Poor Clinical Skills

[Arb]

So far, according to residents that are in the U.S., the common theme with Ireland grads that they encounter is that they are very bright with amazing board scores, BUT they have poor clinical skills. From the information I gathered with these doctors, students in Ireland only get a few hours a week with an attending and the rest of the time they are shadowing residents with no/little hands on experience and they're never on call!?!

I talked for hours yesterday with an internal medicine intern in Detroit who works with an American Irish grad that is really struggling. He has amazing board scores, interviewed at many fine instituitions, but he didn't even know what a IV piggy-back was along with many, many, other things. On the other hand, they have good experiences Carribean grads due to their 2 years of clinical training in the U.S.

Irish grads, do you feel that you have a lot of catching up to do in your intern year?

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[leorl]

The thing is, it's a difference in systems. That's why for those aiming to go back, doing a lot of US electives is recommended or an unspoken requirement. For all FMGs (not just Irish), there is a period of time where you do have to get used to the terminology and procedures they use in the US (i.e. things like soap notes) and a more hands-on approach. On the other hand, Irish grads in particular have better H & P skills and the ability to naturally build rapport with patients quickly at an earlier stage - that is something which US grads also eventually learn how to do well.

 

[Unch]

For actual hands-on clinical, you're probably right since we get less actual responsibility in clerkships in terms of procedures et al. There's more of an emphasis on getting your histories on the wards and building a really comprehensive knowledge base. I know of more than a few irish students doing clinical electives in NAmerica (or NAmericans studying in Ireland) who smoked people back home in knowledge of anatomy and pharm etc. Ireland also excels in differential diagnosis. But since the average Irish national in med school is so young (starting at 18), the emphasis is on getting the hands-on clinical a little later (in the lengthier internship/house officer/equivalent of residency years). So it's incumbent on the NAmericans to get as much hands-on at home during electives (and to use panache to wield their knowledge toward access to procedures-- I know a med 2 here who wiggled his way into doing quite a few procedures between years 1 and 2 because he gave the impression that he knew a lot!). Don't know how much those awarding residencies in NAmerica are really going to know about what procedures you've done until after you've won the position-- isn't it based more on USMLE scores and grades and letters?

 

[Arb]

Well...it's about being a great doctor and not landing a residency spot.

I'm sure Irish grads do eventually catch up. How many weeks of US electives are possible for someone studying in Ireland?

 

[Unch]

Electives are manadatory between 4th and 5th year. All the NAmericans generally do theirs in US or Canada. All do one but many do two during that summer-- up to 8 or 10 weeks' worth, I guess, if you can work out the details. Others do additional electives between previous years but according to your (networking) ability to set them up. Plan way early!

 

[leorl]

You can also do them summer btw 3rd and 4th yr (4th and 5th yr. in a 6 year program, assuming you're a direct entrant). But one caveat is that a lot of schools require you to be in final and have done some cores, so it can be kind of tricky finding a university without these requirements that also don't cost an arm and a leg. Connections help.

 

[Arb]

Not many weeks it seems. I take it clinicals are all up to the student and the schools do not help in this process? I guess there's one thing Carribean schools have right. 50 weeks of US clinicals set up for you.

 

[Mike MacKinnon]

Not many weeks it seems. I take it clinicals are all up to the student and the schools do not help in this process? I guess there's one thing Carribean schools have right. 50 weeks of US clinicals set up for you.

Yup too true,

On the other hand, the Carrib. schools are meant for Americans and the Ireland schools are meant for the Irish

 

[Arb]

Carrib. schools are meant for those that want to practice in the U.S. That's almost 100% of N. Americans at Irish medical schools. It's too bad the Irish admin. don't aid the students that give them so much funding. Still, Ireland probably will give you as good a chance of practicing in the U.S.

When do Irish grads graduate? This is very important for Canadians studying overseas.

 

[leorl]

Carrib. schools are meant for those that want to practice in the U.S. That's almost 100% of N. Americans at Irish medical schools. It's too bad the Irish admin. don't aid the students that give them so much funding. Still, Ireland probably will give you as good a chance of practicing in the U.S.

When do Irish grads graduate? This is very important for Canadians studying overseas.

