Johns Hopkins; what we thought to be the only notable exception When Serge Harb
received his interview at Johns Hopkins, everyone was amazed. Not only was Johns Hopkins
the number one program in the US, but it was also known to be very foreigner unfriendly: it
accepts an IMG no less than every 3-5 years. What made us even more astonished is that we
knew for a fact that Serge did NOT have any contacts there. So we started speculating on
whether it was his 30 points over the 99 that got him the interview, or his 2 publications, or

35

maybe even his outstanding recommendation letters. Needless to say the neither of us was
convinced and we were right. Serge discovered later how the interview was sent. During
his elective at Cleveland Clinic, he had worked with a fellow from Johns Hopkins and
impressed him big time. In fact, the fellow was so impressed that he wrote to his program
director of Johns Hopkins and recommended Serge. Thats why the interview was sent.
7. Cleveland Clinic: once again, this is not an exception. Although Serge and I didnt know
anyone there, we went and did a one month rotation. We managed to get very good
recommendation letters, and we asked to meet the program director. In other words, we
forged our own contact, and by the time we left, it was exactly as if we knew someone.
As you can see, we were only able to get interviews in category I programs because of contacts, and
in this particular matter, there are no exceptions. So if you hear someone saying he did it all by
himself, dont believe him. Even if hes the Einstein of the 21st century, he still got some kind of
help. Be advised that AUB graduates are more than willing to assist us. So dont hesitate to ask them
for help. Hopefully, you will be able to return the favor one day.
THE LIST:
As I was saying, in terms of getting the proper contact, we are a thousand light year behind AUB
graduates. The reason is simple: AUB has been sending its student to the States for the past 100
years, while we were focusing on France. But this is not all; AUB actually supports and follows
most of the alumni in the States. We dont even know the people that went to the US in the past three
years. Thats why I am currently working on an updated contact list. For the time being, I have
around 35 names and emails. I recently created a PRIVATE Facebook group to try to gather all the
USJ graduates in the US. I am also trying to get USJ involved in order to make the list official.
Unfortunately, I cannot give you access to the full contact list. Many people wish to preserve their
privacy because they feel they might be overloaded with emails. I will however provide you with
some names. I also promise you to be the link between the contacts and the applicants. I already
spoke with Dr. Fady Haddad and I believe he is more than willing to play this role himself.

Name
Georges Nakhoul

Email
Program
georgesnakhoul@hotmail.com Cleveland Clinic

Serge Harb

sergeharb@hotmail.com

Cleveland Clinic

Yorg Azzi

yorgazzi@yahoo.fr

Staten Island

Roland Assi

assiroland@yahoo.com

Yale

Tarek Toubia

tarektoubia@hotmail.com

Henry Ford

Jean Abed

jean_abed@yahoo.com

St Lukes Roosevelt

Georges Azzi

Staten Island

36

Position
PGY1 Internal
Medicine
PGY1 Internal
Medicine
PGY1 Internal
Medicine
PGY1 Preliminary
surgery
PGY1 Categorical
OBGYN
PGY1 Internal
Medicine
PGY1 Internal
Medicine

Dany Gaspard

gasparddany@hotmail.com

UMDNJ Cooper

Walid Saad

UMDNJ Cooper

Carole Macaron

Cleveland Clinic

Anne-Marie
Samaha
Georges Hajj

UH Case Western

Samer Badr

University of Iowa

Hanine Hajj

University of Iowa

Jean-Pierre Khoury

UMDNJ Cooper

Joe Fahed

Massachusetts
University

University of Iowa

PGY1 Internal
Medicine
PGY3 Internal
Medicine
PGY 2 Internal
Medicine
PGY 2 Family
Medicine
PGY 3 Internal
Medicine
PGY 2 Internal
Medicine
PGY 1 Pediatrics
PGY 1 Internal
Medicine
PGY 2 Internal
Medicine

THE MATCHING PROCESS:

