Yes USMLE scores are important - but not everything for a Medical Residency in USA!
To be Pre-Informed is to be In Form :-)
Sharing Wisdom learned through application experience and mistakes - especially for IMGs / FMGs!
*International Copyright ®
Tuesday, September 11, 2007
DOES OBSERVING A PRIVATE PRACTITIONER IMPROVE RESIDENCY CHANCES?
I have had plenty of emails from readers asking if observing a private practitioner in USA, who is most often a relative or a friend of a relative, is a good idea and whether it will help improve chances for getting those residency interview calls. I have a standard 5-point reply to that one :
1. It's better that nothing !
2. It certainly helps you to avoid clinical gaps on the resume
3. Grants you a US LOR (Residents tell me American MD probably more credible than an IMG MD -- aaah well, I don't know...)
4. You should continue to keep looking for observerships / externships at a more preferable place by using the physician's networks/connections of referrals from other MDs or Institutions. 5. One advantage of observing a private practitioner is that the camaraderie builds up much better between you and the physician - you may gradually be allowed to touch-n-examine patients rather than just observe, and your 'observership' may well be qualified to be called an externship ;-). Of course, I suggest you get an OK from the MD about calling the experience as an externship before putting it up on the Common Application Format (CAF) of the ERAS application. Hmmmm...as you hear often - in USA, do not undersell yourself...always oversell ;-)
While it may be the easiest 'observership' to setup and often highly convenient, observing a private practitioner would certainly be at the bottom of my preference list. Here's how the preference scale for a Observership Venue should look like:
University Residency Program>University-Affiliated Residency Program>Community Hospital Residency Program> Non-teaching Or Non-Residency Hospital >Private Practice Physician, Group Practice, etc.
The More well-known the place, the more impact will it have on your resume.
Many residency Programs explicitly mention on their websites that observing a private practitioner does not constitute clinical experience - but then again, as I said, it's better than absolutely no US experience and you can always keep looking for openings through referral MD contacts...
Psst...Psst : If the MD does see some of his patients at a good hospital facility and you observe him there too, you may instead mention that hospital as the venue of your observership on the residency application ;-)
If your residency application were a Cheese-Sandwich, then there is no arguing over the fact that externships and observerships add more cheese to your sandwich ;-) ! At the same time, do not underestimate your potential at the very place where you do the clinical term . Though not always, but often, an observership or an externship is not only an investment that YOU make, it's also a mini-investment that the program makes - because, for them, you could be a potential candidate in their program! Keep this in mind and work on improving your chances for a position in that program.
How do you do this ? Here are some ways :
1. Towards the end of your Observership term, shoot an email to the program director telling him how much you are impressed with the program, the work atmosphere for residents, quality of didactics, seminars or teaching your attending does on rounds, etc. etc. etc.
2. At the end of your observership term, drop in a direct or indirect hint to your attending doc, i.e. the one under whom you did the observership, that you are really keen on the program and would be great if he/she could communicate that to the Program Director.
Trust me, the program director and most faculty will already know about you through all those informal conversations and jokes that attendings exchange when they meet each other over coffee or lunch - but an active interest in the program from you can easily land you an interview in the program.
The Downside ?
Now, agreed that the specific program may not be your first choice and that you may have your eyes set on another program. Yet, you wish to have backups without hurting anyone - how would you handle that ?
Well, schedule your interview in that program towards the end ..or atleast AFTER your better interviews. That way, you will have a fair idea of your chances at the prevous programs and should a Pre-match offer come by, you are in a better position to handle things.
So, if you are already doing a US clinical term and not already doing the needy, it's time to get on to your act :-)
If everyone does an observership and everyone gets the 'letter' - how are you gonna give yourself the edge ? Which means the 'letter' should make the difference :-) And which means, you got to keep your doc enthusiastic enough about you to write some good stuff at the end of your term.
