To whom is interested in pursuing specialty in USA-1

my Dear brothers and friends, I am currently a medicine resident in USA doing my third year .
I would like to help at least by relaying as much information as I can to those of you who are planning or already took their exams and ready to travel to USA.
I know that it is not easy transition or job, but hopefully, most of you will pass successfully. I dealt like you and had the same suffering pathway to arrive and start my residency and know how difficult and exhausting is this way, that is why I am happy to help as much as I can. I am one of those who would be very happy to see the Syrian physician getting higher education in this advanced country and constitute a number where they can be of significance.
I would like whoever has a question to contact me at burhanbtt@go.com
With all the love to all of you dear brothers and sisters and also with all the respect to those who made this helpful website.

My experience in studying for the usmles was a little bit different but doesn't mean that it was the best way to do it although I think it is good way.

I started preparing for the usmle from the first year, starting with the embryology, where I bought an English book( forgot the name now, but it the same one where the Arabic one took the pictures from). I started reading from this book to be familiar with the medical terminology. I also brought a physiology book in the second year and was very serious in reading Lippincots pharmacology in the third year, and almost finished 3/4 of it.
and the same thing for the microbiology where I read from the Lange good parts (also high yield is probably my recommendation here since it is concentrated and really high yield book)

The problem here that it is difficult to find time to read your subject in Arabic for the Syrian exam and then in English, so it depends on the one's abilities and desire to go to USA or UK or...

I thought that I may be able to take Step 1 in the fifth year after finishing the rest of the required books, but what happened is that , we started the forth year and I started reading the clinical books (Davidson) was the first one (though now I don't highly recommend it for USMLE since it's British book and is not focused like others such Cecil essential . so I got busy with the clinical side of medicine and couldn't take my USMLE step 1. that actually was not bad since Step 1 in big part depends on information taken form step 2 especially knowing the diseases well which will need you to read Internal medicine books before taking it to get high scores easier.
I also read Board review in ob/gyn and Dms4 with board review in Psychiatry, also I remember reading NMS with the many parts of Cecil for the Internal medicine and Blue print in Pediatrics. Also I read The Kaplan note( carlos pestana) in surgery with recall which was big but simple book .
It doesn't again mean the this was the best way, as example, I read a little bit from MedStudy although I practiced most of its questions. and this series actually is the best for the American board of internal medicine after you finished your specialty, but I think they are very up-to-date and concentrate on the important points for the usmles and the boards.

Step one recommended books (old version)

I will put my experience on this topic here , but remember that it is 3-4 year old

Books for studying for steps are changing so fast. The most recent ones are trying to condense the information so it gets easy to be memorized. I also found it much better to read small book which is concentrated but gives you the most important facts you need for the steps than a big book that take for ever to read and finally you don’t remember mush of it!.
As example: in the old days, people used to recommend NMS pediatrics which was too much big since most of the pediatrics questions can be answered from IM except for the Neonate part and few other well known questions. So the trend changed to read Blue print in pediatrics which was much concentrated and both easier to read and memorize.

I will give the names of the books we used for step 1 ( I got 99 in Step 1 taken in 2002) and hopefully the other guys will provide you with the most recent recommendations.

We also used to read First aid for step one which they reported being very good for step 1.

I also asked one of the interns here (first year resident) about the latest things they are studying and he told me people in Pakistan are now studying Kaplan for almost every thing and many of them gets good scores in the 90s. He said they are now buying the set of Kaplan and go through it.

1. Microbiology: High yield. In the old days it used to be the lange.

2. Pharmacology: we used to study the first 100-200 of lippincot, but I am sure there should be smaller book by now. High yield( as I remember) was also advised with the first 100-200 of Lippincot.

3. Biochemistry: High yield. In the old days, it used to be Lipincott (very big).

4. Pathology: Board review. Most of the questions here are Internal medicine questions like diagnosis of disease or treatment. SO don’t understand the word pathology as only slides and microscopy for the exam. If you studied for step 2, you will see that this part is much easier since you know how to recognize and diagnose the diseases fast.

5. Physiology: We use to read the board review, but it was not the greatest!

6. Genetics: we used the high yield: molecular biology( I hope I remembered the name correctly). Some also recommended the last 60 pages of Lippincots biochemistry!!

7. Behavioral science: I don’t remember exactly where we read for this from, but it was very small lecture or book

8. Neuroanatomy: high yield

9. Anatomy: High yield.

10. Histology: high yield

Again according to the new resident who took his exam in the last year: Kaplan is now used for most of these topics.