When you decide to go through the match and start to ask around, you will hear a ton of theories.
Each will come up with a different advice and you will end up feeling very unsure about the
outcome. Here is what you should know:
The matching process respects the priorities of both the applicant and the program. Lets suppose
that you have ranked program X as number 3 on your ranking list. As long as the programs you
ranked 1 and 2 have not filled ALL their positions, there is no way you end up in X. Only after 1 and
2 have no more available position can you expect to be in X. Be advised that this is true NO
MATTER where program X ranked you on its list.
Now lets look at it from the program point of view. Lets suppose that program X has 20 positions
and you are ranked as number 25. The matching process will first consider applicant number 1.
When applicant number 1 finds a spot in another program, the place will be vacant for applicant
number 2. The matching process will now look at applicant number 2. If he matches in the program,
the spot will be filled and the list will go down to applicant number 3 and so it goes. So if you were
ranked as number 25 in a 20 position program, and in order for you to match, five of the applicants
ahead of you have to match somewhere else.
As you can see, the priorities of both the program and the applicant were respected.
There is a small detail you must always keep in mind. I know this for sure because I was told so by a
chief resident. As foreigners, and no matter how high we are ranked, we will always be placed
AFTER the Americans. Here is an example of things go: lets suppose program X has 25 positions.
Statistically, X will interview 10 applicants for each position, roughly 250 applicants. The first 25
applicants on the list will be American MDs. The next 25 will be a mixture between American MDs
and ODs and the FIRST foreigner on the list will be ranked around 55 to 65. Now beware! This does
not mean that the foreigner will not be taken. At the contrary, each program has its own statistics.

37

For instance, if you are ranked among the first 60, you have a 90% chance of getting in. If you are
ranked between 60 and 90, your chance will be 60% and so on If the last applicant to get in
program X was ranked 120, then the year was very bad for the program but excellent for the
applicants. If the last applicant to get in program X was ranked 65, then the year was excellent for
the program but bad for the applicants.

38

VISA ISSUES
This is one of the most important issues. Most of the people I met in the states (including working
MDs) made the following statement regarding the VISA: At first, you dont think it matters. You
are young and enthusiastic and you just want to be in the States. But believe me, it will make a lot of
difference, try to get an H1. Some other people will say: Dont even think of getting an H1. It will
make the fellowship almost impossible.
Before giving my personal opinion on the matter, lets first try to understand what H1 and J1 mean.
The J1 VISA means that YOUR country is in need of a person in a given specialty. You are only
supposed to go specialize in the States and you are not allowed to stay or work there. You have to go
back to your country. However, if for some reason you dont want to go back, then you will have to
work for 3-5 years (the law is changing) in an underserved area in the States. This is what people call
the waiver. Where this underserved area really depends on your luck. You may find a place in a
nice suburb right next to a big city. But you can also be exiled to the middle of nowhere. Another
disadvantage with the J1 VISA is the fact that it has to be renewed every time you go to Lebanon.
For instance, if you go back to Lebanon in your PGY2 year, you have to renew your J1 VISA from
the American Embassy. Usually, it is not too hard to do. However, we know many people who got
stuck for 6 and 7 months before getting their clearance. They practically lost a whole year and their
spot in their program. One final disadvantage with the J1 VISA is that you cant even BEGIN
processing the greencard before completing the waiver. So if you spent 3 years doing your
residency, 3-4 years for the fellowship, add a year or two for the sub-specialty, and count 3-5 years
for the waiver, you would have spent around 10-14 years in the States without dreaming of getting a
greencard.
The J1 also have some advantages. First of all, it is valid for 7 years, which gives you enough time to
finish the fellowship and maybe even the sub-specialty. Second, it is probably easier to get a
fellowship since programs tend to sponsor J1 more than H1. This is especially true for competitive
fellowships such as cardiology and GI. Third, you will make a LOT of money during the waiver
years.
The H1 VISA means that AMERICA is in need of someone in your expertise. So you are basically
going to work in the United States because the united States need you. You are not required to do a
waiver, and you dont have to worry about renewing the VISA when you go back to Lebanon. The
major advantage of this VISA is that you can acquire a green card after having worked for two years
(When I say work, I mean after finishing the fellowship not during the training years). The problems
however are the following: First, the chances of getting a fellowship are not as good. Second, the
VISA if valid for 6 years, and that is really tight if you want to complete a subspecialty. But these
problems can both be overcome by a simple solution which is the final and most valuable advantage
of this VISA: you are allowed to work in the States.
So the scenario would be the following: you go to the States for residency. After that, if you match,
well done but if you dont then it is not a big deal. You work as hospitalist for 2 years, you get a
green card (dont forget, with the H1, you can get the green card after 2y of work) then you reapply
for fellowship. By doing so, you would have solved the fellowship issue (you are now applying as an
American citizen not as a foreigner on a VISA), and the 6 years validity issue. You would have also
gained 2 years of experience, possibly published a couple of articles and made around 150-200
thousands dollars a year. Not bad!

