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How to match in general surgery? The different pathways to general surgery in the US!

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How to match in general surgery? | The different pathways to general surgery in the US!

Matching in general surgery residency in the US is not an easy task. In 2022, 3071 medical students/graduates applied to categorical general surgery residency and 1619 matched successfully for an overall 52.7% match rate (1). The route is even more arduous for international medical graduates who might do multiple years of preliminary surgery before getting into a categorical general surgery spot. 

The discrepancy can be explained by fewer available general surgery programs (supply) and high number of applicants interested in the specialty (demand). Matching into general surgery is challenging, but not impossible. Here we are going to discuss how to match into general surgery and the different pathways that applicants can take to end up as fully trained surgeons.

What are the two main pathways for matching into general surgery?

Preliminary and Categorical. For a candidate who decided to apply to general surgery, there are two available pathways through the NRMP match® (2): categorical and preliminary. 

A categorical position offers a full residency training that is required to become a Board-Certified Physician. For general surgery, this is usually a 5-years long program. On top of that, some programs offer 1-2 or even 3 years of dedicated research, making it a 6 to 8 years program. Upon completion of a categorical general surgery program and passing the board exam, you will become a Board-Certified Surgeon who can either practice independently or go into a subspecialized fellowship of choice. 

Preliminary on the other hand, is a one year position, upon completion of which you still have to find a place to do 4 more years of required training. So, if you enter a preliminary position, you are not guaranteed to complete the other years of training to become a surgeon. Prelim is often viewed as a bridge to a categorical spot for international medical graduates (IMGs), US medical students who did not match in competitive specialties, students who are required to do a preliminary year for an advanced PGY 2 position (such as ophthalmology, dermatology, radiology), or US students who did not match into categorical general surgery. 

Why prelim is a more likely outcome for IMGs?

Although many programs offer both categorical and prelim tracks, IMGs are more likely and sometimes exclusively offered prelim positions. This is largely because of two factors: 1) categorical general surgery is highly competitive and categorical spots are offered to US students/grads; 2) programs want to learn more about their IMG applicants who are coming with a distinct cultural and educational backgrounds and are not familiar with the system in the US. Prelim helps to understand if they are good fit for the program from all aspects (e.g. clinical, surgical, and communication skills as well as cultural competency). 

A 1-year prelim is often used as an opportunity for program directors to further asses their foreign applicants. As a PGY 1 prelim resident, you will be exposed to the same clinical experience as a categorical PGY 1 resident. A prelim year is an opportunity for IMGs to showcase their work ethics, hard work, clinical and surgical skills, and improve on any deficiency they have to prove to the program director and the resident selection committee that they are good fit for the program and indeed deserve a categorical spot

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What are your options after a prelim year?

Since prelim is a 1-year position, it is your responsibility to find a place for a subsequent training. Otherwise, you will not get the required training to become a surgeon. Here are the different routes available for prelim residents:

1. PGY 1 categorical:

The first option after a prelim general surgery year is to apply to the Match for a PGY categorical general surgery spot. In this instance, you will be Matching into a first-year position (PGY 1) again, but in a traditional 5-year categorical track. As a result, the total length of your training would be 6 years (1-year prelim + 5 years categorical). Keep in mind that you don’t have to apply to general surgery exclusively. You can choose to switch to any other surgical or non-surgical specialty. 

Most prelim programs take a certain number of their prelims into categorical track the year after. For example, if a program had 10 prelims in 2022, they usually pick 1-2 of them (based on different criteria discussed below) to match into a categorical spot in 2023. However, not all programs offer that. It is important to ask residents who did a prelim year at a certain program to know the ins and outs of these important information that are not shared on the program website. You can also apply and get admitted to PGY 1 categorical general surgery spots in other programs through the NRMP match.

2. PGY 2 categorical

Alternatively, upon completion of your prelim year, you could jump straight into a 2nd categorical year (PGY 2 categorical). This is the dream of every prelim resident as you do not repeat any years of training in this case (1-year prelim + 4 years categorical = 5 years of training). 