I just want to point what we have been told about the percentage of the questions:

1-Pathology: 40-50% since most of the questions are similar to step 2 and need you to know who to diagnose and treat the diseases.

2. pharmacology, Microbiology, Biochemistry, and physiology: for each of them may be 10% and the remaining few questions would be distributed between the rest: Anatomy, Histology, Genetics, Behavioral.

You may go to one of the library and take a look at the books and see which one you feel after reading few pages would fit you best. Also you can check with the people who are studying now for the exam to see what is the current recommendation and suggestion.

You also need to practice questions, ask about good books for questions

Step 2 books ( general recommendation)

I will put my experience in this topic here, but remember it is 3 years old and things change quickly.

As I mentioned when talking about step 1: some currently are buying Kaplan series and study it for step 2 and others blue print…..

Step 2 is mainly not memorizing special books and going to test the knowledge you have memorized, but it is rather more about your understanding of the diseases and how to diagnose and treat them. So if you read from Arabic resources and you understood how to make good differential diagnosis on each sign or symptom, then you will get good score in step 2. Off course I am not saying not to study from a the recommended books, but I am just giving you an idea how this exam works.

I think small books are very good for the exam itself, but if you are a forth or fifth or even a sixth year, I think it is very good idea to start reading text books especially if you are planning to apply for medicine. This will make you understand medicine better cause the American or even the English books are very organized and go step by step starting from each disease’s pathophysiology to diagnosis and ending in treatment and prognosis.
The bottom line you have to know most of the diseases’ clinical presentation and work up in addition to treatment. If you become good at that and you are able to recognize the diseases and its treatment just from the history and some physical with or with out labs, then you are well prepared for the usmle step 2 and all what you need is to practice more questions and clinical scenarios.

Internal medicine:

1.Nephrology; I recommend Cecil essential: Renal is usually complicated and not easy to understand especially glomeurloneprhtitis topic from any other source, but I think it is will explained here. Myoclinic internal medicine review also has good section in nephrology.

2. Infectious Diseases (ID): Cecil in HIV was extensive but important and comprehensive review for HIV.
I studied the rest also from Cecil but you may find a book like NMS or Medstudy to be less extensive and simpler. Now if you have enough time, you wont lose any thing by reading the whole ID chapter of Cecil.

This information ( as the rest of Step 2 information especially the medicine part) is not like step 1 which you need to know a lot of information only for the exam and it is not very much related to the real life, rather here in Step 2 the more information you know, the better help you get in your real life as a physician later on.


3. Cardiology: NMS was good start. Medstudy also is good. I didn’t like to read it from Cecil since it was too complicated. The murmurs are important and so are the EKGs and unstable angina/Mi treatment. To be good at EKG, you need to read simple small book of EKG and get familiar with them.

4. Pulmonary: NMS was very good. Medstudy is also good.

5. Hem/Oncology: I used Cecil for it and it was great. NMS was not enough. You need to know how to diagnose the different types of anemia and so is for the Leukemia.
I think I also used Mayo clinic internal medicine board review. I didn’t read the whole chapter in the mayo clinic, but I used the video tapes of mayo clinic.

6. Allergy: the chapter in NMS was very good including the immunodeficiency disorders.

7. GI: I think that NMS was good book in GI. Cecil is good review book

8. Rheumatology: NMS was very good one. Also medstudy is very good.

9. Endocrine: NMS was good book in this field. Medstudy is not bad too

10. Neurology: I used Davidson( which is British and I do recommend reading American books if you are planning to take USMLE) and NMS. I think NMS was good one to cover the basis, while Cecil was too complicated in neurology.. .

Obstetrics/Gynecology: most of the people used board review in our time I myself used combination of NMS (but this was big to read the whole book) and Essentials of ob/GYN. The last book was big, but we used to read only the highlighted summary of each section. I think currently, more precise books like Kaplan or blue print may be easier and you can use bigger sources like the essential for specific important topics like Preeclimpsia or abortion

Psychiatry: I read DSM4 for the diagnosis criteria and for few illustrative cases, and we also read the Board review mainly for the treatment of the diseases. I think you have to read the DSM4 for the criteria, but you may find smaller book than Board review to read about the management.

Pediatrics: blue print was new and small book. Most of the questions in pediatric like surgery can be answered by knowing Internal medicine well. the only exception is the neonate section where you have to read this section carefully since the diseases are different from the adult one like necrotizing colitis as example. You also may go over the whole book as it is useful and small. The previous graduate like in 1998 used to read the NMS, but I think it is a waste of time to go over 600s pages only in pediatrics.

