Observerships or Externships

some programs don't even require US Clinical Experience (USCE), but in order to make yourself a more desirable applicant you should get some. And the experience should be as long as possible with hands-on work. 10 days is pretty short and may make it more difficult for you to get a good letter of recommendation, but better than nothing. It's VERY important that you get a good letter of recommendation for US physicians. Ideally, you should try for at least 1month per attachments. I've come across programs which require IMG applicants to have 12 months of USCE.

A good letter of recommendation will GREATLY increase your chances of getting invited to interviews. you should aim for at least 3, if not 4 letters from US physicians. Presumably you could get one from whoever you're conducting research with. Of course, there are IMG's that match with no USCE.

How much does an externship cost an IMG (no loans)?

Depends on where you do the externship. Will vary from zero dollars to over a thousand. you need to contact the programs directly to ask.

iamcatwoman said:

Depends on where you do the externship. Will vary from zero dollars to over a thousand. you need to contact the programs directly to ask.

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Do they give free USCE for IMGs with no GC???!!!!!!!!!!!!!!!

You should be able to find some hospital/physician willing to take you on for a couple of months. You just need to be flexible about where you go.

and how do i do that? i mean how do they choose between applicants??
Do you know any website where i can find average externships' costs??
Thanks.

FaddyAcids said:

and how do i do that? i mean how do they choose between applicants??
Do you know any website where i can find average externships' costs??
Thanks.

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Externships vary from free to standard tuition costs for the period of time you are at the facility. There is no good estimate of the average and even if you saw it, it would be wildly deceptive because it has no bearing on what you might pay for the opportunity.

In regards to lack of a GC, you will at least need a visa to come to the US and work. Generally a travel visa prohibits you from working full-time.

No one here has details on what each program offers. You must go to hospital websites in areas you are interested in and follow their links to clinical clerkships, electives, visiting students, etc. to get more information.

so it should be in that order:
ECFMG certified - Visa - USCE. And I should have couple of months on externship before being interviewed, right?

FaddyAcids said:

so it should be in that order:
ECFMG certified - Visa - USCE. And I should have couple of months on externship before being interviewed, right?

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The order should be:

Visa to come to US (since you will need one to come here to take USMLE Step 2 CS exam)
USCE
ECFMG Certification
Apply to residency
Interview for residency
Match to US residency
Begin Visa Process for H-1 or J-1
Get Visa
Start Residency

The whole point of doing USCE is to get good letters of recommendation from US faculty so that your application is better received when you apply. The more you have, the more preferable but there is probably a point of diminishing returns. Generally a month is enough to get a letter, so if you have two months, do them at two different hospitals.

Externships are not guarantees that you will get an interview. Its a method to learn about the US medical system and as I noted above, get a letter from a US physician. Without these letters, most programs won't look at your application, let alone give you an interview. The best you could hope for without them is that the place you are doing an externship offers you one.

so if someone doesnt get a visa for any reason to take step 2 CS the whole issue will be screwed up loool!!!!

I guess letters of recommendation from foreign physicians are not very helpful, are they?

Kimberli Cox said:

The order should be:

Visa to come to US (since you will need one to come here to take USMLE Step 2 CS exam)
USCE
ECFMG Certification
Apply to residency
Interview for residency
Match to US residency
Begin Visa Process for H-1 or J-1
Get Visa
Start Residency

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that was really helpful..Thanks!

You both are the greatest people here

I know that alot of people just come in on a tourist visa/visa waiver to do the USMLE CS, however you'd probably need a student or working visa for externship. However, for observership or volunteer work, you are neither working nor studying, so I don't know what sort of visa you would need. Again the program that you do your externship/observership with would know what sort of visa you need as they will probably be the ones sponsoring it. I came in with a Visa Waiver and that was fine with the hospitals/physicians that i worked with.

FaddyAcids said:

so if someone doesnt get a visa for any reason to take step 2 CS the whole issue will be screwed up loool!!!!

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I have heard anecdotes of people being refused visas to come to the US to take Step 2 CS. However, I am by no means an immigration or travel expert so do not know details. But yes, you must have a visa from most countries to enter the US to take the exam.

I guess letters of recommendation from foreign physicians are not very helpful, are they?

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Not unless they were well recognized as an international expert with knowledge of how the US system works. Remember, the reason for a US LOR is because US physicians are familiar with what it takes to succeed here. Getting a letter from a physician outside the US with no US experience is practically worthless because they have little idea of what we require.