This type of arrangements, however, happen outside traditional NRMP Match. Some residency positions can open up due to people dropping from the program, electing research years or switching specialties. You can be offered to fill these positions in the same or other institutions. Often programs help with such arrangements. If a program director is impressed with your work as a prelim resident, he/she will try to offer a categorical position in their own program or reach out to other places to find an opening for you. If your program has a tradition of keeping 1 or 2 prelim residents at their institution for a PGY 2 categorical, you’ll get a chance to prove that you worth this spot(s). This is why it’s so important to work hard in prelim, so that a program director is confident to keep you for a categorical spot or recommend you to another institution. If you are lucky to get this spot, you will continue training as a categorical resident for 4 more years.

3. PGY 2 Prelim 

Another option would be staying for another prelim year. That is the least favorite option for prelim general surgery residents as this is another year of uncertainty. After the 2nd year in prelim, you can be offered a spot in PGY 2 or PGY 3 categorical program. If you match into a PGY 2 categorical spot, you will be doing 2-year prelim + 4 years categorical = 6 years of training. 

If you match into a PGY 3 categorical spot, you will be doing 2-year prelim + 3 years categorical = 5 years of training; this is the same number of years as if you matched into PGY 1 categorical from the first year. 

If you do not require J1 visa sponsorship, you could also try matching as a categorical PGY 1 (through NRMP Match) again.

If you require J1 visa sponsorship, you cannot apply to PGY 1 categorical spot after a PGY 2 prelim as you are required to show that you are advancing in your training for the ECFMG to sponsor your visa.

4. Changing Specialties

At anytime during the training you can apply to a different specialty or even seek non-clinical jobs such as research or working in companies

What are the chances of matching into a categorical general surgery after prelim?

Despite the amount of stress and uncertainty that prelim carries, it is often not as bad as it sounds. A research evaluating outcomes of non-designated general surgery prelim interns over 25-years’ experience was conducted by a Mayo clinic research group in 2019 (3). 315 non-designated prelim interns were included in the study with 232 being IMGs and 83 AMGs (3).  

Overall, following one year of prelim, 21% of IMGs matched into a categorical PGY 1 general surgery, 20% into a categorical PGY 2 general surgery, 22% ended up with a prelim PGY 2 in general surgery, 8% matched to other surgical specialties, and 20% matched into non-surgical specialties (Figure 1) (3). 8% of IMGs left Graduate Medical Education (GME) after doing one year of prelim (3). 

Figure 1. IMGs after 1 year of preliminary general surgery (3)

For AMGs: 14% of matched into a categorical PGY 1 general surgery, 10% into a categorical PGY 2 general surgery, 5% ended up with a prelim PGY 2 in general surgery, 35% matched to other surgical specialties, and 32% matched into non-surgical specialties, and 4% left GME (Figure 2) (3). 

Figure 2. AMGs after 1 year of preliminary general surgery (3)

In the same study, comparison of outcomes before and after 2006 was performed (Figure 3). Importantly, the percentage of prelim interns matching into categorical PGY 1 and prelim PGY 2 increased for International graduates after 2006, but only prelim PGY 2 matching rate showed significant change (3). However, the percentage of interns matching into categorical PGY 2 and other surgical specialties decreased (3). The percentage of IMGs taking prelim PGY 1 spots at Mayo significantly increased after 2006 compared to AMGs (62% to 83% for IMGs vs 38% to 17% for AMGs) (3). 

In the recent years (after 2006) matching outcomes changed slightly. Significantly less IMGs matched into categorical PGY 2 in general surgery and other surgical specialties, but significantly more of them got prelim PGY 2 after year 2006 (3). On the other hand, no significant changes for AMGs before and after 2006 were identified (3). 

Figure 3. Matching trends following preliminary year before and after 2006 (3)

For those who continued as PGY 2 prelim, the majority eventually ended up entering a categorical general surgery program (67% for IMGs, 75% for AMGs), others switched to surgical or non-surgical specialties with only 1 person leaving GME (3). Overall, 95% of interns from the original cohort ended up practicing in the United States (3).

This data highlights that if you’re hard-working, dedicated and persistent, you have good chances to find categorical spot to continue your surgical education after prelim general surgery. Moreover, you can switch to non-surgical or research positions if you wish to do so. 

What has been the experience of prelim general surgery residents?

A survey conducted by a Mayo clinic research group provides additional insight into what prelim residents think about their experience (151 residents completed the survey) (4). The majority (>50%) of residents named “Exposure to diverse pathology”, “Opportunity to work with experts”, “Hands-on skills instruction”, “Simulation based learning” as positive experiences during their prelim year (4). The most notable negative aspect (with 78% response rate) was “Uncertainty of the Prelim year” (4). 82% of responders were willing to commit to the same journey if they had to do it all over again (4). 