Why would the aid US students? Half the classes are international, and maybe 20% of the internationals are americans, the rest are european/aussies/malaysian/singaporean/etc etc etc. Irish and UK schools are meant first of all to provide doctors for their own countries. Sure, in order to do that, they rely on international money but that's another issue. Loads of Irish go to the US to work and do J1's, and we don't let them (or any other nationals) in our medical schools, so don't get the impression that americans are getting jipped here. Think your attitude is kind of a "want something for nothing" one.

Also, some universities have exchanges. I only know about Trinity, but there's a connection with Columbia and I think JHU and a couple others, but the thing is, there is more demand than spots. So if you don't put your name on the waiting list soon enough (usually cuz we don't ask about it in time), then you find your own.

 

[leorl]

Also, and I won't advocate this because it's not exactly the right thing to do - I know of a couple americans who skipped some of their Irish rotations in their entirety to do rotations in the US. You can get caught and it might hinder your graduation, and administrations are getting better at keeping track of their students, but sometimes you can get away with it.

 

[Arb]

Hardly,
most schools offer career services and aid to their students no matter which country they come from. Apparently, it's a MUST to have oversea clinicals so it's even more the case. It's not outrageous and certainly nothing to get defensive about when it is lacking. I'm sure things will be more formalized as the years progress. Medical schools' main purpose is to produce doctors. All schools are there/should be there for their students. Hardly an outrageous demand and certainly not something for nothing. I guess the constant defense from attacks makes one this way.

The exchange programs are great. Those are in one's final year?

 

[leorl]

Not sure what your point is. Nothing in my post is defensive, I merely point out a fallacy in thinking that things should be done for you. I think perhaps US med schools at the moment are the most efficient in getting things done and handholding students through the process, something which maybe you think they should do, as the universities are businesses who are profitting from everyone's tuition money which covers the necessary materials and personnel. Nowhere else in the world has those kinds of resources or money. And if you come over to Ireland for school, which it seems you are going to do but are hesitant about, then you'd better get over wanting to be coddled pretty quickly, as you will have to do it for yourself - I actually think this is better.

Sure, we pay nearly the same amount to be here (or more), so you can argue that we should get special allowances and things should be done for us - they should make it so all US students here can be guaranteed electives all the time and be babied so we have to do as little work as possible. But the admins just don't have those kinds of resources. This brings in the whole issue of the entire country's med ed being funded by international students (whether it's malaysian/african governments or individual international students), so that the money brought in benefits the whole. Because of this, there is not really a profit being made or any extra money channeled to efforts outside internal Irish needs. I wouldn't really place blame for the "deficiencies" you see in Irish med ed on the school administrations and what you seem to view as their unwillingness to do more for us, because until the whole Irish medical system is restructured, the individual administrations can't really do anything about the system's limitations.

At Trinity anyway, there is an international student advisor, who does inform students about upcoming elective opportunities, and there are meetings with students to discuss how to go about arranging electives, where you can look, etc. There've also been USMLE talks arranged to detail what it takes for us and other Irish to go to the US. Also, Trinity has what's called a MOVE society which is 4th yrs. who are going to go abroad for electives to fundraise and draw on the experiences/contacts from previous years. For yourself, when it's time for you to arrange electives and you want to go back to the US, talk to people in the class above you to see where they were successful. And lastly, no you don't HAVE to go anywhere for your elective. You could stay in Dublin/Ireland to do them if you really want to.

Even though the admins have limited resources, they do respond to concerns we may have and will do their best to answer them. But a lot of the most helpful things (informative meetings, etc.) come from the students themselves, and proactivity can go a long way and aid loads of people with minimal work.

 

[Rasmustown]

I have only been here a few weeks but I have already been reminded in no uncertain terms that the Irish medical schools did not even reserve any medical school places for NAmericans fifteen years ago. The feeling amongst some administrators at my school appears to be that the NAmericans in Ireland don't appreciate that and always want the schools to give them more and more. As I was told, "this is an IRISH medical school and its purpose is to train IRISH physicians. North Americans are not the only foreign nationals represented here but they do make the most unreasonable requests" . I was told this in a polite but stern way and I must admit that I had to agree. They do not need us and they could offer the places to students from other countries. Why should they be responsible for guiding us through the USMLEs, etc.?

