observership or clinical experience in a private clinic

[multiplemyeloma]

I was wondering what is more useful a one month observership at an accredited top-notch university program or hands-on clinical experience for 3 months at a private clinic?

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[Winged Scapula]

Hands down its clinical experience.

Observerships are worthless, IMHO.

 

[Elfy]

Do both, if you can. Use the private clinic experience for USCE and the university hospital experience for LOR.

Also, depends what field you're in. Observerships in internal medicine, especially in teaching programs, can be quite useful: if nothing else, at least you get to understand how a US hospital functions: talk to patients, read imaging studies that are centrally computerized instead of chasing loosely attached films, learn how they put orders in a computer, familiarize yourself with God-awful abbreviations you can't find in most books and which people seem to make up as they go, navigate the maze of a chart (in the US the chart is a three-ring binder and has a social work section! who knew?) attend grand rounds, ask and answer questions, catch up with the jargon, and so on.

Observerships in internal medicine can also be a great way to build self-esteem. The most important thing I've realized during an observership here in the US is that my medical school abroad offered a damn fine education for anyone who cared to listen: what they lacked, and still do, is the funds to acquire competitive medical technology. So, again, it depends on what specialty you go into and what the culture of the teaching hospital is. Some of the staff can be immensely supportive and help you bloom. This whole observership business shouldn't be necessarily just about making connections in the workplace: it should be about connecting with the workplace itself.

For surgery, perhaps not so useful.

 

[Winged Scapula]

This isn't about surgery vs IM.

All of the above about observerships is correct: it can help you learn about how a US hospital runs, how the charts are put together, etc.

However, since almost everyone who is considering one is hoping to use it for USCE or to get an LOR, they should bear in mind that it is USELESS in that capacity. An LOR from someone who has never seen you work clinically does not enhance your application.

And I disagree...it IS about making connections rather than connecting with the workplace.

 

[Elfy]

However, since almost everyone who is considering one is hoping to use it for USCE or to get an LOR, they should bear in mind that it is USELESS in that capacity. An LOR from someone who has never seen you work clinically does not enhance your application.

If that's how you evaluate applicants to your surgical program, that's your privilege as an attending and I understand how it could make sense given your specialty which by definition is "hands-on." But this is not the first or second time you state that LORs from observerships are useless at all times, in all specialties, in all circumstances, and now ALL CAPS, and I cannot understand such generalizing power from someone who otherwise offers nuanced and specific advice on this forum on a regular basis. If I didn't personally know of graduates from my country who matched or prematched solely on the strength of their LORs from US observerships plus USMLE scores in IM, pediatrics, psychiatry, and even anesthesia, maybe I would agree with your discouraging post. As things stand, I don't.

For foreign applicants who have already graduated from med school there is no option of doing clinical rotations in the US. All they are allowed to do is observerships, which in their case are not useless, they are better than nothing.

Also, for the most part, US medical students aren't running around on their medicine rotations doing unsupervised procedures all day long either (Again: I have no idea what they do on their surgical rotations). They "work clinically" in the sense that they interview patients, do physical exams, present cases to faculty and residents, listen, nod, maybe do a supervised procedure, which is what FMGs did in their respective medical schools as well in order to graduate, even if they went to medical school in the jungle. This is what Step 2 CS is for: to evaluate the FMGs' history, physical exam, communication and patient note writing skills in a minimally supervised setting and on a standardized scale compared to their American peers (for the record, I doubt anyone practices totally unsupervised medicine in the US except from the attending level and up, and even so, I see IM subspecialties seeking reciprocal consults, and surgical consults, two or three times a day).

You seem to think that LORs are there just to double for Step 2 CS. That would be redundant. If they both measured the same thing, there would be no need to ask for both.

Also, for graduates who have been away from clinical medicine for a while, a clinical LOR from a former professor back in their home country wouldn't be necessarily a better predictor of performance than an observership US LOR. Many candidates who have graduated for a while aim for a combination thereof, since according to ERAS, LORs should measure not just clinical ability, but also "professionalism and interpersonal skills both in the patient setting and with hospital staff." So while there is some degree of overlap between the two, this shouldn't be read as redundancy.

