Every medical student and graduate comes to a point where he looks for observership/externship opportunities to add meaningful experiences to his CV before he applies for a residency in his specialty of interest. As a medical graduate, I have also been through this process, and I know how important it is to find good observership opportunities and utilize them to finally get to your dream job. And if you are like me, you want to be fully prepared before you dive into this unique territory and do all the research you can to succeed flawlessly and score a great Letter of Recommendation (LOR) for your observership/ externship.
This post discusses the factors that every observer/ extern should consider to ensure he aces the Observership/Externship.
Now we will discuss in detail all the things you need to know to ace your observership experience.
1. How to Select Your Observership/ Externship?
Hospital Vs Clinic:
A crucial factor to consider when selecting observerships is how they can help you achieve residency. The locations can be categorized in decreasing importance as follows:
University Hospital Observership > Community Hospital Observership > Private Clinic/ Medical Centers > Nursing Homes
Having said that, it can be challenging to secure clinical experience in a university hospital due to availability or financial constraints. And it is essential to remember that there are other deciding factors when evaluating the value of USCE, which will be discussed below. The best possible approach to securing an observership of your choice is to start looking for it 6-8 months in advance. Another thing you can do is to reach out to your contacts (colleagues, seniors, mentors, relatives) in the USA who can help and guide you. Even little help and information can go a long way in helping you find what you are looking for.
Should I choose observership/externship via commercial agencies?
Several commercial agencies exist that can arrange for an observership at a private practice (for a hefty fee). These paid experiences are primarily at a private clinic where the physician receives payment for hosting you. Any LORs you get from the time spent here will not be viewed as an unbiased account of your abilities (due to the conflict of accepting a fee). Most of the physicians in these private practices are likely unknown in academic circles, thus further negating any advantages in the residency application process. Residency application is already costly, so saving on this step can reduce expenses. This money will let you apply to more programs you’re interested in later.
Another wise thing to do is to apply to a program where you would want to work as a resident in the future. Some programs prefer to choose residents who have previously worked with them. In this way, they can better understand the candidate’s strengths and weaknesses and determine whether their qualifications make them a suitable candidate for the program. Regarding matching into a particular program, LORs from physicians in the same program carry greater weight and make your CV more competitive.
2. How to work as a team being an observer?
It is essential to know that although the observership implies observing the physician while you are at the hospital, you are also part of the healthcare team. So being able to work in a team efficiently with the residents, other attendings, nurses, and the paramedical staff weighs a lot in scoring an outstanding experience. Many qualities can make you a good team person. I will discuss some essential tips I found helpful while adapting to the new system.
- Knowledgeable
It is always a good idea to revise the essential concepts of the field where you will be rotating before the start of the experience. It will make you feel more confident while interacting with the residents and discussing the cases during rounds. It will also help you ask relevant questions showing your understanding of the disease and its management.
- Willing to Learn
As an observer, you are still a learner and need to understand how to apply your knowledge in a clinical setting. Therefore, you must always show willingness and interest in rounds or procedures whenever you are with the residents or attendings. Many program directors find this quality most vital in applicants for their residency program.
- Always ready to give a hand
The hospital is chaotic, and residents and attendings are very busy. It is your job to ascertain the routine and needs of your team and try to find a way to fit in and be helpful. Believe me, there is no better way to earn recognition and respect than to help relieve their burden. This can be tiny things like writing notes, putting information in EMR, taking patient history, doing examinations (if it’s an externship), reading labs, etc.
- Contribute Ideas:
Remember, being a team player means that every member must contribute to the goal somehow. Therefore, you must always strive to convey your ideas of the best next step in any clinical scenario. This will help you gain their trust and feel more comfortable engaging with them.
3. Tips for morning rounds for an Observer/ Extern:
- Arrive early
- Always arrive at the hospital before the attending starts the round. This will allow you to become familiar with the patient’s cases and the schedule for the day. This will also be an opportunity for you to assist the residents with their daily tasks and learn from them. This creates a special bond, and they will be more willing to teach you and pass on a good word to your supervising attending.