Since they take few (if any) foreign students, it is easy for American and Canadian schools to steer everyone through exactly the same route year after year. It's just an assembly-line. Since the Irish medical schools are more international and have students from all over the world, they can't operate in the same way. They are providing us with the education we asked and pay for. They never made us any other promises and they don't owe us any more. I think we should be grateful for the opportunities they are giving us and just get on with our studies.


Amy

 

[Rasmustown]

Not many weeks it seems. I take it clinicals are all up to the student and the schools do not help in this process? I guess there's one thing Carribean schools have right. 50 weeks of US clinicals set up for you.

The Irish schools do, of course, provide (mandatory) clinicals in the numerous teaching hospitals and it is not up to the students to arrange them. Where did you get such misinformation? The Caribbean schools do not even have their own clinical teaching hospitals.

Students can, if they wish, do clinical electives in the USA or Canada but the Irish schools do'nt require it so why would they be involved in it?

 

[Arb]

I am not American so maybe the language isn't clear.

I mean, schools want their students to succeed. Schools become successful and more recognized when their students succeed therefore, it is in the best interest of the school to help. Logically, Irish schools should/would do this unless they are not schools? Good to know there is a connection already for clinicals.

After many years on my own and many years of graduate school I think things will be alright

 

[Sage880]

Since they take few (if any) foreign students, it is easy for American and Canadian schools to steer everyone through exactly the same route year after year. It's just an assembly-line. Since the Irish medical schools are more international and have students from all over the world, they can't operate in the same way. They are providing us with the education we asked and pay for. They never made us any other promises and they don't owe us any more. I think we should be grateful for the opportunities they are giving us and just get on with our studies.


Amy

Good point. It's tough to keep this in the front of your mind all the way through medical school though. Not only are you trying to graduate, you're trying to learn a slightly-different layed out set of information for the USMLE's.

BTW, I did an elective after my first year in Canada and have 2 lined up for next summer. One in Canada and one in Florida. Don't listen to people who say it's impossible to do electives until final year. You just have to work a little at getting them set up but it's all about meeting people and making connections!

 

[Rasmustown]

Good point. It's tough to keep this in the front of your mind all the way through medical school though. Not only are you trying to graduate, you're trying to learn a slightly-different layed out set of information for the USMLE's.

BTW, I did an elective after my first year in Canada and have 2 lined up for next summer. One in Canada and one in Florida. Don't listen to people who say it's impossible to do electives until final year. You just have to work a little at getting them set up but it's all about meeting people and making connections!

Exactly. Sage! Well said. You get exactly what you put into it. You're not spoon-fed in Ireland and you have to grow up pretty quickly and take responsibility for your own fate. They give you all the right tools and then they let you to get on with it. After that it's up to you if you do well or not.

Cheers!

Amy

 

[Arb]

Electives as in observerships?

 

[leorl]

No, Sage got electives that are electives. If it was an observership, she'd have said it was an observership. Which, by the way, don't apply for unless you have some free time (maybe summers of 1st and 2nd yr. if you don't want to have a summer). Some people do manage to get electives 1st and 2nd yr. before any clinical training, especially if they have friends at home who are doctors (Sage, not saying you used personal connections, but even if you did, Kudos). Observerships in terms of ECFMG/residency programs are a bit useless. You could use an observership to let you get to know the doctor/field, and then you'd have made a connection to come back and do an elective.

 

[leorl]

I mean, schools want their students to succeed. Schools become successful and more recognized when their students succeed therefore, it is in the best interest of the school to help. Logically, Irish schools should/would do this unless they are not schools? Good to know there is a connection already for clinicals.
QUOTE]

Um, obviously they want their students to succeed. But there isn't one sole way to go about it with the materials they have (i.e. handholding and providing ooodles of elective exchanges, etc.) That's just unrealistic. They have to look at the collective whole. Not everyone of their students want to go to the US when they graduate - why would they cater to the wishes of a few? Most of their interest is in benefitting people who want to practice in Ireland, and I really don't understand why this is such a hard concept to grasp. In the US, our medical schools do not accept say...loads of British people and then gear our medical curricula to take the PLAB so that they can go back to England, do we? That would be absurd. The same applies the other way around.