Overall, prelim brings a certain level of uncertainty and anxiety, but should not be considered as a dead end of your medical career. There are plenty of opportunities both inside and outside the surgical world following a prelim year. 

What about matching into a categorical general surgery program?

Matching into categorical general surgery is much more competitive than matching into prelim. This can be reflected by the number of unfilled position and the match rate (# of matched applicants/# of overall applicants). In 2022, only 3 categorical positions were left unfilled, while more than 500 preliminary positions remained unfilled (Table 1). Match rate in categorical general surgery was 1619/3071 (52.7%) compared to 632/2077 (30.4%) in prelim general surgery (1). 

Matching into categorical general surgery is much more difficult for IMGs compared to US students and graduates. In 2022, the categorical general surgery match rate for US seniors (4th year medical students in the US applying to the match) was 72% (1059/1467), 53% for DO seniors (212/397), and 29% (348/1207) for other applicants (US IMGs, non-US IMGs, and MD grads (1). Overall, 65.4% of spots were filled by US MD seniors, 9.6% by US MD graduates, 13% by US DO seniors, 1.8% by US DO graduates, almost 5% by US IMGs and 5% by non-US IMGS (1). Out of 1619 filled positions, only 81 non-US IMG matched into a categorical track (1). 

The crucial aspect that is not illustrated by NRMP data, is that among those who matched into categorical programs there are candidates who already finished their preliminary year. A question: how many IMGs got matched straight into categorical positions without a prelim year remains unanswered, but the percent is even smaller than that reflected by NRMP data. This further highlights the competitiveness of matching into categorical general surgery.

Table 1. Filled and unfilled general surgery positions from 2022 NRMP data (1)

Are IMGs more likely to match into prelim general surgery?

As evident by the data, the majority of IMGs matched into prelim (n=167) as opposed to categorical general surgery (n=81). The 81 number again includes those who did prelim then matched into categorical general surgery. That does not mean that IMGs cannot match into categorical general surgery directly. Based on the authors personal experience, there are numerous cases of IMGs who matched into categorical general surgery without doing a prelim year. 

How can prelim residents increase their chances of getting a categorical position after a prelim year?

ABSITE scores, clinical performance, surgical skills, Being Affable, Available, and Able, a portion of luck, and connections are the main factors that are considered when deciding which prelim surgery residents will match into a categorical spot. 

How can I maximize my chance of matching into a categorical position directly?

As previously mentioned, getting a categorical general surgery spot as an IMG is challenging, but not unachievable. In order to be viewed as a competitive candidate, you often need to start planning ahead. Here are some of the factors that can make you a competitive applicant for a categorical general surgery spot.

Are USMLE Scores Important for Matching into General Surgery Residency?

High USMLE scores are one of the tools program directors use to screen candidates for the residency. With Step 1 becoming pass/fail, a higher priority is expected to be given to a Step 2 CK score.  However, USMLE exams alone does not make you a competitive applicant as many other factors are considered when evaluating applicants for a spot. 

In 2020, the mean STEP 1 score of US medical students who matched into categorical general surgery was 237 vs 219 for those who did not match (5). For non-US IMGs, the mean USMLE STEP 1 score was 242 and 233 for those who matched and did not match into categorical general surgery, respectively (6).

Are Electives/Away Rotations Important for Matching into General Surgery Residency?

Electives/away rotations in general surgery are another great opportunity for applicants to demonstrate their competency for a categorical spot, especially for IMGs. An elective or away rotation is generally 1-month clinical experience in a particular US hospital in which the rotator can scrub in surgeries, exam patients, write notes, and participate in the different activities of the department. It is usually said that electives are a month of interview as the electiver is evaluated continuously by everyone. That is why they are very important in increasing your chances of matching as your clinical skills and fit with the program are being evaluated all the time. So if you pass the test, you have a high chance of matching in that program even if you do not have high USMLE scores. That is true for both US students and IMGs. Acting internships (AIs) are a special type of electives in which the medical student functions as an intern (first year resident) with more responsibilities than a regular electiver. 

For IMGs, remember that only medical students (not graduates), generally in their final year of medical school, are allowed to take electives. Therefore, learn about requirements and associated costs in advance. 