Furthermore, what all observerships have in common is that the FMG observer should not be involved in direct patient care- i.e. FMGs should have their hands practically "tied", or almost, when they are in the room with the patient and the staff, and should never be alone with the patient, which is essentially correct for the purposes of malpractice insurance. Nowhere in the protocol of observerships does it say the FMG has to be a deaf, mute statue as well, and some of the more experienced teaching staff are often able to evaluate some of the observer's "clinical abilities" that could not have possibly been caught by Step 2 CS by the way s/he asks or answers a certain history or imaging question. Again, "some" and not "all" clinical abilities; your post is black-and-white, mine is gray.

And, frankly, LORs alone won't make or break an application when it comes to FMGs. They may help push an otherwise very strong, or an otherwise very weak, FMG application over the edge. For many FMG cases the LORs, the MSPE and other "subjective" criteria are little more than a formality speaking more to the completeness than to the strength of an application, because traditionally there have been FMG-unfriendly and FMG-friendly hospitals. One can do almost nothing to impress the former (who see the world in black and white), while the latter (who see the world in bright colors) tend to select FMGs based on "objective" criteria such as USMLE scores and publications, or their own internal "subjective" criteria, e.g. the performance of former residents hailing from that particular country or medical school. ERAS even allows FMGs to not submit a MSPE if it is not their school's policy to provide it, with ECFMG acting as their dean's office and generating a blank form in lieu of MSPE.

3 LORs from observerships plus a generic blank MSPE will change the status of an application from "incomplete" to "complete" and will prompt its downloading by a program. It's up to the individual PD and department culture what happens next after reading the application itself. But an application without at least 3 LORs will eventually be deemed incomplete and will most likely not even get a shot at downloading by most programs.

 

[Winged Scapula]

If I didn't personally know of graduates from my country who matched or prematched solely on the strength of their LORs from US observerships plus USMLE scores in IM, pediatrics, psychiatry, and even anesthesia, maybe I would agree with your discouraging post. As things stand, I don't.

Clearly people match every year without an ounce of USCE, with US LORs, etc. We cannot say whether or not the USMLE scores or the "strength" of their LORs was the deciding factor.

For foreign applicants who have already graduated from med school there is no option of doing clinical rotations in the US. All they are allowed to do is observerships, which in their case are not useless, they are better than nothing.

Fair enough, they are better than nothing. You are correct that I neglected the nuance and overstated "USELESS". My POV is that, in my 10 years here on SDN (and several more prior on another BB, and as an IMG myself, I have experienced countless of IMGs/FMGs who somehow think that the observership is akin to a clinical elective. If you have no choice, if you've graduated, then yes, I agree, it is better than nothing. But to encourage users, such as the OP, who appear to have a CHOICE, to do an observership, seems to fail to recognize that these are not nearly as helpful as an elective.

I do not think surgical programs are any different in this regard. I am sure others will correct me, but given equal candidates with LORs, one from a clinical elective and one from an observership, I'm fairly sure most would look at the latter with a more jaded eye. How can you evaluate someone as a resident (which is NOT just procedural...as a matter of fact, surgical programs are not evaluating potential residents on the basis of skills but rather work ethic, intelligence, etc. - the very same things that all other PDs are looking for).

Also, for the most part, US medical students aren't running around on their medicine rotations doing unsupervised procedures all day long either (Again: I have no idea what they do on their surgical rotations). They "work clinically" in the sense that they interview patients, do physical exams, present cases to faculty and residents, listen, nod, maybe do a supervised procedure, which is what FMGs did in their respective medical schools as well in order to graduate, even if they went to medical school in the jungle.

But unfortunately, as an observer you are not allowed to do physical exams, take a history from a patient, etc. so how is the faculty really able to assess your skills?

This is what Step 2 CS is for: to evaluate the FMGs' history, physical exam, communication and patient note writing skills in a minimally supervised setting and on a standardized scale compared to their American peers (for the record, I doubt anyone practices totally unsupervised medicine in the US except from the attending level and up, and even so, I see IM subspecialties seeking reciprocal consults, and surgical consults, two or three times a day).