So if letters of recommendation from foreign physicians are irrelevant and I can see all programs require at least 3 LORs and some of them do not require USCE!! How can one get LORs from US physicians without having had USCE?!

With great difficulty. Your choices are to submit non-US LORs (in which case you will need some kick ass Step 1 scores and want to train in one of the less competitive specialties) or to submit US LORs.

To get US LORs you would need to organize some USCE as the LORs are suppose to recommend both yourself and your clinical skills. You should definately try to get US LORs as it will greatly increase the number of programs who will consider your application. Some PDs told me straight out that the only reason I was offered interviews over other IMGs was because of my US LORs.

The list of aims given by Kimberly Cox is bang on. There are some decent books out there with advice for IMGs: "First Aid for the Match" and "The Successful IMG - Obtaining a US Residency" and more detailed timelines. Ask around at your medical school and amongst doctors where you are as you'd be surprised at how many others are going through the same process. Talk to your medical school Dean and faculty - see if your school/anyone has links to a US hospital.

As for how to get USCE, you have to be creative. The most straight forward way is to get busy on the phone and email and contact all the programs/hospitals listed on FRIEDA and ask them if you can spend a couple of months with them. Most hospitals have a Continuing/Graduate Medical Education (CME or GME) department who will deal with this.
VA hospital are apparently more easy to get placements at.

Failing that, the next best thing is to start contacting private doctors offices. There are lots of physicians out there from other countries who may be more sympathetic towards helping out a fellow IMG.

If you're still a medical student then you are at an advantage as you can still apply for an externship which will allow you to obtain Hands-on USCE which is like GOLD! However, if you leave it until you graduate then it becomes really (REALLY) difficult to get an externship and most hospitals will only offer Observerships which technically do not allow hands-on work which will mean that your LOR from here probably won't be able to comment on your clinical skills, and consequently will not help you much in applications.

More and more hospitals are requiring a fee. USF in Tampa wanted $1000 for just one month of observership and they stressed that I was in no way to have hands-on experience, which as far as i was concerned = waste of time and money. Miami charges about $400 for one month of a "Mini-observership". I can't remember what that actually means. But if you persevere, you should be able to find something for free.

It's frustrating at the moment, but keep optimistic. Getting good LORs are totally worth the effort and will make your application/interview/match period much less stressful.

miaow

Thank you so much for the great post!!!

iamcatwoman said:

If you're still a medical student then you are at an advantage as you can still apply for an externship which will allow you to obtain Hands-on USCE which is like GOLD! However, if you leave it until you graduate then it becomes really (REALLY) difficult to get an externship and most hospitals will only offer Observerships which technically do not allow hands-on work which will mean that your LOR from here probably won't be able to comment on your clinical skills, and consequently will not help you much in applications.

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Why is that?? I am still a student but I wanted to try to get some externship after I graduate because I can't leave my rotations and go abroad for an externship. So do they only accept students in the last year of medical school?
And does the externship have to be in the same specialty I am applying to?

I think that this thread needs to be moved to the international forum.

Are you sure that you cannot do a rotation outside of your medical school? Have you asked them this specifically?

Externships exist specifically to train medical students. They allow medical student to experience training in specialties that may not be available at/different to their own institutions. They also allow medical students to check out hospitals/residency programs in different parts of the US which may influence where they go for residency. They are not meant to train already graduated MDs.

Your best bet would be to try to get an externship whilst you're still a med student. Waiting until after graduation will greatly limit your options.

But does an externship in some specialty have any advantages in getting matched to a different one?
For instance, if I have had USCE in Internal Medicine. Will it have any effect if I am applying to OB/Gyn?

Externships, aka visiting clerkships, are designed for final year medical students. Once you have graduated you are not eligible for them and only for an observership.

The latter are MUCH less desirable because you will have no clinical contact with patients and letter writers are therefore unable to assess your clinical skills. This is a malpractice issue. As a student the program (or your program) can provide malpractice insurance to you for a nominal group fee. Once you graduate you are no longer eligible for the student group rates and would have to find independent insurance on your own. In my 7+ years here at SDN, I have never seen a thread from a user which stated they found such.

On one point I disagree with iamcatwoman: the issue of doing electives with private attendings. For programs that require USCE, they will expect those rotations to be in association with an ACGME residency hospital. I speak from experience...having had a friend who had one of her 4 week rotations "not count" since it was done in a PP without any university/residency affiliation. Fortunately, she had enough weeks otherwise.

