What are my expectations of a clinical observer in an observership? Five things an attending wants you to do and NOT do.

As a followup to my last blog on clinical observership at my institution, I felt it would be very useful to share 5 pearls of wisdom on what I expect from a clinical observer. These specific pieces of advice may turn out to be very useful for an observer who strives to make the most of his or her limited time in an observership.

1. As your teaching attending, I am fully aware that your goal as an observer is to obtain a letter of support at the end of the observership. There is no secret about it.

So when a faculty member asks you as to what you aim to achieve in your observership, yes you can certainly talk about 'wanting to learn clinical medicine', 'gain exposure to US health care system' or 'learn about residency training or evidence based practice'. I would also urge you to be upfront and state that you wish to obtain a letter of support from me. This demonstrates honesty and that you are not hiding anything from me. The words may need to be carefully chosen, for example: 'I wish to learn how residents work as a team and with consultants to take care of the patient. My observership is 4 weeks long. I would greatly appreciate you writing me a letter of support at the end of my observership as the US clinical experience and your letter of support will greatly strengthen my residency application."

This way, I can be on the lookout for strengths in your performance and presentations during the observership for inclusion in a glowing letter of support. Also, sometimes if the division chief (whom you may or may not have interacted with) takes the role of being the author of the letter, I can apprise you of this arrangement and then I can make sure I rightly forward my feedback of your performance to be included in the letter. Be ready with your CV (your ERAS CV or a traditional CV) as this is needed to write a letter of support. Also, instructions on how to upload the letter to ERAS would be needed.

As a corollary to this advice, I recommend that you stick with an observership period of four weeks at the least as opposed to two weeks. A longer duration in the division gives you the chance to interact in multiple occasions with many different attendings who can provide the necessary input to the one faculty member writing the letter of support. This may also give you a chance to work with the division chief whose letter carries the most value in the academic hierarchy.

2. At my first meeting with an observer, I always ask an observer 'which topics should we focus this week (or in the next few weeks)?'. A common response is 'whatever you wish'. The intention behind this question is to gauge your sincere interest in learning. You should be ready to answer this question in as much detail as possible. Here are few examples from a nephrology perspective:

• "Could you introduce us to a patient on dialysis and show us how dialysis corrects electrolyte imbalances?"
• "One of the patients that I am following has hyperkalemia. Could we review the causes and management of hyperkalemia?"
• "Could we go down to Pathology and see the kidney biopsy slides?"
• "Could you show us how to do urine microscopy?"
• "I noticed that one of the dialysis nurses was doing plasma exchange on a patient. Could we review the indications of plasmapheresis?"
• "I have always struggled with choosing the right diuretic. Could we review the indications for diuretic use and which diuretic is to be used in a specific situation?"
• "I have only read about kidney transplantation but have never seen a patient with kidney transplant. Could we review the rejection medications in a kidney transplant patient?"

The above requests send out a clear message that you are sincerely interested in making the most of your observership time and want to improve your knowledge of medicine and the clinical practice. Since you know much in advance which specialty you will be rotating, it is best to review an intern's book such as 'The Massachusetts General Hospital Handbook of Internal Medicine' or 'The Washington Manual of Medical Therapeutics Paperback' and do your very best in identifying topics of interest.

In case you are not asked as to your goals of observership (maybe because the attending is busy with other work), don't hesitate to bring these to the attention of the attending.

3. Be polite and courteous to everyone. From the fellowship coordinator to the nurses, techs, medical students, residents, fellows, patients and just anyone you encounter before, during and after observership.

Yes, I realize that you are trying to project your very best and wish to make a lasting impression on me. But doing so at the expense of another person by belittling or proving them wrong will not be tolerated. I shudder when I recall the observer who would just not wait for the attending to finish her question and would just cut her short to make a point. Or the observer who just did not show up when she was supposed to start observership and did not have the basic courtesy to notify the coordinator well in advance. We could have another observer in her absence.

So please be patient and appreciative. As a busy attending on service, we are really going out of our way to accommodate you and your needs just for an altruistic cause i.e. your professional success.

Please be respectful of my time as I have multiple responsibilities including documentation, chart review, interacting with the medical and surgical teams, family members, nurses, dietitians, social workers, administration roles and teaching. Try not to hang around me in an attempt to seek my attention when I am in the middle of other work.