- Morning rounds: Dos and Don'ts
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- Always keep eye contact with people doing rounds, whether they’re attending, residents, or fellows. Doing so demonstrates your confidence and attention, and they will reciprocate by asking for your input during the decision-making process.
- Be careful not to ask unnecessary questions! You should refrain from asking those questions if you can find information on the Internet. Identify high-order questions and note them down. Keep in mind that observership is not a training position where you are taught everything step by step. In contrast, you should actively learn by observing and understanding how medical knowledge is applied in a practical setting.
- In the medical wards, be sure not to violate the Health Insurance Portability and Accountability Act (HIPAA). Whenever possible, avoid discussing sensitive topics in public. Consult the physician in his or her private office or arrange an after-hours meeting.
- Rounds are the busiest time of the day. Often, they are chaotic and unpredictable. In the hours leading up to the rounds, a team is working hard to gather all the information they need to make an accurate clinical judgment. Let the residents and interns collect patient data, review charts, and talk to patients. Your team members will appreciate your efforts if you limit interruptions during this process.
- Individuals may be sensitive to their personal space, so it is critical to always respect that space. It is possible to be perceived as creepy or aggressive by standing too close to someone you have just met. A safe distance is 2 to 3 feet. Now, with your arms hanging down, flex your elbows while keeping your shoulders straight. The other person must be at least that distance from you.
- Ensure that the team feels comfortable and safe in your presence. Do not begin flirting with junior medical students or hitting on other team members. Once you give off a ‘creepy’ vibe, you are done for. Ensure the conversation is safe by looking people in the eye and avoiding topics that may cause controversy.
4. Networking during Observership/Externship
Why are networking skills important for an observer?
Networking skills enable you to build and maintain professional and social contacts. In order to be successful, you need a special set of skills. Like in other fields, your credentials and experiences are one part of the package that gets you the job. The other vital parts is the connections you make during those experiences that can vouch for your clinical skills and attest to your professional behavior. Remember that most residency programs in the USA offer 3 years of training; hence it makes sense for program directors and the team to try to find someone compatible with their goals and values.
What worked for me during my observership/externship?
Now, I will share some helpful tips that worked for me. Remember that the core principle of connecting is having something in common. Find a topic that is comfortable for both of you to discuss. You could share the same college, city, or country. Or you both have a common habit of playing or watching a similar game or sport. Once you find that something, you can have a casual talk now and then, and it helps create a special bond that exists beyond the profession. You can ask for advice easily, share personal experiences, and laugh together. Remember, such a person is highly likely to make positive recommendation for you in the future. Since the individual is invested in you personally, his or her recommendation will feel much more genuine than if it were done merely out of courtesy. So make sure you make as many connections as possible while doing your observerships/ externships in the USA.
5. Understanding your role as an observer/extern
The most successful outcomes come from communicating with your preceptor. You should first understand their needs, your responsibilities, and how they run their practice as soon as possible. However, being aware of their expectations is only half the battle. It will be easier for you as an observer to progress if you can pick up on unspoken cues and decipher the needs of your attending. Many doctors are busy and stressed, so you will need to actively ask them about their expectations of you. Determine the doctor’s expectations on day one. Do they require you to be at the hospital/clinic at a particular time every day? Do you have any presentations, assignments, or case reports to prepare? How should this material be presented? Does this observership/externship require a particular dress code? How do you request a letter of recommendation? In terms of patient interactions, what is expected? Will there be procedures available to observe and assist? Several questions can provide insight into how to perform at your optimal level during the observership/ externship.
6. Letter of Recommendation (LOR)
There is this misconception that every observer/extern deserves a LOR, no matter how good or bad he did at the rotation. The simple fact is that an attending does not owe you a LOR simply because you worked with him/her for a short time. Keeping this in mind, an observer/extern should be very humble when asking for a LOR. First, you should ask your supervising physician to give feedback on how you did on the rotation. If the attending is satisfied and happy with your performance, you can humbly request him to write you a LOR. He will say so even before you start talking if he is not interested.