Please check with your school because most will allow you some elective time. Perhaps they will allow you to extend your final year to do more electives in the US after you finish your requirements.

As Blade notes, you want your rotations in the US to be in the same specialty as the one you are interested in. IM, especially critical care, is probably acceptable for OB-Gyn and even Gen Surg, although only if it is one of 3 or 4 other letters.

So since observereships are not quite helpful, nothing will actually account for USCE when an international student is already graduated...is that true?

I am planning myself to do 2 clinical electives in final year(available in our curriculum as compared to faddyacid's). What would be the best to do in the period between graduation, June, and the interviews( given that i'll be done with the steps)? I guess observership won't be an option. I am thinking about research...any idea? Thank you.

rox said:

So since observereships are not quite helpful, nothing will actually account for USCE when an international student is already graduated...is that true?

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If you have the choice, always choose an elective when you are still a student. Observerships are not very helpful, IMHO and doesn't really count for USCE because you don't actually have CLINICAL contact with patients. You can still get LORs from them but they will not be as comprehensive.

I am planning myself to do 2 clinical electives in final year(available in our curriculum as compared to faddyacid's). What would be the best to do in the period between graduation, June, and the interviews( given that i'll be done with the steps)? I guess observership won't be an option. I am thinking about research...any idea? Thank you.

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A research job is probably best but most places are going to want a several month or year commitment. Observership is an option just don't expect it to be a good one and you won't be paid.

"On one point I disagree with iamcatwoman: the issue of doing electives with private attendings. For programs that require USCE, they will expect those rotations to be in association with an ACGME residency hospital. I speak from experience...having had a friend who had one of her 4 week rotations "not count" since it was done in a PP without any university/residency affiliation. Fortunately, she had enough weeks otherwise."

True, clinical experience at an ACGME residency hospitals is the ideal and should be the thing to aim for. However, this can also be really difficult to obtain (unless you are totally flexible about where you can go for the experience, which i was not) - especially when the local ACGME residency hospitals flat out refuse to allow IMGs to observe in their hospital, which happened with me.

I am an IMG and all my LORs are from private and non-ACGME hospital physicians and I can say that they have been really helpful with getting me interviews at most of the programs that i have applied for in my desired location and specialties. Every PD that i've interviewed with so far has mentioned how impressed they were with my letters. Granted, it's FM and it's in the SE so I guess less competitive and probably a totally different ball game from other specialties/locations. But one thing i'm sure about - i definately got way more clinical experience than i would ever have had at any observership, and consequently really good LORs and an added advantage of working with physicians local/in the same state to the programs that you want to apply for is that the program faculty may know the letter writer (which is good ... as long as the letter writer is liked!). However, one program did reject me because I didn't have 12 months of USCE at an ACME residency hospital. Which is a shame ... 'cos they miss out on meeting me!

So always try to do placements at ACGME residency hospitals, but don't think that it's the end of the world if you can't get any - there are other options. You just have to make what you have work.

Agreed there are other options and my comment above about ACGME approved rotations was not meant to state that they are better, but that there are some states which will not accept non-ACGME rotations toward the required number of weeks of medical education, if they are completed in the US. It appears that you ran across the same situation...therefore, it would be wrong to tell the OP that it is ok to do non ACGME rotations without having him/her even try to get them.

Pennsylvania used to be notorious for this and would not count any weeks done at non-ACGME or osteopathic sites toward your total educational weeks...so my advice to the OP is to check the requirements of the state medical boards before setting these up. It may be fine, but it would be a real drag to be in the situation of a friend of mine and find that you cannot use that rotation toward the required number of medical education weeks.

GATO said:

Thank you for your kind response. While I don't look at this forum, now it is getting bigger.

The professors I work for are all PhD. Not MD. Is that OK?

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No. Letters need to be from someone who can assess your clinical skills. Since PhDs are not in a clinical setting, these are not useful letters.

I know some MD who are my friends or my friend's brother. We are friends, but they don't work with me. Are they fine to write my LOR?

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Absolutely not. Letters from people who have never worked with you, who are family friends, etc. are worthless as the paper they are written on. LORs are to be from physicians who have worked with you in a clinical capacity and are not related to you.

My ex-coworker said MD in my home country are OK. You bet MD in US are better for LOR?

Thank you.

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If you are applying for a position in the US, you want letters of recommendation from a US physician because they are in a better position to assess your ability to perform well in the US medical environment. An MD in Timbuktu has no idea what the US medical system is like and what it takes to succeed here; IMHO letters from non-US physicians, especially those who have never trained or worked here, are useless and will likely be ignored.