Agreed. Without getting into a discussion about whether or not Step 2 CS really measures what it purports, I would argue that while these are important skills to develop as a student physician, they are not the only ones important as a resident. In addition, since many FMGs/IMGs have not taken Step 2 at the time of clinical electives, this cannot be used as a substitute for a clinical elective.

You seem to think that LORs are there just to double for Step 2 CS. That would be redundant. If they both measured the same thing, there would be no need to ask for both.

No, but it is an important measure to have someone who understands what it takes to be a successful resident assessing a candidate rather than a standardized patient (who might have some idea of what a good physician is, but not necessarily what a good resident is ). I am just trying to let people understand that most LORs say the same thing. If someone presents with an LOR based solely on superficial experiences like an observership, it will be judged against all others where the clinical skills are paramount. Can you honestly say that if presented with two letters, one from an observership and one from a "real" elective, that you might prefer the former? It was my impression that you valued the "name" program that the OP is asking about over a real elective.

...according to ERAS, LORs should measure not just clinical ability, but also "professionalism and interpersonal skills both in the patient setting and with hospital staff." So while there is some degree of overlap between the two, this shouldn't be read as redundancy.

So, how do letters from observership measure clinical ability or professionalism when there is so little chance to exhibit those skills?

Furthermore, what all observerships have in common is that the FMG observer should not be involved in direct patient care- i.e. FMGs should have their hands practically "tied", or almost, when they are in the room with the patient and the staff, and should never be alone with the patient, which is essentially correct for the purposes of malpractice insurance. Nowhere in the protocol of observerships does it say the FMG has to be a deaf, mute statue as well, and some of the more experienced teaching staff are often able to evaluate some of the observer's "clinical abilities" that could not have possibly been caught by Step 2 CS by the way s/he asks or answers a certain history or imaging question. Again, "some" and not "all" clinical abilities; your post is black-and-white, mine is gray.

Undoubtedly you are right...it is not as black and white as I painted it. But I am simply trying to express the commonly reported experience that FMGs get as observers where they are not incited to think, where there is no attempt to evaluate clinical abilities and hence, a bland impersonal LOR is produced. Having seen several of these myself, I can tell you, they are not very impressive, regardless of how hard the observer tries to demonstrate their clinical abilities.

And, frankly, LORs alone won't make or break an application when it comes to FMGs. They may help push an otherwise very strong, or an otherwise very weak, FMG application over the edge.

This is true for almost any factor in the application and I agree with you except in the case of a bad LOR (which I have seen on rare occasion) - this CAN break an application.

So, I agree that my "advice" was less nuanced than it should be but it was based on my experience that many FMGs do not know the difference between electives and observerships and do not try and get electives (where feasible and possible) because of inaccurate information about the value of observerships. Over the last few years it has gotten more and more difficult to get into a US residency - more programs are requiring ECFMG certificates to apply, US clinical experience, etc. We should do everything we can to encourage FMGs to do US clinical electives where at all possible (which is the case for the OP).

This is a contentious issue and I am sure that there are many others who share your opinion and I thank you for the clarification.

 

[multiplemyeloma]

Winged scapula, Elfy, thank you very much for your feedback, I am an IMG and I am applying to Pathology. I am going to try and secure both, although one is in Texas and the other in New Jersey..plus the time-constraint...is it a given that you recieve an LOR at the end of an observership? or do you have to ask for it? Cheers

 

[Elfy]

Winged scapula, Elfy, thank you very much for your feedback, I am an IMG and I am applying to Pathology. I am going to try and secure both, although one is in Texas and the other in New Jersey..plus the time-constraint...is it a given that you recieve an LOR at the end of an observership? or do you have to ask for it? Cheers

If you're still a student, then you should do what Winged Scapula said and try to get a US elective at any cost, time or money (that means a clinical rotation where you are guaranteed to receive a grade or evaluation at the end, with a teaching hospital).