Surgery: same thing apply, where you can answer many of surgical questions from Medicine, like acute cholecystitis as example, but We went over surgical recall although I didn't feel it was very helpful, but u can review it fast . I also found the Kaplan note (Written by Carlos Pestana) very helpful since it was all about teaching cases. I recommend reading this and it has good section in orthopedics too

Behavioral: you can read small note about Ethics and some teaching cases and how to deal with them. As example Do you treat a patient when refuses : the answer no You don't treat unless he is not competent to give decision. So you have to know the approach to such cases. I think we used small section in board review of behavioral at that time to learn this and I guess Kaplan now may have something about that. These questions are frequent in the USMLE and it just need to understand the different situation to be able to answer them.

Statistics: I used a small book of Lange series named epidemiology and biostatistics which was about 70 pages and was ok. To tell you the truth, these question are usually difficult one unless it is easy and straightforward one like asking about sensitivity or specificity. I used to avoid reading these questions to save time for other questions unless I feel that it looks easy one

Things like Ophthalmology, Dermatology and ENT: We studied that from secrets for step 2. It had very good review of the important points that is important for the exam. For ENT: your book of ENT in the university is good but off course too big, you have to know Weber test and rennie and how to diagnose and treat the ear infections

I took step 2 at the end of the sixth year and got high scores which I think help me taking the visa, because I felt he basically looked at two things:

-The Step 2 score( I was not done with step 1 at that time, but I registered to it and show him the orange permit to take it).

-The second thing he payed attention to was my ranking in the medical school as I was ranked the second in the graduation period( although I was probably 12 or 13 in the whole year but in November when I graduated I was fortunately the second out of 210. and these 2 facts were the ones he paid attention to and made him give me the visa with no hesitation.

Always remember that USA is highly dependent on the immigrant from other country to keep their predominance in the world, so their borders are open for those who they think will be of great benefit to their system.

after taking USMLES before graduation in November, I took step 1 early next year and was ready to leave to USA.

I won't talk now about studying for step 1 but it is more like memorizing than thinking and understanding rather than step 2 where you have to have good logic approach to disease and know how to make good differential and find the correct diagnosis and know its work up and treatment. the pearl in step 2 is to know all most of the disease, how to diagnose, work up and treat, which is very good also for you as a clinical since this would make you real physician , off course with applying that in the clinical experience.

How to increase your chance to get into residency in USA

This actually depends on your application which you send through ERAS and also on your interview and personality. I will think loudly taking the position of program director

The application :

1. High scores: in addition to what I mentioned previously that the very high scores will increase your chance to get visa, it also is one of the first things that they take into account when they offer the interviews. some say that step 2 is more important , this may be true , but you need also high score in step 1.

2. Letter of recommendations : mainly if there are ones from USA, that is what really counts, if the one who is writing your letter is well-known, that will be passport for you t get to very good program. Also what is written in the letter is very important, you need one designated for you from somebody who knows how the letters should be written.

3. American experience: the longer and the more involved you are in a rotation in USA, the better your application would be. The system in USA is very different and need time to learn, so programs directors are interested in somebody who did good rotation in USA, especially if you had to take responsibility of patients. This would be easy to be known for them if one of the American physicians you work with during this rotation give you a good letter and write in it what you have done during it. Off course this rotation if they are real and efficient, they will make you familiar with the USA system, so you don't get shocked when you start your residency, It would also make your English language better, and easy to understand them. It would also make you familiar with the medical terminology they are using. That is part of the reason why we suggested on SAMS to look for who can offer such rotation in USA

4. Experience: although, they may prefer fresh graduate, but if somebody has very good clinical experience, like fellowship in Syria..., this would be taken into consideration.

5. Research and Publication: if you have good research or publication especially if they are in USA, that would improve your chance to get interview and to be ranked high

Now what about the interview;

after you get strong application as mentioned above, and get interview, you need to do good interview to have high chance to be ranked high in the hospital ranking list which makes you get good chance to match.

The good interview means to have nice, pleasant , strong personality, without being proud, or rude. You also need to have good English, and express yourself well. You also need to prepare for the interview, what questions are common and what are your answers to them, especially those big, repeated questions, like why our hospital?, why did you choose internal medicine, what is your plan for the future, tell me about yourself, your experience, your medical school, a case you found interesting..., and many more
Make sure there is not much of difference between what you tell and what is in your application.

If they like you during the interview, your chance to get into your program would be increased a lot.