4. Be productive and keep yourself busy during the short observership period and make the most of your time. See if you can be of assistance in the teams daily work. For example, you may assist the student, resident or attending in completing the assessment and recommendations in the patient note especially on the patient that you are following. While observers usually are not allowed to write a note in the electronic medical records, I still fondly remember the observer who typed the complete history and physical including assessment and recommendations in a word document that he sent to me by email that I copied and pasted into the chart after making minor edits. Remember that anything you do to make the life of an attending easier will surely be greatly appreciated and well remembered.

Offer to research topics on Uptodate or on Pubmed either on a question that may have come up during rounds or at any time. If you find yourself dozing or getting bored waiting for a consult, do not start chatting on Facebook. Have a lunch break or check out the library. If you are starting on the inpatient side, ask the attending if you can go to the clinic to observe. Attending medicine resident morning report or noon conferences are other great learning opportunities and will help you in your residency (plus you can add to youe personal statement).

5. Finally, be proactive. You will soon realize that the work culture in a US hospital demands a thick skin at times. You cannot be soft spoken or modest as this is usually equated with lack of confidence. Make eye contact. You don't need to be loud but sometimes one needs to be forceful to get the work done. A university officer shared with me his opinion that the work culture in US is a bit unfair to introverts.

Making presentations to the entire division especially a case presentation that generates a discussion and literature search for evidence is a very high level of learning and is appreciated in any academic program. These skills will surely be highlighted in your letter of support (and you can describe these experiences in your personal statement). Try to do one PowerPoint presentation each week to your rounding team.

Be bold. Be smart. You can do this. And don't forget to remind your letter writer towards the end of your observership for the letter of support and send them your CV.


Always thank the letter writer and any teaching attendings for taking the time to teach and draft the letter. Oh and don't forget to tell them where your matched. All the best!

Note: I just found out that some observership programs ask for payment (for example, this program charges upto 18k for observership) likely to cover liability and teaching efforts. This puts a strain on an oberver's financial resources as any observer needs to bear the expenses for travel, stay and food which can quickly add up to a lot and can be burdensome when not having an income. Use your best judgement and understanding of available resources when deciding where to do your observership. All the best!

Ed4Med LLC (www.ed4medus.com)

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit of image on top of webpage: https://www.reviewjournal.com/life/health/medical-societys-mini-internship-gives-perspective-on-doctors-jobs/

Observership - what is it like in an academic hospital?

The Division of Nephrology and Hypertension at the University of Vermont offers opportunities for observership to IMGs (no payment required). I am a faculty member in this wonderful division. For the last two years, we have been hosting 1-2 observers at any given time round with the inpatient Nephrology team at the hospital. I believe we have been able to do so as the declining interest in Nephrology left us with no first year Nephrology fellows for two years in a row.

The observers have been visiting us from India, Pakistan, Nepal and Greece. Typically, the observers (through some discussion forum) would reach out to me or a faculty member in this division. We would then have them contact our fellowship coordinator who then reviews the observer's CV, obtains permission from the division chief and arranges for the observer for a two or four week observership period. This is usually done anywhere from 4 to 8 months in advance. Certainly, the the longer you can stay the more likely you will get a chance to interact and be assessed at multiple levels thus allowing more details to be included in the letter of recommendation that you request.

After the observer obtains his or her ID for hospital use, they are usually expected to be available starting Monday from 9am to 5pm. I would meet with the observer usually in the fellows office and assign them 1 or 2 patients to follow (chart review only). Everyone would have 1-3 patients to follow. Because of rules regarding patient confidentiality and liability, observers would go into the patient room only with a medical student or resident, talk with the patient after a brief introduction, do a focused exam and prepare a brief progress report for presentation at rounds. After I complete my rounds on new consults or followups by 10.30am, I would touchbase with the observers, other medical students and residents in the inpatient team.

At rounds, we would listen and learn from every patient seen. At the bedside, we would discuss any questions at rounds or in the fellows office using a white board if more detailed discussion is warranted. A example would be to discuss the pathophysiology of hyponatremia or hyperkalemia and their management. It needed a little fine tuning on how to improve their case presentation but the observers I interacted with were quick to learn. One observer realized early that a platelet count of '3 lakh' was incomprehensible to many listeners.

