 One study came to the result that almost half of IMGs were unsuccessful in their first attempts in the pursuit of a U.S. residency position, and three-quarters began a residency after five years.It also indicated that IMGs were considerably older when they first applied for a residency position than are most U.S. medical graduates, with mean age of IMGs when the ECFMG certificate was issued being 32.4 years, with a standard deviation of 5.8 years.All applicants to residency programs in California need a "" (PTAL), colloquially called a "California Letter".