After they finish the interviews season, they will meet and start count the scores you got during your interviews( each one you interview with will give you score) and I think your application (usmles scores, letter of recommendation ...) would also has score. They will calculate all this scores and give you one and rank you depending on this.
If you know somebody who has connection with a program director or with strong faculty, and he recommend you to the program, that would increase your chance too much.

Basic information about the application to ERAS ( i.e. to the hospitals).

I took usmle step 1 in the spring and was ready to go to USA, since I got the visa few months earlier. My next step before leaving was to arrange what I need to do there and where to stay. I was lucky and got few good friends who answered my questions about the steps I have to take and what to do to pass each one. That helped a lot. The second good part was that I had a second or even a third degree relatives in whom 2 of them were physicians and were very helpful. The plan for this journey was to take CSA( you only can take it in USA) and apply to the programs through the match (ERAS) and do the interviews after I receive invitation from the programs who took a look at my application which I sent through the ERAS.

( The system in USA that works by having a center Called ERAS which gathers your documents that you sent to them by both email and regular mail -like letter of recommendations and medical school transcripts, i.e. kashef alaalamat,....- and some of them you fill on line (internet) as there is an application which you have to fill online).

So basically, You have 2 components of your application:

-The first one is the online application which you fill and include your personal information like, name... and also your medical school information, your previous research if you had and clinical experience. It also include your previous residency if you had one, and your publication. When you are in this process you will ask your friends how to fill this, so don't worry about it now.

-The second component of the ERAS application is the things you send by regular mail which include letter of recommendation, picture, medical school transcripts.

You also have to fill in your online application something called personal statement, where you talk about yourself and why you choose this field and what are your plans in the future.

You can fill this application after paying a fee of about 100$. then you will be allowed to fill the application. You usually can start applying to the programs after you fill your application and when the ERAS open for this. This usually starts in September, the first.

You have to have at least one of your steps to be able to fill your application and send to the programs, but off course if you just have one step, you may not get any interview, so most of them complete the 2 steps, 1 and 2 and then apply to the programs though the match, and actually it would be better if you have the ECFMG certificate which constitutes of Step1, step2 and CSA, also it used t have the TOEFL to get this certificate, but I heard that this is no more required , but you may check on that.

Now after you do all of these exam, you may apply for the ECFMG certificate and it takes 2 to 4 weeks to get it after applying.

many programs prefer when you apply to them to have this certificate, and if you want H1 visa and the hospital offer that (will talk about that later), then you also would better have step 3 taken on the time of applying and you can't take this unless you have your ECFMG certificate with all the exams that you have t pass to get it.

again, you don't send your application directly to the programs, rather, you send all your documents t to the ERAS and also fill your application online and then the ERAS send all of this to the programs you chose to apply to. This actually is easier than to send all you documents to all the hospitals yourself, rather, here you send it only to the ERAS and they send it to all the programs you want, but the downside of this that you pay more. since the first 10 program you send to will cost you around 110$, and then 8 $ for each additional program till number 20, then 15$ till 30 programs are applied to, then you pay 25$ for each hospital (program) you apply to after number 30. So you will notice that if you will apply to around 50 programs which is reasonable, you will pay around 700-800$

Let's go back to me: I started preparing for the CSA, by reading 2 books, one of them was CSA aid as I remember and it had clinical cases which you practice with a friend and by yourself, and also Kaplan book which had summary on the exam (I hope My memory is working well tonight).

I had to also to arrange where to go and where to stay, since these things are expensive in USA, as example if you wana find a room for rent with a room mate, you will end up paying at least 200$/month and this may be more expensive in the big cities. I also had friends of my parents who were willing to host me for good period of time, but the problem was that they live in Arizona and the interview process happens mainly for the Syrian graduate in the east cost (New York, Philadelphia and Pennsylvania, Connecticut New jersey... and in the mid west: Ohio, Detroit and Michigan, Chicago and Illinois, Missouri, Iowa...., ) and Arizona was very far, and expensive and exhausting if I have to live there and start my travel from there.

USA is very big and any travel between 2 big close cities will take you 4-5 hours or more, so you have to try to live in good area for the interview season, otherwise, you will pay a lot for the travel. As example, At the time of the interviews, I bought 2 open tickets of the greyhound bus company, each one cost me around 450$ and was valid for 1 and a half month, and I could go any where in USA when I have it. Off course the greyhound buses are one of the worst transportation means in the USA, but they are the cheapest. Few of the friends rented car for the interview process, others used to fly. It all depends on how much money you have and how much you are willing to spend.

