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    Navigating Culture and Lifestyle in the U.S.

    Addressing Cultural Factors, Language and Communication

    IMGs come to the U.S. from diverse international backgrounds. They can have different value systems and customs, and English may not be their primary language. Furthermore, communication norms may vary based on societal norms.

    Toastmasters is a member organization that IMGs can join to practice the English language, public speaking and leadership skills, and to meet new people while adjusting to life in the United States.

    Impostor Phenomenon

    Dr. Pauline Clance first described “impostor phenomenon” as an experience whereby individuals feel that they do not deserve their successes, despite objective evidence to the contrary. These individuals believe they will eventually be exposed as an impostor, not worthy of their status or achievements. IMG residents and psychiatrists can experience this phenomenon as a negative impact on their mental health. If you believe you are experiencing impostor syndrome, here are some helpful resources:

    • Kwan, V. 2015. “Asian Americans and the Impostor Phenomenon” (master’s thesis).
    • Metz, C.J., Ballard, E. and Metz, M.J. 2020. “The Stress of Success: An Online Module to Help First‐Year Dental Students Cope with the Impostor Phenomenon.” Journal of Dental Education, 84(9), pp. 1016-1024.
    • Seritan, A.L. and Mehta, M.M. 2016. “Thorny Laurels: The Impostor Phenomenon in Academic Psychiatry.” Academic Psychiatry, 40, pp. 418-421.
    • Thomas, M., and Bigatti, S. 2020. “Perfectionism, Impostor Phenomenon, and Mental Health in Medicine: A Literature Review.” International Journal of Medical Education, 11, p. 201.

    Tips for Navigating Life in the United States

    IMGs (especially non-U.S. IMGs), when starting their residency in the United States, face many challenges as they start settling into not only a new city but also a new residency program. In addition to the typical frustrations of being an intern in a new work environment, obstacles can appear as IMGs attempt to figure out basic things like where to stay; how to obtain a Social Security Number (SSN), driver’s license, credit card or bank account; and so forth.

    Below is a survival guide of tips and advice for IMGs entering their residency in the United States. These are tips and recommendations only; for legal advice on immigration, contract and licensing issues (and others), please consult an attorney. The information provided is subject to change.

    Obtaining a Social Security Number

    • A Social Security number (SSN) is a unique identifier issued by the U.S. Social Security Administration. You need an SSN to work, and it’s used to determine your eligibility for Social Security benefits and certain government services.
      • Your SSN is considered sensitive personal information and should be protected from unauthorized access or disclosure.
      • For J-1 visa holders, refer to Educational Commission for Foreign Medical Graduates's Validation of Initial Arrival in J-1 Status (.pdf). ​​
      • SEVIS validation is required to apply for a U.S. SSN. ​
      • A J1-physician must wait 11 business days after being validated in SEVIS before applying for an SSN. ​​
      • Validation status can be confirmed in OASIS (Online Applicant Status and Information System) Validated records are marked “active.” ​ ​​
      • On the SSN application, for the question about “citizenship,” J-1 physicians should select “other.”​
    • You must physically visit one of the many Social Security offices with the required documents to apply for an SSN.
    • A quick reference for some of the documents you may need as a non-U.S. citizen, view the Social Security Administration's Social Security Numbers for Noncitizens (.pdf).
    • You will receive your SSN about two weeks after applying, by mail to your U.S. home address.
    • After obtaining your SSN, make sure to supply it to the medical licensing board.
    • Also inform your program coordinator and human resources (HR) department, as medical insurance and benefits (and possibly your work salary) may begin only after you provide an SSN.

    Opening a Bank Account

    • Try to open a bank account as soon as you arrive, as having one will be essential to your life in the United States.
    • Certain banks in the U.S. (e.g., Bank of America, PNC Bank) allow you to open an account without an SSN. You simply need your ID and visa. You will have to visit the bank physically, however, rather than open an account online.
    • Some important resources can be accessed here:
    • If you are in a residency program, you may qualify for a student account.
    • Most people choose a checking account, which should allow you to obtain a debit card and a few blank checks immediately upon opening the account.
    • Some banks require that you maintain a minimum balance to avoid a monthly maintenance fee. Banks also have additional requirements, such as enrolling in paperless services, to waive this monthly fee.