BTW, you list yourself as a "pre-med" - this forum is for residency. Are you asking really really far in advance, did you list your status wrong, or have you posted your query in the wrong forum?

So if a residency program requires 3 LORs, does that automatically mean USCE?

FaddyAcids said:

So if a residency program requires 3 LORs, does that automatically mean USCE?

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Letters do not = USCE. USCE is the method most use to obtain US LORs.

Technically, you do not have to have US LORs unless they otherwise specify it (but I can't say I've ever seen that).

Practically, you do.

Our point is that you can submit LORs from foreign physicians but in most cases they will not be considered as a significant contribution toward your application. When you have an LOR from a US physician, it carries more weight but most programs do not specify the letters HAVE to be from US physician.

GATO said:

Dr. Cox,

Actually I am not a pre-med. But I could not find the categories to fit with my situation. That's why I put me as a pre-med.

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I would have chosen "Non-Student", its less confusing to those here. <shrug>

I have a license in my home country, worked as a OB & GY doctor for 5 years. I moved to US, working as a researcher for 15 years in San Diego. I am single and a permanent resident in US. I just passed Step 1 in November. My plan is pass other exams and apply for the residency next year. My friend who is MD in LA said I need to have clinical experience.

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That is correct...especially if you have not practiced clinical medicine for 15 years. That puts you in a very undesirable position as far as PDs go...they prefer people who have not been out of medicine for more than 5 years. Some programs specifically state this on their websites.

But the problem is money. I have to quit my job, take a externship for 1 month or more to get recommendation letters.

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You cannot get an externship if you are not a medical student. All you are eligible for is an observership unless you can find someone to give you malpractice insurance. Otherwise, you are restricted from clinical contact with patients and can only observe.

After that, I have to look for a job. Otherwise no income until getting into residency.

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Understandable; can you not take a leave of absence from your job or use vacation time to do these observerships?

I think I need recommendation letters until September and can get into the residency in March or after. Is that correct? I don't have any practical ideas about that. Just information from First Aid.

I appreciate your suggestions and comments.

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You can begin to apply for residencies via the NRMP in September and most programs have specific deadlines for which everything has to be in. Do you have a letter from the Dean of your medical school? This is required as well. The results of the match come out in March. I urge you to look at:

http://www.ecfmg.org
http://www.nrmp.org
http://www.eras.org

if you have not already done so. The process can be complicated if you are not familiar with it.

I AM GETTING CONFUSED HERE!!!!!!!!!!

1. My medical school will not let me go to get an externship when I am a student.
2. US hospitals will not let me get an externship after I graduate.

Plus it's basically hard to get an externship if even I am still a student, and again they do require it!!!!!!!!

Deans letters are now called Medical Student Performance Evaluations (MSPE). There is a template available for download ... I think that it's on the ERAS or ECFMG website. I will have to double check that one. Whereas previously Dean's letters were more like letters of recommendation for the student from the Dean, the MSPE is a more detailed academic evaluation of the student.

As an IMG it will be difficult to follow the template exactly. I am aware that some draft out the MSPE themselves following the MSPE to the best of their abilities, and then get the dean of their medical school to sign it. My medical school did not have any of the sort of data that the MSPE required, so I just drafted a more conventional Dean's letter which was then reviewed and signed by the current dean of my medical school (a different prof to when i was in school). I then contacted every program that i was applying to and explained the situation about my differing MSPE and every program told me that that was not a problem. Most programs are aware that Deans letters/MSPEs from IMGs will be different. One program even told me that they considered our letters to be "useless" but would still look at the applications. Many of the programs were fine with accepting another LOR in place of the MSPE. But you have to submit some sort of letter/MSPE otherwise your ERAS application will not be complete. Oh, and you will need to include your medical school transcripts with your MSPE.

I'm sorry, I was wrong. Here is a link to the MSPE Template from the AAMC:
http://www.aamc.org/members/gsa/mspeguide.pdf

It's pretty comprehensive

Blade28 said:

I think you asked this already (post #26). The answers to your questions are in posts #27, #29, and #30.

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I wasnt asking I was just talking does it sound very bad to you?

FaddyAcids said:

I wasnt asking I was just talking does it sound very bad to you?

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It just sounded like you were asking the same question again instead of venting.

So your medical school doesn't allow you to do any electives away?

That's too bad...because you're right, it puts you in a bind: you need USCE but your school will not allow you to work it in the schedule.

same team??