Also, the Irish schools are already known as excellent schools, and the students they produce do very well in the US, hence their reputations. Obviously, there is a catchup time to get used to the way things are done in the US, but you said it yourself - the contact you know said the Irish grad is very good academically and knows his/her stuff. They don't really need to do anything more to improve their recognition. They already have at least 10 times more applicants than there are places for. And there are plenty of people who realize the value of a different education system and living outside the country for awhile.

 

[Unch]

As I am in the trenches of Med1 and up to my eyeballs with lectures and the brachial plexus and lipid metabolism, I'll just be so glad to get to my clinical years here or anywhere!

And as for Sage (who wasn't a "she" last time I checked!), he's the standout since he's done some great networking and made things happen for himself in the summers. While his path takes some moving and shaking, it's a good lesson for all. Any school and any path is what you make of it. We all knew (or know right away now) that we have to adjust our education here to meet our eventual goals. We're getting all the right coverage of material but, yes, I've already bought Step1 review books so i can fit what I'm learning now into the exams I'll need to pass in two years. That's just common sense I think and more than reasonable as an expectation. (I think it would be weird if they covered USMLE topics in our regular classes when we NAMericans are only 12-15% of the class. We do have a session tonight, though, with a guest speaker who will be giving a USMLE presentation).

Clinicals are the same, here or at home. You can be passive on the wards and take what comes your way or you can be modestly assertive and show you're interested and get access to that much more. Similarly, being organized and pre-planning well in advance for clinical electives at home (including those beyond the mandatory 4/5 summer) can make a lot happen. Aym, jest doo it, oi?

 

[leorl]

ooops, sorry sage. He, she, they're all the same

 

[Sage880]

Ha ha! Yes, I'm a "he" and yes, they were electives. I didn't use personal connections but I did only apply to rural areas the first year and got friendly enough over email with one of the co-ordinators that she really helped me out in landing a spot. Wasn't easy though.

Before I left I shadowed or did an observership or whatever you want to call it at an Irish hospital. I felt like I could fake it through a H&P after doing that and reading a textbook about it. The biggest change back home was the technology. SOAP notes and I felt weird at first doing dictation in the hospitals. Also, everything was computer based. I still wrote everything down myself for the whole elective and then dictated it or entered it in the computer after.

I was the only first year foreign student. I don't think I was actually too far behind the other students. Surgeons used to ask us questions all the time and 99.6% of them were about anatomy. Coming from Ireland where we have an entire year of anat I really did well! Pharm was a big problem though..... the other students were all reasonably comfortable with the different drug classes and I couldn't tell Viagra from Morphine. Not that the other students were experts or anything but they had some sort of knowledge base to integrate new drug info into and I didn't. Before my electives next summer I'm buying a text and maybe those pharm cards or something and trying to get at least semi-comfortable since we don't start pharm until next year!

Anyway, about the original question, my personal opinion is that people have the "blue moon" effect when they talk about foreign doctors. You don't rememeber every foreign doctor at your hospital who comes over and is fine but you do remember the one who is lacking in skills. Therefore you think that the general level of foreign doctors is lower because you over-represent the doctors with poor skills when thinking about the sample. It happens everywere and in everything and is one of the hardest pitfalls of thinking to avoid. I'm not saying that starting in a new country after training in another is simple but I don't think the road is quite as bumpy as some would make it seem. I only know about 4 people personally that started in America after working in Ireland but they're all success stories.

I think if you have faith, have fun, work hard, and don't sweat the small stuff it will all work out!

 

[Arb]

That is very cool. My friend studying in Canada (Alberta med) had electives first year too but he didn't actually work with patients, mostly observed. Is that what is called an observership or is that something different? He said as a first year student, he didn't have much hands on experience or responsibility even though he was insured by the school. Did you have problems getting insured and was it expensive?

 

[leorl]

I'm not sure how it is at UCC, but I think it'd be the same. We're insured or have medical indemnity (whatever it's called) through the college, they provide us with letters saying we're insured x amount (I think it's somewhere like 1.25 million) so it's not a problem when arranging electives cuz you mail that letter in with your application.

