Getting Skins Tests within US for Clinical Experiences

This may not appear like a very refined post - since I am merely copy-pasting a hasty email response I had shot off to someone. Shall leave refining for another day - it's sleep time for me and I already too much of time reading specs / reviews on the Apples new ultra-thin Macbook Air laptop .

Here goes:

In most places, the hospital / university will need candidates doing Observerships, externships, clerkships or any other voluntary roles to have a documented skin test (the tuberculin test). Here are some ways to get that:


1. The US TB Prevention and control program makes such skin tests available in every state - at low prices or at times even free of charge.So, depending on which state you are in, look up the websites of the states department of health website, to check it out. The CDC maintains such a listing of state-wise TB control offices - Click here. You might need to search further on the state site to find information about TB skin test offering locations / prices. For example, here's information about skin TB tests in South Dakota

In case the website is not listed, call the phone numbers listed to get directions to where you can get a low-cost TB test done.

2. IMGs who came to the USA for Masters / PhD Programs would have already undergone such tests administered by their colleges themselves. All you will need to do is request the student health center of your college to forward that report to the organization that requires documentation of your skin TB test.

3. If you carry health insurance, the insurance company itself should be able to tell you which areas they cover for TB skin tests, if at all they do.

4. If you are still unsure, simply call up the nearest doctors office in your area (look up Business search on Google Maps) to get some phone numbers and the office clerk / nurse should be able to tell you where you could get one for a decent price.

5. Often private practice IMG physicians from your own home countries might do these tests for very less:-)

Observerships Basics for IMGs

There are three entities that must come together to make an Observership happen:

1. You, of course

2. The Physician that you will be observing: The physician that you end up 'observing' is also referred to as the 'sponsor', preceptor or the mentor. The term 'sponsor' in the context of an observership often finds some IMGs scratching their heads wondering if that 'sponsors' involves some visa or money matters - Well, No, that does not. The term in this context means: "a person who vouches or is responsible for a person or thing" [yeah , I scrubbed that off dictionary.com ;-) ]

3. The administrative office that will take care of the paperwork and other stuff depending on the hospitals / programs / institution policies. Paperwork involves getting your immunization / medical records, visa issues and HIPAA issues (shall deal with HIPAA soon)


Now, looking at the way various IMGs have historically got observerships, I tend to classify observership arrangements in three categories:

Informal, Semi-formal and Formal

[Lol...I am almost making this sound like a science in itself ;-) ]


1. Informal:

In a majority of places trying for observerships is an informal affair, it is upto you to make contact with a potential physician 'sponsor' via email or phone or in person to make a request. If you are lucky to write to the right person at the right time and right place, you will find a doc who is willing and get the stone rolling with the administrative office. Hmmm..so the more efforts and more places you contact, the better your chances will be. And if you got contacts in the form of residents, physician relatives, your 'chances' almost become a 'certainty' ;-)

2. Semi-Formal:

In this scenario, the department will allow observerships but will typically want you to first make contact with their physicians themselves - i.e. you gotta find a willing physician 'sponsor' yourself, and then the administration does the rest of the paperwork for you. Thus, they have an observership program in place, just that there are no formal applications accepted.


3. Formal:

This category, unfortunately the most uncommon, where the office will formally accept potential applications and then forward them to their staff physicians to make the selections on a rolling basis. The observerships mentioned on this blog with a link to application forms belong to this category, some are free while some need you to pay a fee.






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BASICS: Electives, Clerkships, Externships, Observerships, etc

So what exactly is the difference between Externships, Observerships, Clerkships, Electives, Mini-Residency, Sub-internships, etc. ?

They are various types of USCE terms that you will come across scattered all over the Internet and USMLE forums. Though I have already clarified the differences on the Tips4Match blog, I guess it's a good idea to put the food where the mouth is ;-) I mean, placing that info on this blog exclusively meant for USCE.

Before we begin, let me clarify that these terms are explained here in the context for International Medical Graduates.

1. CLERKSHIPS or ELECTIVES: In most cases, the terms 'Clerkships' or 'Electives' are clinical rotations granted by US Medical schools to medical students. Note that I said students and Not graduates. This implies that you need to be still enrolled in the 4th year of your home-country medical school while applying and will be doing part (one to three months) of those 4th year rotations in the US. Such rotations, besides being accepted by the US Medical school, also needs a "NOC" - No Objection Certificate, from the Dean of your own medical school or University.

Note: The term '4th year medical school' is often referred to as internship year in some places like India. While in the USA, an Intern is the First year candidate in any Residency program , also called PGY1

Experience-wise, Electives are 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. You are not held liable for errors because of your student status.

Once you graduate out of your Medical school you become an "IMG" for US purposes and you no longer qualify for Electives / Clerkships in the USA, (unless you re-enroll in a US Medical school - Yeah, some rich fellas do so). Instead, IMGs can avail of the following kinds of USCE.


You do the same thing as an externships, except that you are still a 'medical student' - not a medical graduate.

2. EXTERNSHIPS: Externships are clinical rotations for International Medical Graduates that give a solid hands-on experience working as a resident under supervision. You do almost everything that a PGY1 resident does except that your medical notes need to be approved by a resident or attending and you will not have the authority to write orders and prescriptions.


Often an externship spans a single department, while a sub-internship or mini-residency may be longer over several specialties.


3. OBSERVERSHIPS: An Observership or shadowing (Sometimes also called as a preceptorship) 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.



Some places may also call Externships as or a Sub-internships or a Mini-Residency, but the terms are not always strictly externships. Likewise, at times, when a program says "externship" it may actually mean an Observership - so it's upto you find out beforehand, the nature of the rotation.

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.

Sometimes a program may explicity mention that Observerships do not count as USCE ! For example, the University of Michigan psychiatry residency program at Ann Harbour. 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 :

"Hands-on Experience is Better than Observerships"

Q. Doc, I only got an observership - no externship. Am I doomed ?

A. Agreed that an externship is better, but having an observership is still better than having nothing at all! 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. At times, the specific Program may need a specific visa type like a student visa, visitors visa, etc. and they will provide a supporting visa letter for the same.


Q. Requirements for USCE ? Do you need USMLE Steps for Observerships/Externships ? ECFMG Certified ?

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, since you do similar stuff as a resident would, 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 endeavor to find those out via emails / phone.




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