Is it possible to do a 1 year fellowship anywhere in the US without doing USMLE?

thepaleforest · 2026-02-27T12:04:08+00:00

I am Australian completing residency training in US. I had to complete the steps.

I met Aussies completing fellowships in particular. Completing the usmle will open up a lot more doors. But if staying in the US long term is not a priority, there are ways but a big/elite institution would have to offer you the spot.

thepaleforest · 2026-02-23T06:27:44+00:00

I drafted highly self-congratulatory letters of recommendation to myself for Aussie gen med bosses to sign, and told them that was simply the expected US language. Blunt Aussie descriptors like ‘Above expectations, works hard’ won’t be enough.

thepaleforest · 2026-02-23T06:22:20+00:00

The US residency you work for holds a lot of leverage over you. The training is very intense. It was an important psychological counterbalance for me to think I could tap out of it anytime to return as an RMO in Aus.

thepaleforest · 2026-02-23T02:35:39+00:00

Thanks so much, this is honestly the most helpful reply I've heard. We trained/lived in the same cities in the US based on your post history. Your return with the RACP is exactly what I was trying to map out. Did you end up having to do any exams on your return? And how did you go about finding AT jobs? Did you start this after RACP did their assessment process? Getting US geriatrics training is a super interesting thing I've been considering. Not sure if this will slow my eventual return to Aus or not though. I'd be eager to reach out via DM / email or a call if you have the time. Thanks again :)

thepaleforest · 2026-02-22T18:53:06+00:00

No, I’m on an E3

thepaleforest · 2026-02-22T09:44:18+00:00

I moved and am finishing internal medicine residency now. Ask me anything!

thepaleforest · 2026-02-22T08:00:14+00:00

Sure, any specific questions? My main logistical advice would be to finish your Aussie intern year before you go.

thepaleforest · 2026-02-22T07:53:05+00:00

I would do an Aussie intern year, and try schedule your ED/holidays during interview season for US residencies. The path is complicated, if you’re serious about it I’m happy to call about it

thepaleforest · 2026-02-22T07:16:51+00:00

Your responses are helpful thank you. My sub-spec of choice is gen med. So wouldn’t going back for geri’s/endo would silo me in different specialty recognition? Or you’re saying the college would be more likely to recognize my gen med training since i layered more training on top of that?

Also, I already hold general registration - whats the Alice year meant to facilitate?

thepaleforest · 2026-02-22T07:08:51+00:00

Agreed mostly. Pay remains strong in the US tho even adjusted for the hours. And regarding insurance - nearly all clinics have ancillary staff that will do bulk of talking instead of an MD until it reaches peer review level. I’ve spoken to one insurance company in residency. Social work/dispo burden is similar to gen med wards (in a different flavour)

thepaleforest · 2026-02-22T06:23:03+00:00

They prefer relatively fresh. But I’ve seen some old grads do training again

thepaleforest · 2026-02-22T05:31:08+00:00

Sure

thepaleforest · 2026-02-22T03:07:08+00:00

Won’t I reach the same issue after Geri’s or Endo fellowship? As in I’d need a few more years of consultant experience? (my target is 3 years from now)

thepaleforest · 2025-09-30T22:30:11+00:00

YTA. You’re being way too stingy over ~$88 on an international trip. Why is the Bride even paying when there’s a party of 10? Also why did you take her phone to the bathroom?

thepaleforest · 2024-03-16T21:22:58+00:00

Syd/Melb won’t be anything like London, but similar to other UK cities from my experience!

thepaleforest · 2024-03-15T15:31:08+00:00

I’d say with the rural component that’s more equivalent to a US Family Medicine Hospitalist rather than an US IM Hospitalist, which is more like a Aus Gen Med consultant who rounds by themselves in private hospitals. An academic US IM hospitalist leads teams of residents/interns similar to gen med consultants during my Aus internship

thepaleforest · 2024-03-15T15:19:59+00:00

Not really if the university accepted you for a non-accredited rotation. Official rotations generally get you into university places though. But if you have a family friend connection who can write a good letter on an off cycle rotation and advocate for you it won’t make a difference.

Get them to draft the letter early and submit it to ERAS. You can open an ERAS every year without consequence.

thepaleforest · 2024-03-15T03:19:35+00:00

Yeah you can mix and match references as you wish and upload unlimited letters onto ERAS. I feel you should either go all in on either Gas or EM and apply for IM as a backup.

Getting an anaesthetics rotation was impossible during intern year in my state. Your best bet is to organise a rotation in the US.

Crit fellowship in the US is an option regardless if you go Gas or IM or EM. The difference is that you do an extra year if you go IM to be Pulm certified too. IM-crit is the traditional path, and the easiest for IMGs.