I usually give reading assignments to the observers (either research or review papers) and assign them topics to help me with a literature search. For example, one observer whom I worked with recently reviewed the indications for use of tolvaptan in patients with polycystic kidney disease, a novel treatment strategy approved by the FDA. He did an amazing job creating a short PowerPoint slide presentation from available guidelines. Another observer was following an ICU patient with suspected toxic alcohol ingestion and finding of acetonemia. She reviewed the biochemical pathways of acetone production and very elegantly identified causes of acetonemia, thus excluding isopropyl alcohol toxicity and diabetic ketoacidosis (the patients acetonemia was due to alcoholic ketoacidosis) in our patient. These efforts greatly improved the learning environment in our small learning team.

They went a step ahead and using available library resources including Uptodate and printing resources, they presented a PowerPoint talk each on Friday of the week (attending rotations in our division are one week long). I would review their ppt slides with them to ensure that the content is concisely presented and pertinent to the Nephrology division. For example, a thorough family history is needed for a case presentation of a patient with polycystic kidney disease. The observers each presented their 10-15 minute talk to the entire faculty Division on Friday afternoon with rest of the time being used for discussion. In the absence of fellows and having a variable number of medical students and residents every week, the observers filled an important void in the learning environment by their case presentations and evidence based practice. These talks have been greatly appreciated by the faculty members. I also feel thrilled at having been able to contribute, in some minute way, to the careers of these wonderful observers.

Some days when the service was slow, the observers would go to the outpatient clinic in the afternoon and had assigned attendings in that clinic. They would have opportunities to observe at a general nephrology clinic, kidney transplant clinic or kidney stone clinic. I have not been able to have observers in clinic, but I hear that the attending first goes into the patient room with the observer, introduces the observer who then takes a brief history and reviews followup information since the last visit (as he or she has electronic medical record access). The observer would then report to the attending and they would go back to the patient, examine and talk with the patient in 10-15 minutes. Patients have been very appreciative of our learning environment in this busy academic hospital.

In the next blog post, I will discuss how observers can make the best use of his or her time in a clinical observership.

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

Photo credit of image at top of webpage: http://www.barriedoctors.ca/medical-learners/observerships/

Which specialties are most popular among US and international medical graduates?

Which specialties do USMGs and IMGs mostly match into?

That's an interesting question and it gives a feel for competitiveness of a specialty. We need to look at the tables 8 to12 from the NRMP 2019 match data.

USMGs were very likely to match in the following specialties: (Please note that I created this list of specialties from Table 8 with more than 100 offered residency positions of which >75% was obtained by USMGs).

1. Otolaryngology 93.9%
2. Orthopaedic surgery 91.8%
3. Plastic surgery (integrated) 91.9%
4. Neurological surgery 91.8%
5. Interventional radiology (PGY2 position, integrated) 89.4%
6. Dermatology (PGY2 position) 82.8%
7. Medicine-pediatrics 80.8% 
8. Vascular surgery 78.8%
9. Radiation oncology (PGY2 position) 76.6%
10. Obstetrics-gynecology 75.2%

IMGs were most likely to match in the following specialties: (Please note that I created this list of specialties from table 12 where >15% of the residency positions in that specialty was obtained by either US citizen IMG or non-US citizen IMG):

1. Pathology 46.6%
2. Internal medicine (categorical) 39.4%
3. Neurology 33.2%
4. Family medicine 27.1%
5. Pediatrics (categorical) 18.5%
6. Psychiatry 16.0%

Few points to be noted:
1. The above is a % of offered residency positions, not the actual number of IMGs. That is, though Pathology residency has the highest proportion of IMGs, in terms of numbers, there are more IMG internal medicine residents than any other specialty (due to a greater denominator for internal medicine residents).

2. The above %ages suggest that for an IMG (either US citizen or non-US citizen IMG), Pathology is the least competitive residency position to get into because the odds for an IMG to match into Pathology are the highest.

Now this does not mean that an IMG can never get into, say, OBGYN. It just goes to say that IMGs are very likely to face a stiffer competition to get into OBGYN when competing with a USMG for that residency position. All the best!