    Credit Scores and Credit Cards

    • A credit score (or FICO® score) is a numerical representation of an individual’s creditworthiness based on that person’s credit history.
    • The higher the score, the better the individual’s creditworthiness, and thus the more likely they are to be approved for loans, credit cards and other forms of credit. Base FICO scores range from 300 to 850; between 670 and 739 is generally considered a good score.
    • Unfortunately, as an IMG moving to the United States, you will not have a credit history here. Hence you’ll have NO credit score.
    • To get started, you can apply for a “secured" credit card, which requires a deposit but not a credit score.
    • Secured credit cards function a lot like traditional credit cards. The primary difference is that with a secured card, you pay a cash deposit upfront to guarantee your credit line. For example, if you pay a $500 deposit, your credit line on this card will be $500.
    • Using this card will allow you to begin building your credit score.
    • This card will be automatically converted to a regular credit card in about a year if you use it appropriately. At that time, your initial deposit will be returned to you.
    • Consider the following tips for building your credit:
      • Sign up for autopay by linking various bills to your checking account.
      • Pay the statement balance in full every month.
      • Utilize less than 30% of your credit limit. If you exceed that amount, pay it off immediately to keep it under 30%, as this utilization ratio will significantly affect your credit score. For example, if your credit limit is $1,000, utilize no more than $300 on the credit card. If you have an expense that exceeds $300, pay it off the same day (or the next day) to avoid a report of high usage to the major U.S. credit bureaus.
      • Avoid opening multiple credit cards or lines at the same time.
      • Applying for a new credit card or asking for a credit limit increase will negatively affect your credit score (although usually temporarily), even if your request is approved. Ensure at least six months have passed before applying for a new card/credit line.
    • The following factors go into calculating your credit score:
      • Payment history
      • Credit utilization
      • Length of credit history
      • Credit mix
      • New credit
      • Credit inquiries
    • American Express may issue you a U.S. credit card without a credit history if you have had a credit card with American Express from your home country.
    • Entities like Nova Credit can help with opening a U.S. credit card by using your credit history in your home country. Although this service is limited to certain countries, you may receive, for example, an offer to take out a car loan based on your previous credit history.
    • Following is a list of advantages of using a credit card (not a debit card) in the United States:
    • Using a credit card will help you build your credit score in the U.S., which will be required in the future if you wish to buy a car or house.
    • Many credit cards offer cashback and rewards. Because the interest rates on checking and savings accounts at traditional banks are typically very low, the best way to make your money work for you in the long term is by using credit cards for all purchases if possible (and then paying off your balance immediately).
    • Credit cards may offer travel and purchase protection and extended warranties.
    • Credit cards offer better fraud protection, so they’re safer to use and carry around than a debit card.

    Driver’s Licenses and Vehicles

    • Check your local state laws to determine whether you can drive on an International Driving Permit (IDP), or a foreign driving license will suffice. Obtaining an IDP from your home country is recommended before arriving in the United States.
    • If you are not familiar with driving, try learning to drive in your home country first. After beginning residency, your busy schedule may not leave you enough time to practice driving in the U.S. Also, driving schools can get quite expensive in the U.S.
    • Many YouTube videos have excellent driving tutorials that can help you learn the rules and regulations about driving in the U.S. before you arrive.
    • Find more resources at your state's Department of Motor Vehicles' website. Find your state's Department of Motor Vehicles website here.
    • To obtain a U.S. driver’s license, check your state website and follow the steps outlined there.
    • Usually, you will need to obtain a learner’s permit before you can obtain a driver’s license. To take this first step, you will need your SSN along with the documents you’re required to submit at your local Department of Motor Vehicles (DMV); you will also need to pass a knowledge test (multiple-choice questions). Once you pass the test and obtain your learner’s permit, you are then eligible to book a road test for a full driving license.
    • Your local DMV can also issue a state photo ID, which is helpful if you are not looking to drive but still want to avoid carrying your passport everywhere. The DMV website should include instructions about this application, which will require you to submit similar documents as for a driver’s license.
    • Check your local state laws regarding expiration dates for your driver’s license. Usually, for J-1 visa holders, your driver’s license is valid only until your visa expires. Thus, your license is valid only for one year and will require renewal every year. So, whenever you receive your new DS-2019 each year, make sure to also renew your driver’s license. No knowledge test or road test will be required; just submit the required documents to the DMV for renewal.