Let's hang on to some simple rules and tips:
1. Be professionally dressed at all times with a doctor's coat , steth, pen and a notepad.
2. Make sureyou are fully aware of what you are allowed and not allowed to do in the hospital under the contract.
3. Be dot on time daily.
4. Don't just observe like you were watching a movie - ask questions now and then to show you are trying to understand too.
5. Dont ever show that you had enough and wanna rush home, even if you feel like :-)
6. If you cant make it someday, it's alright, but call and inform promptly, don't wait till the next day.
7. Be active in attempting to answer when the doc shoots questions to their own medical students / residents - but don't try to be a smart alec either.
8. Often the attending will let you and medical students in advance what he will be talking about that morning - be smart and read about it - which means, you gotta keep a reliable pocket book in your doctor's coat pockets ;-) The one I used for my medicine observership was Treatment Guidelines pocket book by Paul Chan, since the residents had the same. I loved the book ! Concise, perfect and tells you exaclty what residents should be doing for various cases in a US hospital setting. The book itself is not expensive, less than 12-13 $,for a new one. To look for a used / new copy of this book, Click Here.
8. Keep bugging the residents to tell you about any patients with good physical signs and check them out - residents feedback to the doc matters a lot :-)
9. If you go alone to see the patient at times, always introduce yourself politely to the patient (like in Step 2 CS) before you ask history-questions - "Good Morning Mr. Roland, I am Dr. ______ and am observing with Dr. ______ for a short time as a student. Would you mind if I asked you about your illness ? It's perfectly fine if you are tired and don't feel like."
10. Ask you doc about upcoming teaching seminars and attend them during your term.
11. And be smiling, warm and confident - show lotsa interest
12. In the middle of ur term - ask your doc about his advise on how to overcome some weaknesses like communication skills (or whatever you can think of) and then follow his lead - its a way of showing progressiveness and proactiveness.
13. If possible , present a case !
14. Suppress all sexual urges please :-)
15. Avoid the common social mistake that IMGs make = don't huddle up with residents or people from your home-country only ...be open and friendly to all residents and AMGs...ALSO SPEAK ENGLISH ONLY - avoid talking in native languages when others who don't understand the language are present - it's downright rude...
16. At the end of your term - A simple "Thank you" card to ur doc and residents is acceptable and gracious :-)
Disciplined Professionalism at all ages is a must - even if you become a megastar in your field - otherwise the results ain't good ;-) Like the Hollywood Star Lindsay Lohan received this Bad Letter from her Movie Boss
SAMPLE EMAIL TO USE WHILE APPLYING FOR USCE [US Clinical Experiences]
Here's a sample email format to use while writing to places to enquire about observerships and externships (Of course you can call too). This email format is specific to places with residency programs, but that does not mean hospitals or other health-care institutes like Long Term Care Facilities, Ambulatory care centers, satellite clinics, etc. are not to be considered, coz something is better than nothing at all. What I want to stress it that you gotta change the format according to the kind of specialty and institute you are writing to. Did I hear you say "Duh" ...hehe
"Dear _____________,
Greetings! My Name is ABC D EFG, an International Medical Graduate from University of the Philippines, Manila, Philippines. I intend to apply for residency traning at your esteemed Internal Medicine program and am keen on exploring an opportunity to observe or, if possible, work in the capacity of an extern at your institution. Besides your program being highly recommended by peers, I studied your website and was impressed by the wide scope of learning opportunities available.
In addition, Kindly find my resume attached to this email as a word document.
I assure you a completely professional behaviour and a committment to uphold patient privacy, confidentiality and safety. I am open to purchase my own malpractice insurance to cover me during the period, in case your institute does not provide one.
Awaiting your reply,
Thank you,
Sincerely,
ABC D EFG"
Search Keywords to this article:
- "SAMPLE EMAIL TO USE WHILE APPLYING FOR OBSERVERSHIPS, EXTERNSHIPS OR MINI-RESIDENCIES"
Digitaldoc at your service again ;-) Trying to compile a set of rules , policies for IMGs undertaking an Observerhip from various sources over the Internet - remember these will apply only for observerships.
