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As an international medical graduate (IMG), completing an elective, observership, or externship in the US can be a valuable experience for your medical residency application. Not only will it allow you to gain exposure to the US healthcare system, but it can also provide opportunities for networking and potential residency program connections. At least three letters of recommendation are mandatory for your residency application. By doing well on such clinical opportunities in the US, you can secure strong letters that will make or break your application. Many programs have mandatory requirements for how many months of US clinical experience (USCE) you need as an applicant, and electives, observerships, and externships all count toward these requirements.
However, these clinical experiences can also be especially challenging if you are unfamiliar with the US healthcare system and culture. To help you succeed on your away rotations, we have compiled a list of tips to set you up for success.
1. Reach Out to your Clerkship Director
Before starting your rotation, you must prepare yourself by familiarizing yourself with the healthcare system and relevant medical literature for the specialty. Reach out to the clerkship director and ask if they recommend any specific reading materials. This will help you better understand the system and show that you are proactive and eager to learn. Before one of my electives, my clerkship director sent me short reading materials on eleven common diseases, and they helped me do well during my rotation.
2. Read about the US Healthcare System
To be successful in your away rotations, it is essential to understand the US healthcare system. If it is your first time in the US, it can be overwhelming, so take some time to read up on topics such as Medicare, Medicaid, and insurance payment systems. Understanding these concepts will help you navigate the system and better understand the patient population you will be working with. I really liked this primer by Celine on Medium.
3. Do a Dry Run
It is crucial to arrive on time for your rotations, so ensure you know how to get to the hospital and where to go. Doing a dry run of your commute to your location to the hospital the day before your rotation can help you avoid any confusion or delays on your first day. I took the bus to my hospital, timed how much it would take for me to walk from and to the bus stop, and had physical copies of the bus schedule with me in case I missed a connection and did not have internet. The day before my rotation, I did a dry run and noted all the bus numbers and important stops.
However, on my first day, I boarded the wrong bus. I got on the same bus number, but I unknowingly took the uptown bus instead of the downtown bus because I did not know they were different. Luckily, I had enough time to get out, get the next connection and make it to my rotation on time.
4. Show Up Early, Leave Late
As an international medical graduate, it is essential to demonstrate a strong work ethic. Arriving early and staying late shows that you are dedicated and willing to put in the effort required to succeed. Now is not the time to sleep in; this is your one opportunity to showcase how hard you are ready to work. Be the first person on your team to arrive and one of the last to leave. This will be noticed and appreciated by your team members and attending physicians.
5. Be Professional: American Style
In the US, being professional involves more than just clinical knowledge and skills. Simple gestures such as saying good morning, holding the door, and being polite are seen as common courtesy and expected in the workplace. As an international medical graduate, it is vital to be aware of these cultural norms and consciously integrate them into your daily routine. I struggled with this initially. Small things, such as holding the elevator door when someone is trying to walk in, did not come to me naturally because I was not used to doing them in India. I had to consciously try to do them and learn from how others did them.
6. Dress Professionally
US medical students doing clinical rotations always come dressed in complete professional attire. For male rotators, professional attire for clinical rotations typically involves a suit or dress pants, a button-up shirt, a tie, and dress shoes. For female rotators, professional attire may include a pantsuit or a dress with conservative hemlines and closed-toe shoes. Avoid flashy jewelry or accessories, and make sure your clothes are clean and wrinkle-free. White coats are mandatory as well. If your rotation allows you to wear scrubs, clarify that beforehand.
7. Brush Up on Your Medical Knowledge
I thought this was the easy part. As a medical graduate from India, expectations from me were huge, and hence I learned a lot through rote memorization and patient exposure. Therefore, compared to the typical US medical student, when you arrive for your rotation, you will notice that your medical knowledge will be above average. If you are too far out of medical school, then it would help to read up on common diseases beforehand.
8. Nail Your Presentations
This was a bit more challenging though I could adapt to it quickly. In the US, I noticed clinical presentations are generally more concise. Hence, be ready with your long presentation if needed, but typically, you can get away with a brief, to-the-point presentation, giving only the pertinent information.
But more importantly, always end your presentations with a plan. Make sure to have a clear assessment and plan, and be ready to explain your thought process. Review guidelines and practice your presentations to ensure they are polished, accurate, and concise. Attendings will appreciate a rotator who takes the time to prepare and can justify their clinical reasoning.
9. Be Proactive
As an international medical graduate, it may be challenging to be proactive since many cultures value more reserved behavior. As an international medical graduate from India, I was trained never to speak until you are told to, and this attitude really held me back during my rotation. In the US, being outgoing, enthusiastic, and willing to ask questions is essential. Attendings and residents want rotators interested in learning, which means asking for clarification when something is unclear or offering to help out in any way possible. This also extends to non-medical interactions as well.
For example, you may ask the residents about their weekend plans or engage in small talk about current events. These actions show that you care about your colleagues’ well-being and want to be a team player. However, do this sparingly, as you do not want to be seen as “brown-nosing.” On the flip side, it is also essential to maintain appropriate professional boundaries with your colleagues, which may be necessary for some IMGs due to cultural differences in their country.
10. Be the Person Who Helps
One of the best ways to stand out during your rotation is to be the person who helps. Find tasks that need to be done and volunteer to do them. For example, if a patient has a rare disease, offer to read up on it and present your findings to the team. Alternatively, offer to take care of them if phone calls need to be made, such as to a nursing home. Attendings appreciate rotators who make their workload more manageable, and your willingness to help will not go unnoticed.