    Buying or Leasing a Car

    • Check first with your residency seniors. Someone may want to sell you their used car.
    • In the U.S., car dealers have leasing options if you prefer not to buy. Some programs and universities have arrangements with car dealers to pre-approve you for car leases or loans. Check with your program coordinator and/or HR representative.
    • Popular car insurance providers in the United States include:
      • Allstate
      • American Family Insurance
      • Farmers Insurance
      • GEICO
      • Liberty Mutual
      • Nationwide
      • Progressive
      • State Farm
      • Travelers
      • USAA (for military personnel and their families)

    Winter Driving Tips

    • Carry a winter emergency travel kit.
    • Listen to weather and travel advisories.
    • Adjust your plans if possible so you don’t have to travel in bad weather.
    • Keep your gas tank at least half full.
    • Slow down and increase the distance between you and the vehicle ahead.
    • Avoid sudden stops and starts.
    • Beware of roads that may look wet but are frozen (often referred to as “black ice”).
    • Use extra caution on bridges and ramps, where ice often forms without warning.
    • Do not use cruise control while driving on snow-covered roads.
    • Turn on your headlights when your wipers are on, particularly if your state requires this by law.
    • Use your low beams in particularly bad weather, especially in cases of heavy or blowing snow.
    • Remove ice and snow from windows, mirrors and all vehicle lights — before you drive and as often as needed.
    • Remove snow and ice from the hood and roof of your vehicle. Some state laws say you can be ticketed (or receive an even more severe penalty) if snow or ice from your vehicle strikes a vehicle or person and causes injury or death.
    • Do not park or abandon your vehicle on a snow emergency route.
    • Do not pass or get between trucks that are plowing in a plow line (i.e., several trucks plowing side by side).
    • If you become stranded, staying with your vehicle until help arrives is usually the best option. Run the engine every hour or so, but make sure the tailpipe is clear and keep the downwind window cracked open to avoid inhaling noxious fumes.

    Source: National Highway Traffic Safety Administration's Tips for Traveling Safely.

    Accommodations

    • Start researching and looking for housing as soon as possible after your match result.
    • If possible, sign a lease online before arriving in the United States. Finding housing after arriving in the U.S. may be difficult, as housing options often are limited — and your busy residency schedule may not leave much time for a proper search.
    • If you are already in the U.S., recognize that many property managers will not show the actual apartment until you sign a lease to move in. Instead, they may show a specific demo to potential renters like you — or even just the photos online.
    • Talk to your residency seniors. Where do they live? Their answers likely will point you toward the best options. Plus, their recommendation to their property manager will make it easier for you to obtain approval for your housing application.
    • Check some of the popular apartment search websites, such as Apartments.com, Rent.com, Trulia and Apartment Finder.
    • Rental property managers may not approve an application if your monthly income is less than three times the proposed rent. Also, some properties may deny an applicant with a poor credit score (or none at all).
    • You may need a “guarantor” — usually a family member or friend who agrees to take financial responsibility for the rent and other charges if the tenant is unable to pay. Guarantors typically must provide proof of their income and creditworthiness and must sign a legal agreement with the landlord.
    • As soon as you move in, take adequate photos and videos of your apartment. Your landlord will provide an inspection checklist; identify and document all damages (even if minor) and save a copy of the checklist for yourself as well. Taking this proactive step upfront can help you avoid unexpected damages charges that your landlord may try to impose when you move out.

    Renters Insurance

    In the United States, most apartments will require you to show proof of renters insurance on the day you move in. Some apartments may offer their own policy but may not provide the best coverage. You could purchase your own insurance policy as well, before arriving in the U.S. Following is a list of the most popular options:

    • Allstate
    • Farmers Insurance
    • GEICO
    • Lemonade
    • Liberty Mutual
    • Nationwide
    • Progressive
    • State Farm
    • Travelers
    • USAA (only available to military members and their families)

    Cellphones and Network Providers

    • Most international cellphones should work in the U.S.
    • Ensure you unlock your phone from your local network provider before coming to the U.S.
    • Consider purchasing and activating an international roaming plan from your home country initially, before arriving in the U.S.
    • After landing in the U.S., turn on roaming in your phone settings.
    • The most common network providers in the U.S. are:
      • Verizon Wireless
      • AT&T
      • T-Mobile
      • U.S. Cellular
    • Mobile virtual network operators (MVNOs) offer a different option. These are companies that provide mobile phone service to customers using the network infrastructure of another mobile network operator (MNO), such as Verizon, AT&T or T-Mobile.
    • MVNOs typically purchase access to network services at wholesale rates from MNOs, and then repackage and sell those services under their own brand to end customers. Because they don’t have to invest in building and maintaining their own network infrastructure, MVNOs often can offer more affordable plans and pricing options than MNOs. Examples of MVNOs are:
      • Boost Mobile
      • Cricket Wireless
      • Google Fi
      • H2O Wireless
      • Lycamobile
      • Metro by T-Mobile
      • Mint Mobile
      • Simple Mobile
      • Straight Talk Wireless
      • Visible
    • Google Fi Wireless is one of the best MVNO options, operating on the T-Mobile and U.S. Cellular networks to offer excellent coverage and customer support. The main advantage is its e-SIM option, which allows you to purchase a plan online, install an e-SIM and start working immediately (if your phone also has an e-SIM facility). Individual Google Fi plans can be expensive compared with family plans. Excellent for international roaming, e.g., when visiting your home country for vacation.
    • Lycamobile is one of the cheapest providers and offers quite reliable coverage, operating on the T-Mobile network. It is particularly best for free international calls to many home countries or elsewhere abroad. Availability in stores is limited, so it’s best to order e-SIM online (preferably about 10 days before you arrive in the U.S.). The only drawback is the very poor international roaming service.