So I arrived to USA, after talking to one of the physician relative who told me that I can come and do rotation with him( mainly like observer) where I just round with him and observe him while taking care of patients . I didn't take care directly of patients, although, I had the chance to examine and take history from many of them. I spent around a month with him and then had to move to the next step.

After finishing the 1-2 months rotation in my relative hospital, I had to leave the city, since I was paying a rent to my roommate who was from morocco and it was expensive for me (and for any Syrian guy who is not working in USA) around 250$ a month and with utility it goes up to 300$. That city was very beautiful and in good location for the interview, but unfortunately, I didn't have any friend to stay with for free there.

It had a very nice university where you can go the library and take a private studying room and set there for a long time with no one bothering you. At the same time you have free internet almost all the day, where you check your email, do the online part of you application and read the news. We as you all know miss that back home. You start knowing people by visiting the mosque or the church and in both places you will find few of them who are eager to help. I advise you to visit one of this two places and build good relation with the people there. you will get a lot of help from at least few of them. and they are very nice people. In addition to that you see people from the area you grew up in and break the home sickness you will feel after few days of leaving your family, neighbors and friends.

I found 2 friends who were happy to host me for the rest of the interview period. I stayed with one of them for a month and then left his city again to stay with the other one for the rest of the interview process till the end of January. I am very grateful for all of them.

I started to prepare my application and was chatting every day with few of my colleagues who arrived with me to apply for residency. That was very helpful since we were discussing the details of the process, such as how to fill the application, which hospital to apply for, what to write in the personal statement, and what to do to pass the CSA.....

The ERAS (the center for receiving and delivering your application to the programs which you apply to) opened in august as I remember to receive your application and in the first of September to start sending it to the programs. It is preferred to have your application and all the other related materials (letter of recommendation...) be ready by the first of September and that is because few of the programs give all of their interview spots in the first 2 weeks and thus, if you send late, you will lose the chance to get interview in these programs. I remember that I sent my application on the 9th of September and that was due to waiting for the son of my relative who was born in USA to take a look at the personal statement that I wrote and tell me if there are any weak sentences that I need to correct or revise. and also because of other issues which not on top of my head right now.

Any way that time was still early one and I don't think I lost any interview due to being late just few days. Off course there are programs that wait till November to start giving interview, but this is not the rule. and the earlier you send your application after the ERAS open, the better your chance to get more interviews.

Many programs prefer somebody who has the ECFMG certificate in his hand, this means, as I mentioned in previous talk, passed both steps and CSA and then applied for the certificate and got it( which takes 2-3 weeks after he sends his application for the certificate to get it back). The reason behind this was that few of the strong applicants didn't pass the CSA exam although their steps scores were high, either because their language, communication skills, personality, preparation for the exam or clinical skills were not good or simply because they were unlucky. So many programs prefer somebody who has the ECFMG certificate and thus his chance of getting more interviews may be better even if he has lower scores than somebody who doesn't have it. Also those programs that give H1 visa prefer somebody who passed step 3 too.

Regarding the visa and which is better H1 or J1 this is the facts I have:

J1 visa: is the most common type of visa you will get to start your residency. you don't have to have step 3 to get it. Most of the hospitals offer this visa.

The advantages of this visa are the following:

1.most of the university hospital gives this, so if you are looking for good university program, your chance to get J1 visa is relatively higher.

2. You don't have to pass step 3 to get it.

3 for the fellowship, it is easier to get fellowship (subspecialty) if you are on J1 visa than on H1 visa.

The disadvantages:

1. It just allow you to stay for 7 years in the states, then you have to leave for 2 years if you want to come back, unless you find a job in rural area which is not easy thing and you have to stay in this rural area for 3 years at least (these process is called to find a weaver) and it is not impossible and most of the guys who wants to stay here are finding a job, but it is also not easy and all of them recommend you to get H1 visa if you decided to stay in the us to work.

H1 visa: not all the programs offer this and the problems that most of those who offer this kind of visa are small community program where they try to attract the good IMG to come by giving them this visa.

Disadvantages are:

1-If you are looking for a university hospital to do your residency, your chance to find one who agrees to give you H1 visa is less.

2. For the fellowship, it is harder to get one if you are on H1 than J1.

3. It requires you to have step 3 by around the time of the match result (late March) or even earlier for many hospitals (may be at the time of the interview, i.e.: December or November).

Advantages:

If you decided to stay in USA, then this visa will make your life easier to find a job wherever and then you can transfer it to green card in less time than J1.