Yeah, the "shadowing" thing where you just watch people and aren't really allowed to do anything is an observership. Yeah, definitely learning how to do SOAP notes before I go over for electives and it'll be nice not having to scribble everything down! Also, for pharm I think they get more used to the trade names even though they know the generic names, whereas we pretty much only learn the generic names for awhile. Guess that's where the pda drug reference comes in handy ...

 

[Sage880]

That is very cool. My friend studying in Canada (Alberta med) had electives first year too but he didn't actually work with patients, mostly observed. Is that what is called an observership or is that something different? He said as a first year student, he didn't have much hands on experience or responsibility even though he was insured by the school. Did you have problems getting insured and was it expensive?

I've heard that people have had problems getting insurance but a company in Ireland/UK provides free insurance to all the med students. Took me one phone call giving them the dates and I got my info for the school in the mail. All totally free.

I was seeing patients by myself on day one and doing all sorts of procedures (under supervision) by the end of the week. The trick is to go somewhere small where the doctors love to teach. Everyone I worked with was great. Patient, interesting, and generally concerned with making sure I got to do everything I wanted to do. I think the trick is to go to under serviced areas because they're very interested in you coming back some days. At a big town hospital, they couldn't care less if you do or not!

 

[Arb]

Hi
I seem to recall that clinical rotations and electives have to be conducted at a hospital recognized as a teaching institution? I believe there's a list of accredited hospitals in North America? Are these electives on the list or does it not matter?

Oh I found it. ACGME accreditation and the green book.

 

[leorl]

It depends on your particular Irish school has requirements. For example, we have a "non-residential clerkship" and an "elective." The Non-Res month has to be done through a teaching hospital. The elective doesn't have to be, and can be done at any hospital. But both will count towards your "electives" in terms of applying for the Match and getting LOR's.

 

[deleted21609]

...They do not need us and they could offer the places to students from other countries. Why should they be responsible for guiding us through the USMLEs, etc.? ...They are providing us with the education we asked and pay for. I think we should be grateful for the opportunities they are giving us and just get on with our studies.

I agree with you about the getting on with it. I disagree about them not needing you. You pay WAY more money than EU students. They get charged the break-even rate while the school subsidizes Irish education / their own salaries off of the profit they make off of you.
N.American's are willing to borrow a lot of money for medical school because we expect to make enough to pay it back when we go work at home. Most foreigners can't say this. The Irish schools could try to replace N.American students with non-EU international students to get the same money, but there are problems with that.
A. Most people outside the EU and N.Amer. won't have access to adequate loans to pay the massive bills, so Irish schools would have to rely on getting government-sponsored students and rich kids.

B.I suspect that the numbers of these people who want to go to Ireland is very limited. Americans love Ireland. Asians and Middle Easterners probably don't give 2 squirts of piss about Ireland, so they mostly go elsewhere.

C. Virtually all N.Amer. students want to go home either immediately or within a few years of graduation. This suits the Irish system just fine. They get tuition money and maybe cheap labor (interns and SHO's) without having any competition for reg & consultant jobs or any unwanted immigrants. A larger percentage of other nationalities never want to leave- causing all sorts of problems.

Anyway, that guy's acting like they don't need us is bs. That doesn't give us the right to act like cocky, demanding, a-holes, but it will keep N.Amer. enrollment in Irish medical schools as high as ever.


On the other topic. I wouldn't be concerned about the lack of help in getting electives. It is very easy to get electives in whatever you want. There may be a few locations that won't take internationals, but there are many many more that do. Just apply early and sign up for housing early if possible. Insurance is also not an issue.


One last thing. USMLE topics are covered in all medical school classes in all medical schools in the world because they are the most important topics in medicine. The difference is the test format, and there are plenty of resourses available to prepare you for the USMLE testing format.


Darn, one more thing. I have found that Irish grads have a reputation for good clinical skills as far a H&Ps go. You'll be week in ordering labs, doing procedures etc. because you just don't get much practice in Irish med school. If you get a good pocket book and think/read about what you'd order after you do an H&P it'll help. Electives can give you some practice too.

Sorry this was so long.