    Taxes

    Health Insurance

    • While in the United States on a visa, you are required to have health insurance.
    • For a number of logistical reasons (e.g., a delay in obtaining your SSN), your employer-provided health insurance may not begin until the day of your orientation (or even your first day at work).
    • It is highly recommended that you purchase health insurance from your home country for a period of at least one month from your arrival in the U.S.
    • If on a J-1 visa, make sure you meet these minimum insurance requirements set U.S. Code of Federal Regulations (22 CFR | 62.14), described by the ECFMG here:
      • Medical benefits of at least $100,000 per accident or illness
      • Deductible that does not exceed $500 per accident or illness
      • Co-insurance paid by J-1, not to exceed 25% of covered benefits per accident or illness
      • Minimum repatriation of remains in the amount of $25,000
      • Minimum medical evacuation expenses in the amount of $50,000
    • Include your flight travel days in the coverage period, which will cover any unexpected medical needs while you are in transit.
    • Before completing your purchase, ensure that the start date of the insurance corresponds to the correct time zone/country.

    Insurance Terms to Know

    • Premium: An amount that must be paid to a health insurance company, by a consumer or employer, in return for an individual’s health insurance coverage.
    • Copayment: A fixed amount consumers pay for a health insurance-covered service (also called “copays”). Amounts paid may vary based on the type of service received, whether the health care provider is in-network or out-of-network, and typically is paid at the time of service.
    • Deductible: The amount a consumer is required to pay for health care services before the health insurance plan begins to pay. However, health insurance plans may cover some services before the deductible amount is met.
    • Coinsurance: A consumer’s portion of the cost of an insurance-covered health care service. It is a percentage of the amount allowed by the health insurance plan for that service. A consumer pays coinsurance plus any deductibles and the health insurance plan pays the balance due.

    Source: Educational Commission for Foreign Medical Graduates's Pre-arrival Information, Mandatory Medical Insurance

    Advice on Traveling to Your Home Country/Abroad

    • If you have an unexpired visa stamped on your passport to cover the duration of your trip, then traveling to your home country or another country is as simple as booking your flight and traveling.
    • If the visa stamp on your passport has expired, ensure you have a visa renewal appointment scheduled before you book your flight. Include sufficient time for passport pickup/delivery prior to your flight’s departure date.
    • Always make sure your passport has not expired or is not close to expiring before you travel. You will be able to renew your passport within the United States by contacting your embassy. The amount of time it takes to renew a passport before it expires may vary by country.
    • If on a J-1 visa, you must ensure the “Travel Validation” section on your DS-2019 form is signed by an ECFMG officer, and you must carry this form during your travel. If it is not signed, contact ECFMG/your TPL immediately.
    • If you travel abroad to someplace other than your home country, you must have both an entry country visa and an unexpired U.S. visa to enter the United States. Some exceptions are available if visiting Canada, Mexico or the adjacent islands of the United States. View more at the Educational Commission for Foreign Medical Graduates's Information Sheet for Exchange Visitor Physicians and J-2 Dependents (.pdf).
    • BEWARE: Some countries may require a transit visa for people of certain nationalities who fly through those countries. For example, if you have a valid Indian passport and a valid UK visa but booked an Air Canada flight to the UK that transits via Toronto, Canada, you cannot board this flight, as Canada requires all Indian passport holders to have a Canada transit visa for transiting Canada (which takes a few weeks to obtain). The same is true for some Alaskan cruise lines that transit through Canadian waters.
    • Always double-check your transit countries’ requirements prior to booking your travel.

    Advice for Family Members Visiting from Your Home Country

    • You can sponsor visas for your family members to visit you in the United States.
    • You are responsible for ensuring that family members do not stay past the end date stamped on their passport by the immigration officer upon their arrival. Immediately check the end date on your family members’ passports when they arrive.
    • Obtain appropriate health insurance coverage in the United States (available through, for example, Atlas America and Patriot America) to ensure your family members have some affordable options during their visit. Compare quotes and options on websites such as Insubuy.com.

    Additional References

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