Note: These will apply to most places with individual variations - but should give you a good idea
Observers must be directly supervised at all times by their sponsoring faculty physician.
Observers are not usually covered under the Hospital' / University's Professional Liability Insurance (Malpractice Insurance).
Observers may not see or interact with patients individually. They must inform all patients that they are an observer and ask permission to observe. If permission is refused, they will leave the area.
Observers may not provide medical care, take a medical history, examine a patient, provide medical advice to a patient, or assist in surgery or other procedures.
Observers may not make entries into patient charts. They may not make copies of any patient chart or other materials identified with patient's names or other identifying information.
Observers may not write orders for patients or make verbal orders for patients.
Observers may not have independent access to patient information (electronic or written) or restricted areas of the Hospital / University
Observers may not bill for any service.
Some places might now allow Observers to wear a white coat, so as not to be confused with a resident/fellow, medical student or staff physician - in other places they will give you another badge to wear to clearly identify your status
Observers receive no benefits, including health insurance. They MUST provide proof of their own health insurance, valid in the U.S. They are NOT covered under the Hospitals or University's Workers’ Compensation policy and the hospital / university is not liable for any injury the observer obtains while on this observership.
Observers generally receive no financial support and are responsible for their own expenses, including meals and parking fees.
Observers will follow all applicable policies of the hospital / university.
But do note that these 'rules' not universal, federally regulated laws - rather they are generalizations mostly, are hospital-specific and are under the command of the physician-in-charge. At times, a physician may feel comfortable having his/her observer do some hands-on clinical examination ...thats always good. Candidates, too - when they get comfortable with their mentoring physicians, could try requesting for a chance to participate in regular clinical examination - many do give in :-)
HOSPITALS OFFERING CLINICAL ELECTIVES / CLERKSHIPS TO INTERNATIONAL MEDICAL STUDENTS
Clinical Electives / Clerkships / Visiting Student Programs for International Medical Students
I started off with a list here, but later on have maintained a separate blog for listing US clinical experience opportunities for IMGs on the USCE Blog
These rotations can be done by International / Foreign Medical Students who are currently enrolled in Medical Schools - mostly 4th Year students . If you are already out medical school and are looking for rotations, look up the links on the side-bar for a list of Observerships / Externships instead
Almost all of these programs will provide you with a visa letter to show at the US embassy to help you get the Visitor's Visa required for the elective. Some will want a J1 visa (Remember that this J1 visa DOES NOT have a 2-year home country requirement - so don't freak out ! - go for it baby ;-) ) while some will allow you to do it on a visitors (B1) visa too.
These rotations are somewhat easier to get and carry far more value than observerships for residency applications - so guys, if you are still in Medical school and have decided on USMLE and Residency, clinical electives in desired specialties are strongly recommended. They will be worth every cent and dollar spent ! I agree this list needs better arrangement - that's why I shall soon be coming up with the list on a separate blog dedicated to USCE and classified state-wise. Until then, please do bear with me.
University of Texas Medical Branch - Galveston (UTMB) : They provide their own Malpractice Insurance (2 to 3$ a month) and can even give you a Student Visa (F1) , which I think is a better visa to have, since you can extend it easier than B1/B2 Visitors Visa
Contact these early in the game - coz' slots get filled pretty fast ! Often you will need to pay them - but then ..wut the heck - if you're anyways spending 6000-7000$ who cares for an extra grand ! Some places may insist that you arrange your own Malpractice insurance, some pay arrange it for you but you gotta pay, while some places may not bother you with that all ...
Sample email to use for applying for observerships : Click Here
Shall keep updating this list !