So, in summary: if you are one who is looking to come and get residency and then subspecialty and eventually go back home to practice very soon after this, then J1 visa is good choice especially that it would make your fellowship chances better and getting university hospital easier.

But if you are a guy who thinks of staying at least for few years after his residency in USA, then H1 visa may be better option for him. since the transition to start Job is much easier on this visa.

Off course, you can find someone who got H1 visa and planning to go back home and also got fellowship, but this is not the rule.

After preparing the Paper work, I had to choose the hospital I want to apply to. This was not easy, because the easier thing is to apply to as many as you can, but practically speaking that is impossible, mostly because of the financial situation.
As I mentioned earlier, you spend 60 dollars for the first 10 hospital you apply to and then 8 for each one of the next 10 then 15 for the next 10 and then 25 $ for each one after number 30. So basically each 4 programs you apply to after 30, you will spend 100$, and that is a big number, but at the same time, you have to apply to as many as you can, since the whole process of coming here depends on you finding a position and this chance is increased by the number of interview you get which mainly depends on how many programs you send your application to and off course how strong your application is.

So, basically you have to make balance between your financial situation and your desire to send to as many programs as possible. They used to say that sending to around 50-60 programs should be enough if you have good scores, but I know people who had 99 in both steps and they sent to more than 75 programs. For me I sent to around 40 programs considering that I got good scores and some American experience, but my advice is to send to more if you have good financial support and even to send to more than one spatiality. I guess it is better to get spatiality that not your first priority than to go back without no residency. So apply for more than one and put your favorable spatiality hospital first in your rank list. If you matched with one of them, that is great, if not, then you may match in something else and not go back after spending all this time and money for nothing.

But now what is the difference between university and community hospital?

University hospital: usually has better name and better education system, but it is more difficult to get and American graduate usually try to go there, so it gets more competitive for IMG. Your chance of getting fellowship when you are done may be better, because you are coming from Academic center.
Off course eventually where you are coming from is very important, as example of your coming form famous university like Harvard as example is much different even if you were coming from an other university that doesn't have big name, but still this should be better than community hospital ( off course there are exceptions like Mayo or Cleveland clinic which are really not university hospital, but they are more famous than many of the university hospitals)

Community hospital: your chance to get one as IMG is bigger here than a university hospital, since American graduate don't like to go to this hospital. There is less academic enviournment, and less chance to get fellowship after you finish, but you are still learning what you need to and getting board that make you work wherever in USA and outside.
Also your chance of getting H1 visa in this hospital is better.

I also want to mention one notice about the cost you have to face till you start you residency. It is getting more and more expensive, both the exams and the travel expense, so if you don't have good money reserve or at least somebody to lend you money, it would be very difficult to take the risks of this long way. This is not to depress you, but just to warn you, that this is an additional thing you should consider and get ready for when you first thing about the whole issue.

Summary of the process you have to go through to get spatiality in USA

I will try to remind every one with the first initial steps for the USMLES:

1-There are 3 tests: step 1, step 2 and CSA (I think they change the name for this) also the TOEFL was required, but the last news I got that it is no longer necessary, but check on that.

2-To take any one of the steps(1 or 2), you have to be in a recognized medical school and fill an application which will have your dean of the medical school signature on it. TOEFL was not necessary to be taken before any the steps. You can take step 1 or 2 first and then take the other later, but for the CSA , it was necessary to have passed step 1 and TOEFL before taking the CSA and I am not sure if this change or not. Then you get what is called ECFMG certificate after you pass all these exams(step1, 2 and CSA and previously the TOEFL).

3-To apply for the programs (hospital) you have to have at least 1 step passed, but preferably ( and that what all of us usually do) is to pass at least both steps and preferably the CSA too and have the ECFMG certificate with you when you apply. This would increase your chance of getting interviews.

4-After you do the interview( you send the application through online program called ERAS where you send them your letters of recommendation, states of marks from medical school, and photo and also the dean's letter in addition to filling online application and personal statement) you put your rank list of the programs you want to match (get position in) with in order from one( the one you liked the most to the last one) and wait for the match result to come where you will be told online where you matched( which hospital you had spot in) and this usually happens in the mid'-late March.

Notice:

1-You start filling your online application and apply to the program in September and the earlier you do in September or even early October the better you chance to get more interviews( first apply, first served)

2-So be prepared to get your exams done and papers ready by September if you don't want to lose a year. ( the CSA exam need to be done in specific center only in USA)