11. Be Reliable
Honesty is the best policy, and it can be executed in various ways. If you do not know something, especially during a presentation, or forgot to ask or do something, it is better to admit it than to pretend that you do. Attendings and residents want to trust rotators to perform tasks, and they will appreciate your honesty. Additionally, be punctual, meet deadlines, and follow through on your promises.
12. Take Feedback
Midway through your rotation, ask the clerkship director or attending for feedback. Ask if there is anything that they would like you to do differently for the rest of the rotation. If they provide any specific feedback, thank them for their time and actively work on improving it. Being receptive to feedback shows that you are committed to learning and improving, and attendings appreciate rotators who are willing to change and are teachable, especially if you are an international medical graduate.
13. Make Contacts
During your rotation, make an effort to network and build connections. If the program has a residency program, contact someone from the program leadership and express your interest. Ask for advice about the residency application process and what the program expects from applicants. Bring your CV to the meeting and ask for advice on how to improve it.
If the hospital that you rotate does not have a residency program, then email the leadership of a residency program in that city and ask for advice and mentoring. Explain to them that you are doing a rotation in the town, like the place, and would like to stay here, and would appreciate their advice regarding your application. Remember, it never hurts to ask, and you will be surprised how many doors the mere act of asking will open for you.
14. Offer to Help With Research or Write Articles
If you encounter an interesting case during your rotation, ask your attending if they think it is worth writing up. If they say yes, take the initiative and see it through to completion, including publication. Alternatively, if an attending is doing research, ask if there is anything you can help with. Demonstrating your interest in the specialty and actively working on a project will impress attendings and make you a valuable member of the team. Attendings are always on the lookout for people who can take an idea or a case and see it to publication with minimal supervision.
15. Respect Cultural Differences
You may come from a different cultural background as an international medical graduate. It’s essential to respect cultural differences and understand that what may be considered acceptable or standard in your home country may not be the same in the US. Take the time to learn about US culture and customs to avoid misunderstandings or offenses. It’s essential to recognize that different cultural groups may have different beliefs and values around health and healthcare and may influence how they approach medical advice.
For example, African Americans are more likely to experience barriers to healthcare access, receive lower-quality care, and experience worse health outcomes than other racial and ethnic groups. Some African Americans may hesitate to trust medical professionals due to a history of systemic racism and discrimination in the healthcare system. It’s essential to be patient and understanding with these patients, and to take the time to listen to their concerns and explain your recommendations in a way that respects their cultural beliefs and values.
16. Speak Slowly
Keep in mind that even though you may be speaking English fluently, your accent and the speed at which you speak may be difficult for some patients and colleagues to understand. I have had this experience initially with many of my elderly patients who are hard of hearing, to begin with, combined with the fact that I was speaking swiftly with a thick accent meant that there were communication barriers.
Being patient and understanding with those who may have difficulty understanding you is essential. Speaking more slowly and clearly, and being more animated and expressive in your speech can help improve communication. Additionally, it would help if you were willing to repeat information and use visual aids or written materials to help patients and colleagues understand. You do not want your patient complaining to the attending physician that you were too difficult to understand.
17. Treat Your Nurses Well
Treating everyone with kindness and respect is essential in any workplace, including healthcare settings. Nurses play a critical role in patient care and are often the first to notice changes in a patient’s condition. They also have a good rapport with the attendings and can often significantly influence the attending’s opinion of you. Building a good connection with them can help you learn from their experience and get more insight into the patient’s needs as well.
It is important to remember that nurses are not just there to follow orders but are valuable healthcare team members with their expertise and experience. So even if you were an attending in your home country for many years, you are merely a rotator to the nurses and hence be courteous in your interactions. This goes for other support staff, such as medical assistants, phlebotomists, and administrative staff as well.
18. Be Teachable
Being teachable is important for any medical student, but especially for international medical graduates who may be coming from a different healthcare system with different practices and protocols. Being open to learning new things and being willing to adapt to the US healthcare system can help make the transition smoother and ensure you get the most out of your away rotation experience.
Even if you have been an attending, and are used to doing things a certain way, as a rotator, you are working under the license of the attending physicians. Hence be a tool to help them, and do not believe that how you are used to doing things in the “one true way.” Demonstrating teachability is especially important to an international graduate who has been out of medical school for a long time or has been attending. It’s also important to ask questions and seek clarification when unsure rather than assuming that your previous knowledge or experience will always apply.
19. Show Gratitude
Finally, be sure to show gratitude to your team for the opportunity to participate in the rotation. Thank your attending physician, residents, and other team members for their time and support. A simple thank-you note or verbal expression of gratitude can go a long way in building positive relationships and leaving a lasting impression. I sent individual thank you emails to all attendings I worked with, and they remembered that when I met them a few months later as an applicant. It is also good human behavior to show courtesy this way.
In conclusion, clinical rotations offer a unique opportunity for international medical graduates to showcase their skills and abilities. Even if your application is not otherwise the strongest, excelling during your rotation can significantly impact your chances of being accepted into a residency program. These rotations are auditions, and performing your best can make a difference in your chances of being accepted for a residency at that site. So, put forth your best effort and strive for excellence during your clinical rotations. If you require additional help with the application process itself, then please refer to our USMLE Guide for the International Medical Graduate.