Points-to-Note: 1. Policies change all the time - places that offered observerships before - may not offer today, so call ! 2. These places have a limit on the number of students they take - so act fast ! 3. The best time to do an observership is BEFORE you apply to ERAS - how else will it show on your application ? and How else will you get those US LORs on time ? Act fast ..if you are planning the 2008 match, still act fast :-) 4. Contacts matter a lot for getting observerships / externships - use them ! Resident friends, physician relatives, MD friends of your favorite masters/phD profs. etc
OBSERVERSHIPS / EXTERNSHIPS / SUB-INTERNSHIPS / MINI-RESIDENCIES FOR IMGs:
Jackson Memorial Park Hospital, IL ($800 / Month : Call 773-947-7827)
Good Samaritan Hospital, IL - Dr. Rao Batchu (630-963-4990) - $1000 to $4000/- Charge
Moses Cone Hospital at Greensboro, NC used to offer Externships to IMGs ONLY IF recommended by their Current IM Residents - a resident referral system. The new program director apparently stopped this, but who knows - may start again ?
The book USMLE Step 2 CS for the IMG has a good list of IMG-friendly hospitals and institutions that offer observerships ! I also heard good things about the book for Step 2 CS.
Google Keywords to this Post :
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First, for the uninitiated : USCE = United States Clinical Experience !
Externships, Observerships, Clerkships, Electives, Mini-Residency, Sub-internships are all types of USCE.
1. Externship or a Sub-internships or a Mini-Residency is like doing a medical school internship in another hospital which gives a good hands-on experience, you are allowed to do physical exams, touch the patients besides histories, case presentations and lab-result followups. Often an externship spans a single department, while a sub-internship or mini-residency may be longer over several specialties.
2. On the other hand, an observership or shadowing means exactly what the english word means - to see and note without touching the patient ! In most cases they consist of attending morning rounds, seminars, student lectures and attending case presentations. You cannot touch the patients and perform physicals.
3. Clerkships or Electives: In most cases a 'Clerkships' or 'Electives' implies that you need to be currently in your 4th year home-medical school internship and will be doing part (one to three months) of those 4th year rotations in the US, after a NOC - No Objection Certificate, from your medical school. You do the same thing as an externships, except that you are still a 'medical student' - not a medical graduate...
Thus, Externships, Sub-internships, Mini-Residencies, Clerkships or Electives are considered true USCE since they give you 'hands-on' clinical experience, whereas Observerships or Shadowing only give you a chance to be a passive observer without being allowed to touch the patient.
An example of a "Mini-residency" is the Mt. Sinai Mini Residency Program at Miami, Florida, in 13 Specialty areas (300$ per area) . For registration, Info and contacting - Click Here
Be advised that in terms of importance for getting considered for a Residency position :
Clerkships or Electives / Externships / Mini-Residency / Sub-internships > Observerships > Clinical Research
Q. Doc, I only got an observership - no externship. Am I doomed ? A. An externship may be better, but having an observership is still better than having nothing at all! And having a clinical research experience position at a University hospital is better than having ABSOLUTELY NOTHING. There are thousands of IMGs without any of these.. Q. What Visa Can an IMG do an observership / Externships on ?
A. Any Visa....Yes it can even be a visitors Visa AS LONG AS as the Observership or an Externship DOES NOT pay you. Any USCE that PAYS you (Like a visiting scholar's position or a paid sub-internship ) would need either an J1 (more common) or a H1 visa to be sponsored by the hospital.
Q. Requirements for USCE ? Do you need USMLE Steps for Observerships/Externships ? ECFMG Certificate ?
A. There is no formal American policy on this - but hospitals may have their own internal demands. It's best to find that out when you contact the guys. As a sample, Click here to check out the requirements of the Baylor Neonatology Observership program. And have a look at USMLE step 1 requirements for the IMG requirements for clerkship at the Mayo Medical Schools. Usually for an externship, most programs may need you to be ECFMG certified, while requirements are usually less stringent for Observerships since there is no patient-touching involved.
To reiterate and irritate ;-) : There are no universal policies on these and you must endeavour to find those out via emails / phone numbers for places listed Here...
Search Keywords leading to this post:
- "externship training in Psychiatry" - "what is externship" - "externship observership difference" - "how important is usce for residency" - Very ! - "pm&r residency minimum step 1 score" - "clinical observerships in united states" - "what is externship, observership, research, job shadowing"
HOW IMPORTANT ARE OBSERVERSHIPS, EXTERNSHIPS AND ELECTIVES FOR RESIDENCY ?