If you've already graduated from medical school, then just do your best, both options have their advantages and disadvantages. The hospital is a big name on paper that won't let you do much in practice, like Winged Scapula said, on the other hand, the private sponsor is a smaller name on paper who may let you do a lot in practice, but whose word may be doubted, especially if they are a very small practice with a few doctors who mostly happen to be from the same country as you. I would really do both unless what you mean by "time constraint" is that your visa is about to expire.

Then again, for a pathology residency all this clinical and direct patient care stuff may not be all that relevant, depending what specialty the observership is in, really. If all you do during the observership is reading slides all day, then there's no malpractice insurance limitations to speak of at the hospital, and you might be able to argue that you were exposed to the same quality of education as US students at least for the period of the observership.

Nobody is guaranteed to give you a LOR at the end of the observership if it's not an organized program advertised as such, and even if it is an organized program, all they usually commit to initially is issuing a letter of attendance. They may be so impressed with you they will inquire about your future plans and offer to write you a LOR, but it's not a given. And, of course, it's possible to ask for one at the end and not get it, but then again, trying out is the only way of finding out.

I wish some of the pathology FMG wonderboys/girls preparing for US residencies would chime in on this (Pollux or anyone?)

 

[Elfy]

This is a contentious issue and I am sure that there are many others who share your opinion and I thank you for the clarification.

You're very welcome. I agree with most of what you wrote except for a couple of points.

Over the last few years it has gotten more and more difficult to get into a US residency - more programs are requiring ECFMG certificates to apply, US clinical experience, etc. We should do everything we can to encourage FMGs to do US clinical electives where at all possible (which is the case for the OP).

Yes, we absolutely should emphasize one over the other - that is, USCE over observerships. I don't know what the OP's status is. I assumed, perhaps wrongly, that he has already graduated, since both USCE in private practice and observership in a teaching hospital are not hospital electives/clinical rotations, but are both second-line options. It may just be, of course, that he is misinformed.

In addition, since many FMGs/IMGs have not taken Step 2 at the time of clinical electives, this cannot be used as a substitute for a clinical elective.

Now I'm confused. Unlike FMGs who for the most part have to be ECFMG certified for the purpose of as little as getting interviews, most US seniors don't even have to take Step 2 in time for the match. They just have to take it later. By your logic, it would mean that clinical electives are used as substitutes for Step 2 in the case of US seniors, which they really aren't. It's just a question of timing.

It is an important measure to have someone who understands what it takes to be a successful resident assessing a candidate rather than a standardized patient (who might have some idea of what a good physician is, but not necessarily what a good resident is).

Standardized patients play the same role to real patients as observerships play to electives. Standardized patients and observerships are surrogates that have come lately to replace the real McCoy for litigious reasons. The US can sometimes have a litigious culture where anyone can sue anyone in civil court for the most ridiculous reasons without the suit necessarily been thrown out by the judge as without merit, in which case the defendants have to retain legal counsel and possibly counter-sue for frivolous lawsuit (patient spilled McDonalds hot coffee cup in her lap while driving, sues fast food chain for injury, sues automotive industry for faulty design, sues hospital for neglect, and would probably sue the FMG observer for inflicting culture shock on her if hospitals wouldn't put a lid on the latter). All this can potentially cost a ton of money and it's best if it's nipped in the bud.

And I'm confused again by your post. Real patients don't have a necessarily better idea as to what a good resident is than standardized patients, they just want a good physician as much as SPs do, and as you stated correctly. My point is rather that not all of Step 2 CS is graded by the SPs, just the communication/interpersonal skills and data gathering components. The patient note is graded by a real physician involved in the graduate medical education process, not by George Clooney with his ER tag whipping up a red pen. The patient note (data sharing) is a measure of being a good resident, among other things.

Can you honestly say that if presented with two letters, one from an observership and one from a "real" elective, that you might prefer the former?
I am sure others will correct me, but given equal candidates with LORs, one from a clinical elective and one from an observership, I'm fairly sure most would look at the latter with a more jaded eye.

Again, the key here is the "all else being equal". This may very well work for AMGs who are measured with more or less the same yardstick, more or less in real time. It also may work for a program that takes predominantly FMGs and stacks them against each other.