Electives are a great opportunity to show your competence, clinical and surgical skills, familiarity with the US healthcare system, ethical principles, language and personality fit with the program. They are also a great way to get letters of recommendation from people in the field (surgery in this case) who worked with you clinically and can testify to your clinical and surgical skills who could be potential mentors to you in the future. 

Research

Doing research in the US is additional way of increasing your chances of matching into categorical general surgery. This is a great opportunity especially for those who already graduated from medical school and cannot take electives. These days, even US medical students often take time off to do research in the specialty they are applying for to get research experience and establish connections within the field. 

As a researcher, you will have an opportunity to work on research projects, present your work, and potentially publish articles, which would make you a more competitive applicant and help you establish connections within the field when you go to conferences. On top of that, research is a great way to learn about the US healthcare system, showcase your unique personal traits, and establish connection with influential mentors within the specialty. The downside of research is that you are spending time away from clinical work which concerns program directors especially that residency is a clinical not a research job. 

A study from the Mayo Clinic looked at applicants and program directors’ opinions on value of research for matching in general surgery (7). it was actually shown that only 54% (n=76) of program directors attributed some importance to dedicated research work (7). Moreover, doing dedicated research was not associated with increased chances of Matching (7). The data, however, is limited and the decision about pursuing dedicated research has to be individualized. If your application is not strong enough, research is a great place to start building necessary connections. 

Does research help in matching into general surgery residency?

Probably yes. However, the decision to pursue research should be based on each single application and the applicant interest in research

A prelim at a big institution or categorical at a big institution?

Although big institutions offer you great opportunities and resources, the uncertainty of a prelim year might make many applicants favor a categorical spot at a smaller institution. A categorical spot will guarantee the resident a full 5 years of general surgery training without having to worry about finding a spot the year after. When prelim residents at Mayo clinic were asked to choose between categorical position at a small place versus prelim in a large one, 55% chose the categorical, 31% picked prelim and 14% didn’t decide (4). 

In fact, this is a very subjective decision, and many life aspects (like geographic location and personal preferences) could play a role.

Final remarks

As Theodore Roosevelt said, “Believe you can, and you are halfway there”. Matching into general surgery residency is tough, for IMGs this is even more difficult and often lengthy. However, with right attitude, continuous effort, good exam scores and proper mentorship, matching is feasible. For the majority, prelim is likely, with plenty of opportunities following.

  1. Results and Data 2022 Main Residency Match 2022 [Available from: https://www.nrmp.org/wp-content/uploads/2022/03/Advance-Data-Tables-2022-FINAL.pdf.
  2. Jubbal K. NRMP Residency Match Algorithm Explained 2020 [Available from: https://medschoolinsiders.com/medical-student/nrmp-residency-match-algorithm-explained/.
  3. Rajesh A, Asaad M, Chandra A, McKenzie TJ, Farley DR. Outcomes of non-designated preliminary general surgery interns: A 25-year Mayo Clinic experience. Surgery. 2020;167(2):314-20.
  4. Rajesh A, Asaad M, Chandra A, Rivera M, Stulak JM, Heller SF, et al. What Do Former Residents Say About Their Nondesignated Preliminary Year? A Survey of Prelims’ Experiences in a General Surgery Residency Program. J Surg Educ. 2020;77(2):281-90.
  5.  Charting Outcomes in the Match: Senior Students of U.S. MD Medical Schools [Available from: https://www.nrmp.org/wp-content/uploads/2021/08/Charting-Outcomes-in-the-Match-2020_MD-Senior_final.pdf.
  6.  Charting Outcomes in the Match: International Medical Graduates [Available from: https://www.nrmp.org/wp-content/uploads/2021/08/Charting-Outcomes-in-the-Match-2020_IMG_final.pdf.

 By Yekaterina Khamzina and Malke Asaad.

Yekaterina (Katya) Khamzina. I am an International Medical Graduate from Nazarbayev University School of Medicine in Kazakhstan. I am aspired to become a surgeon. I look forward to enrolling into a post-graduate medical education program in the United States in the nearest future.


My name is Malke Asaad and I am an incoming
PGY-2  surgery resident at the University of Pittsburgh. I graduated from medical school in Aleppo Syria before pursuing my research at the Mayo Clinic in Rochester Minnesota and then MD Anderson Cancer Center where I am currently a research fellow in the Department of Plastic Surgery.

 

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