What can make the answer to this question more transparent than looking up at the application eligibility criteria that some residency programs have put up on their websites ? :-)
"To be competitive, an applicant should have a CV that shows real interest in family practice or primary care medicine. U.S. experience should include family practice experience, or at least a combination of U.S. experiences that together define family practice (such as several months each of internal medicine, pediatrics, and OB/GYN)."
The Internal Medicine Residency Program at the same place says:
"Must have completed at least 12 months hands-on clinical experience within the United States"
"We are generally looking for applicants who have graduated from medical school within the past ten years, and who have approximately two years of U.S. clinical experience (either a third and fourth year of American Medical School or approximately two years of U.S. clinical experience for International Medical Graduates)."
"1 year US clinical experience is preferred but not mandatory" - in such cases, given the flood of IMGs, it's safe to assume that though Clinical Experience is not technically needed, functionally it is !
"For International Medical Graduates, we also require a current ECFMG certificate and recommend at least 3 months of clinical experience that included patient care (not Observership) in the US, Canada, or UK; or at least 2 years anesthesia experience in other foreign countries.
5. Some Programs may even want you to be already worked as a resident in the USA to be eligible. For example, here's what the Fort Collins Family Medicine Residency Program says:
"Unless you have done two years or more of post-graduate medical training in the United States, you are not qualified for consideration for a residency position at the Fort Collins Family Medicine Residency Program"
Enough evidence ? : Some guys often like to call US-Clinical Experience as USMLE Step 4 ;-) . This should hardly be surprising - residency is like a true job with pay and benefits and like any other job (engineering, management, film-making) prior experience is attractive to the prospective employers (program directors).
Note: US Clinical Experience has gained lotsa importance recently in Family medicine ! Most Family Practice Residency Programs have become more stringent in evaluating a candidates sincerity and fidelity to Family practice, since many International Medical Graduates (AMGs too) unfortunately drop the specialty in one-two years and attempt to switch to Internal medicine, psychiatry, pediatrics, etc. Clinical Experience in primary care is evidence of your commitment and sincerity and hence highly valued by program directors to cut-down on specialty shifts by IMGs.
Some pertinent points for IMGs:
a. As discussed elsewhere too, Clinical hands-on experience counts more than observerships (as evident on example 4 above, though having an observership is better that nothing at all since it gives you a US - LOR
b. Have a look again at the 4th example above - Experiences outside the US do not go waste, if they are a in a western country setup like Canada and the UK - so if you are around, its good to have something going on clinically in these places too rather than nothing - the idea is to have minimum 'time-gaps' on your resume.
c. The more competitive a Residency is - the more important experience in that clinical or non-clinical specialty becomes
d. If you have to make a choice between clinical experience opportunity at one place and clinical research at the other, it may make more sense to choose the clinical experience option, because during your clinical rotations, you can always find opportunities to hook up with some faculty in the university / hospital to help him/her on research and get research too on your resume.
e. Remember that places that say "We do not require US Clinical Experience" also see thousands of applications with good-score + USCE combination and will naturally prefer such applications - hence do not go light on the need for clinical experience, try your best to get it. Even getting some in UK and Canada might be better than having nothing at all, unless you are already pursuing a post-graduate specialty training in your home country.
f. Observing a private practitioner is on my least advisable list, yet to make the most of it - Read this
g. A Current residency itself is great US-clinical experience ! That's why they Residents switching specialties are attractive candidates to other residency programs. Since the Last
Q. How long should the Clinical Experience (Observerships, Externships, Electives) be ?
A. The longer the better - Up to to 3 Months to 6 Months is great and even more the better. Of course, a few programs do require a year - but then, just like we can't keep all people around us happy at the same time, you cannot satisfy the criteria for every single residency program on the American soil ;-). All we can do is maximize within our means.
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