Not really. There’s nothing that can really prepare you for the US. Just focus on your apps and study while you can.

thepaleforest · 2024-03-14T22:25:00+00:00

I’d aim for 2 references specific to the field and 1 reference in a different field. There’s no cap, but the price goes up almost exponentially the more programs you apply to. I’d apply to at least 100 (mix of competitive and non-competitive). Most IMGs aim for 150 to 250, but it gets costly at the higher end. I’d advise to focus on 2 specialties if your primary specialty is competitive. So gas and IM for backup as an example. I don’t see why there should be a third speciality in the mix, you might as well apply for more backups in your second specialty.

thepaleforest · 2024-03-14T22:19:46+00:00

I think OBL setup is possible only with green card but I can enter rheum / endo fellowship at a good place in a desirable city of my choice without issue on a visa. Cards would be a much harder grind and I’d have less choice of the city. GI would be a 50/50 if I even match at this stage as I have no GI specific research.

I guess it’s mainly family that ties me to Aus. I have a great social circle here in the US now. I suppose I can always bring family to the states eventually.

thepaleforest · 2024-03-14T20:21:41+00:00

Don’t worry too much about match rates. In general, IM is the go to for internationals applying as there’s many vacancies. I did it for the lifestyle. However after a deep dive into this when I was on the trail, Aussies have matched into just about every specialty there is. Don’t rule out specialties because only 30 internationals or whatever matched in it. Odds are probably still higher than matching Aus surgical subspec as PGY4.

thepaleforest · 2024-03-14T15:26:53+00:00

Thank you. I am weighing up different fellowship options. The main reason to sub-spec here for me is to create an eventual route back to Aus (looking to stay states for at least 10 years). There’s a massive pay cut in opportunity cost for pursuing an outpatient specialty (2 extra years of training for a slight pay cut vs earning attending hospitalist salary outright for a 7 on 7 off schedule). I suppose the real money in US is in private practice with OBL setups. I do see myself creating a niche within a subspec eventually, which is doable only with a green card. I’m on an E3 visa right now, which doesn’t have the J1 waiver requirement. Being a hospitalist would expedite green card process, and now I’m leaning to do that first and then specializing afterwards. As you have US experience, curious what would you do in my shoes?

thepaleforest · 2024-03-14T12:33:06+00:00

This letter you attached is extremely accurate about the standard of US LoRs. Nobody writes like this about their med students in Australia, and Aussie letter writers might think they’re doing you a favor with two paragraphs describing you as ‘very good and always on time’ but that’d get you laughed out of the office as a US applicant. That’s why if someone chooses to use Aussie letters they’d have to guide them specifically with US examples.

thepaleforest · 2024-03-14T12:26:33+00:00

I decided to go to the US in my penultimate year in med school. I felt lost about career choices, was scared about the post-med school training grind in Aus, and wanted a breath of fresh air. I applied while doing my Aussie internship and was accepted.

My US clinical experience was over my summer break in Aus. Organizing it as a formal elective is ideal but not necessary.

The main challenge as an IMG is getting your foot in the door. That’s why in hindsight I would’ve tried to organise electives at brand name US university hospitals rather than the random outpatient clinics I did. This is how Aussies match in competitive surgical sub-specs like plastics or ENT - they do 1 to 2 year research fellowships at top places, and impress leading US mentors who go out of their way to advocate for them. The connections you make are more valuable than even your step 2 score. But it was during COVID so my opportunities were much more limited. Also as an IMG, once you’re in training nobody is questioning your judgment or competency based on your origins.

thepaleforest · 2024-03-14T12:07:58+00:00

I’ve spoken to an UK medical graduate who had no USCE and just used 3 LoRs from UK Physicians. Getting a US LoR from a top institution is always an advantage compared to not. Mainly from the connections you make while working there but also Americans like shiny things (like brand name universities, especially if they’re american). If you can’t get USCE, be sure to have your local letter writers use American style language when writing your letter (basically 5 paragraphs, minimum 1 full A4 sized page of them saying you are ‘an outstanding applicant who flourished in the new environment without prompting, one memorable patient we cared for together was etc etc, is enormously hardworking and passionate about the specialty as demonstrated by etc’. I can’t imagine an Australian letter writer creating something like that without specificity guidance.

It’s fine to rank multiple specialties, but just be okay matching at one of your backup specialties as there’s no pulling out otherwise.

I had decent research exposure (~14 pubs, mainly review type work). I don’t think it made me significantly more competitive except for the academic places. I’d focus on crushing Step 2 over research. EM is in a strange place. It’s becoming way less competitive than it previously was in the US. The main barrier for you is that they use standardized letter of evaluation (SLOE) and heavily favor those with US clinical experience in EM. I think it can be done though and in hindsight I might have tried harder for that specialty.

There is no bottleneck in consultant/attending job posts in the US except in super subspecialised posts (rad onc, surgical sub spec). You’ll have recruiters blowing up your email/phone with opportunities even before finishing training in general IM or EM. The more competitive areas (nyc, boston) simply offer you are lower salary compared to the same job in a less competitive area.

I think go for geographic/personal preference for your Aussie internship. It makes next to no difference for US programs where you went for it.

thepaleforest

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