The best way is to talk to the author after rounds, tell him about your USMLE steps and your experiences in the USA, and then ask him about your CV, Personal Statement, or anything else that needs to be clarified. My Attending Physicians were happy to write me a LOR, so I exchanged emails before leaving and sent a polite reminder that mentioned my rotation dates, name, and team members. Finally, let him know in which month you’ll expect to receive the LOR.
7. Dress Code for an observer/ extern
Your choice of dress reflects how professional and sophisticated you are, so dress smartly. It is generally recommended that you wear a dress shirt with a tie and a white overcoat. Unless told explicitly by an attending and allowed by hospital policy, do not don scrubs. Any informal item that is too flashy or overly obvious should not be worn in the clinical setting, such as prominent body jewelry, chunky rings, earrings, or necklaces. Deodorant is always a smart choice. Remember, it does not matter what the resident or medical student wears because they do not need a residency spot like you.
8. Being punctual and regular during your observership/externship
For many reasons, it is better to show up early during your observership/externship. First, it shows that you are genuinely interested in the specialty and creates a positive impression of your dedication. Secondly, especially for the initial days, it decreases the likelihood that you will be late for work due to transportation issues or any unplanned incident on your way to the hospital. Thirdly, it allows you to bond with the residents while they are preparing for their cases for the rounds. You will experience firsthand how the residents interact with the patients and perform an examination. It enhances the likelihood of bonding with the residents and helps you boost your networking connections, which may come in handy later in the match season. Also, it ensures you have much to discuss with the supervising physician after the rounds. It makes it easy for the supervising attending to write you a genuinely personalized LOR.
9. Treat everyone with respect
Every individual at the hospital is directly or indirectly responsible for patient care and should be treated with the same respect as any other healthcare team member. Each staff member should be treated equally and respectfully, regardless of gender, religion, color, or ethnicity. You must develop your emotional intelligence early in life and your career to succeed. Please remember that if you are rude to any staff member at the hospital or even the patients, your chances of obtaining a residency there are slim. Just like rudeness, arrogance is another trait that is never tolerated in a hospital. Do not give anyone the impression that you look down on them, whether they are medical students, residents, or paramedical staff. Through humility, you will be able to win the hearts of many people over time.
10. Practicing Counseling and Empathy as an Observer/extern
As with clinical skills, mastering counseling and empathy requires time and practice. Medical students are taught to treat diseases rather than patients during their training. However, interactions with patients and their families are much more complicated because patients only sometimes follow the textbook course of symptoms and behavior. They may react negatively to your presence or to recent news they have received. Be attentive to their needs and understand that much of their aggression or sadness is likely due to fear of the unknown. Provide them with an understanding of what is happening and what you are doing as a healthcare team to improve their condition. Imagine how you would console a close family member or friend in such a situation. Your ability to communicate with patients and their families will improve as you practice this art of empathy and counseling. Once you have counseled them, you will also observe a more favorable response. This will help build your confidence as a physician.
11. Understand the limitations of observerships
These are basically shadowing opportunities, so the chance of any direct patient care is minimal. You will not be allowed to take history or perform physical examinations. Sometimes, you are restricted from accessing patient data as well. Violating these rules can have serious consequences, and it is important to respect them at all times during your observership. Another significant limitation is that some residency programs don’t consider observerships as USCE and, as a result, might not consider your residency application (if they have a compulsory USCE requirement). This is why it is advisable to seek out externships rather than observerships if possible. You may, however, still take advantage of observership opportunities by participating in research, presenting cases, networking with residents and physicians, and earning LORs.
This post will serve as a comprehensive guide to anyone trying to get an idea of how to do well in an observership/externship. I have listed all the essential things that any medical graduate and student needs to know to clearly understand what he or she needs to be prepared for. But if you feel I have missed something or if there are any other questions that you want answers to, feel free to share your opinion through comments.
1 Comment
Very helpful.