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Another possible and even better scenario is to go to the States for a paid research position on an H1
Visa. Do two years of research (research is equivalent to work not training) then apply for the green
card. The green card will be processed during your first-second year of residency, so when you apply
for the fellowship match, you would be applying as an American citizen. No more VISA issues!!!! I
would highly recommend you to follow this track if you are aiming for a competitive fellowship.
Dont be scared of loosing two years. Research is not a loss, at the contrary; it is a must if you are
targeting a competitive fellowship.

The main ideas are summarized in the following table:

Validity
Chances of getting a
competitive fellowship
Chances of getting a non
competitive fellowship
Chances of getting stuck in
Lebanon
Waiver
Green Card

Outcome

H1
6y
Lower

J1
7y
Low

Good

Good

Insignificant

Low but real

Not an issue
Accessible after 2y of work

Mandatory
Only possible at the end of
the training AND after
switching to the H1 visa for
2 years
Fair

Better!!!! Solutions are

always available since you
are allowed to WORK.

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FINAL ADVICES
Always keep in mind that you are following a very difficult path. When things go wrong or simply
when you are having a bad day, there are two things that can keep you walking:
1. Friends: it would be great if you could find a study partner. Rudy and Tarek worked together
all along, and so did Serge and me. We even ended up matching in the same place. Believe,
when you are lonely and depressed, especially if you are going to present the CS, its a
blessing to have someone standing by you. So drop all competition and find yourself a friend
with similar goals.
2. Faith: even if you are the smartest man on earth, you will still require a small push from the
Creator. Here are the most valuable tools I used through my journey. I hope you get to
discover their powers yourself:

A. For Inspiration:
Chaplet of the Holy Spirit

B. For Inner Peace:

The Holy Rosary

C. When You Need a Miracle:

Ste Ritas Novena

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CONCLUSION: OUR STORY

Six people began the journey and six ended up with a happy conclusion:
Rudy Rahme was the first to leave. He is currently doing a year of paid
research in neurosurgery and is quite comfortable about getting a residency next
year. Salah Aoun and Remy Daou chose to stay. Nevertheless, they both managed to
get above 250 on the step 1 and passed the CS. Tarek Toubia matched in Henry Ford
(categorical OBGYN). Of the 14 interview invitations Serge Harb received, he only
did 6 and he was offered 5 pre-matches. The only program who didnt offer him a prematch was Johns Hopkins. Serge felt it was too risky to go through the match with a
single program so he ended up taking the position at Cleveland Clinic.

As for me, I actually had to gamble to get what I wanted. I was invited to 11
programs. After doing my first mock interview in Cook County, I realized that there
was no way I would go to a community program. So I dropped my interviews in St
Raphael, Staten Island, Union Memorial, Good Samaritan and Caritas St Elizabeth. I
actually refused two pre-matches, one of which was in an excellent program. I did so
because I wanted to take the chance to end up with my friends, and I am glad I did. I
matched in Cleveland Clinic. Of all the interviews I did, I found Iowa to be the best
program. Not only does it have excellent standards of education, but it is probably the
friendliest program I have ever seen. I therefore strongly recommend it.

If you are still reading this book, then you are probably quite serious about
residency in the States. Thats the first step in succeeding and I am sure you will make
it. Just remember, when you need a hand, you can always count on your predecessors.
Good luck

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SPECIAL THANKS:
I would like to thank all the people that helped me through this long journey:
-

My parents for their endless support,

Prof. Ass. Fady Haddad for his patience and understanding. He is one of the rare people
who would never stand in the way of a student,

All the residents in the States, especially Georges Hajj for his unconditional backup, Fadi
Seif for his constant and valuable assistance and Carole Macaron for her precious advices,

And of course, my friends Serge Harb, Rudy Rahme, Tarek Toubia, Salah Aoun Carla Hajj,
and Remy Daou without whom all of this would not have been made possible.

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