It doesn't work that well when comparing AMG apples with FMG oranges, since there most things are not equal from the start, and can only get further off the mark. And it only gets further off because of programs' and American consulates' official requirements, which can sometimes clash. FMGs usually apply with higher and more complete standardized test scores, because they can't even clear the interview and visa hurdles otherwise. This puts them at a net disadvantage when it comes to time elapsed from graduation year and US clinical electives.

Now I know the average scores for FMGs who matched in a given specialty are slightly lower than the corresponding average scores for AMGs who matched, but that's NRMP data that doesn't take into account the number of FMGs who prematched, who are in the thousands (according to the ECFMG Reporter, while 4,563 IMG/FMGs obtained PGY-1 positions through the 2007 Match, 7,225 entered PGY-1 for the 2007-2008 academic year).

Bottom line is, this is not a linear equation, but one that comports many variables; practically programs cannot stop a number of FMGs from scoring highly or even astronomically on standardized tests, amassing a number of publications, and applying (only ECFMG/NBME can pull the plug on the latter); what individual programs can do, however, on a very practical note, is to turn the US-clinical elective factor into a disqualifying criterion even when it is the sole weak factor in an application. That, again, is, I think, a prerogative they're each entitled to and hopefully the thread won't turn into a debate over this one last point.

 

[Winged Scapula]

Winged scapula, Elfy, thank you very much for your feedback, I am an IMG and I am applying to Pathology. I am going to try and secure both, although one is in Texas and the other in New Jersey..plus the time-constraint...is it a given that you recieve an LOR at the end of an observership? or do you have to ask for it? Cheers

Before you make a commitment, please check the state requirements for licensing, as it is not clear to me what you mean by "private clinic".

For example, all states have a certain number of weeks of medical school rotations that are required for you to be licensed there or to work as a resident. Some states require that all rotations, which are to be counted toward those requirements, be done at ACGME or AOA hospitals. Thus, if by private clinic you mean a physician who is in private practice with no medical school or residency affiliation, this may not count in some states (Pennsylvania is one). I had a medical school classmate who did a rotation with a family friend; fortunately, for her she had in excess of the number of weeks required, but could not count this rotation.

 

[Winged Scapula]

Winged scapula, Elfy, thank you very much for your feedback, I am an IMG and I am applying to Pathology. I am going to try and secure both, although one is in Texas and the other in New Jersey..plus the time-constraint...is it a given that you recieve an LOR at the end of an observership? or do you have to ask for it? Cheers

Before you make a commitment, please check the state requirements for licensing, as it is not clear to me what you mean by "private clinic".

For example, all states have a certain number of weeks of medical school rotations that are required for you to be licensed there or to work as a resident. Some states require that all rotations, which are to be counted toward those requirements, be done at ACGME or AOA hospitals. Thus, if by private clinic you mean a physician who is in private practice with no medical school or residency affiliation, this may not count in some states (Pennsylvania is one). I had a medical school classmate who did a rotation with a family friend; fortunately, for her she had in excess of the number of weeks required, but could not count this rotation.

 

[Winged Scapula]

Winged scapula, Elfy, thank you very much for your feedback, I am an IMG and I am applying to Pathology. I am going to try and secure both, although one is in Texas and the other in New Jersey..plus the time-constraint...is it a given that you recieve an LOR at the end of an observership? or do you have to ask for it? Cheers

Before you make a commitment, please check the state requirements for licensing, as it is not clear to me what you mean by "private clinic".

For example, all states have a certain number of weeks of medical school rotations that are required for you to be licensed there or to work as a resident. Some states require that all rotations, which are to be counted toward those requirements, be done at ACGME or AOA hospitals. Thus, if by private clinic you mean a physician who is in private practice with no medical school or residency affiliation, this may not count in some states (Pennsylvania is one). I had a medical school classmate who did a rotation with a family friend; fortunately, for her she had in excess of the number of weeks required, but could not count this rotation.

 

[SlyWalker]

Bumping up this thread so that someone like me can benefit from this excellent discussion.