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

“What You Lack In Talent Can Be Made Up With Desire, Hustle And Giving 110% All The Time.” – Don Zimmer

Is 2020 a good year for medical residency training in US?

What are the notable trends in applicants, both US and international medical graduates (IMGs), for US medical residency programs?

If you are an IMG, this is certainly of great importance to you.

You may have heard in the US news about the volatile stock market, closing of a major teaching hospital, changing visa rules but also heard about a future physician shortage in US. So it can become very confusing and many questions come to mind about the ground reality. Are there more or less residency training positions in US? Are there more or fewer IMGs applying for residency programs? How do US medical graduates (USMGs) and IMGs perform in the residency match? Which specialties are IMGs likely to get into? We will be discussing all this and more in this blog post.

To understand the trends, we need to look at available data. The authoritative resources for this data are the NRMP data reports published every year. Let's look at some of the tables and figures now.

First question: Are there more or fewer US medical residency program positions?

The answer is: MORE! The NRMP 2019 data reports that "The 2019 Match offered 35,185 total positions, 2,018 more than last year; of those, 32,194 were PGY-1 positions, 1,962 more than in 2018. The total number of positions and the number of PGY-1 positions were all-time highs." Also, "... more than half the increase was attributable to growth in Family Medicine and Internal Medicine."

Concurrently, there are more applicants (see Figure 1 below). This is great news! It certainly is disheartening for a medical graduate to pursue training in a health care system or country with declining demands for residents. The job market for residents in US is thus growing!

Second question: How many USMGs and IMGs apply for US residency training?

There are 5 types of applicants. Let's make sure we define these types clearly:

1. US seniors: current 4th year medical students who will graduate prior to starting residency.
2. US medical graduates: former graduates of US medical schools.
3. Osteopathic medical graduates: senior or graduate of US osteopathic medical schools.
4. US citizen IMGs: US citizen who attended a medical school outside US.
5. Non-US citizen IMGs: non-US citizen who attended a medical school outside US.

I am sure it comes as no surprise to you that US seniors make the bulk of applicants (58.1%) who successfully match into a residency program (see Table 2 above). US seniors are most exposed to the work ethic, training and current medical practices in US hospitals and thus get the highest priority.

Osteopathic medical graduates are physicians with the title D.O. and though their medical school training is a tad different from an allopathic medical school, these graduates constitute a significant proportion of the residency applicants (16.6%).

Non-US IMGs are medical graduates from countries outside US and do not have US citizenship. I am a non-US IMG. Non-US IMGs are an important (13.2%) contribution to the US residency programs.

US citizen IMGs are medical graduates born in US (or naturalized) who chose to train outside US for a variety of reasons such as family reasons, tuition costs or desire for international experience. These graduates have no visa restrictions and are the fourth largest group of applicants (9.8%).

Former US medical graduates are a small number in the applicant pool. These are physicians who did not pursue residency training after graduation but went for other training such as Masters programs (such as Masters in Public Health (MPH), research or military service.

Third question (a very interesting one): Are there more or fewer IMGs applying and matching into US medical residency programs?

This is another important question and so let's look again at the NRMP data tables. The 2019 data show that FEWER US citizen and non-US citizen IMGs applied to US residency programs in 2019 as compared to 2018.

So there were 1.5% fewer IMG applicants (US citizen and non-US citizen) in 2019 when compared with 2018. This can be seen in the cyan bars above.

But wait! There is an encouraging finding (hint: look at the darker blue line in the figure slanting upwards). The success of IMGs in the NRMP match has been the highest (~59%) since the 1990s!

The NRMP 2019 data set reports that "Of the 5,080 U.S. IMGs who submitted rank order lists of programs, 2,997 matched to PGY-1 positions for a match rate of 59.0 percent. Of the 6,869 non-U.S citizen IMGs who submitted rank order lists of programs, 4,028 matched to PGY-1 positions for a match rate of 58.6 percent. The PGY-1 match rates for U.S. citizen IMGs and non-U.S. citizen IMGs were the highest since 1991 and 1990 respectively."

Woohoo! Now the improved match rate for IMGs could be because the denominator (that is total number of IMGs who applied) has decreased. IMHO, I look at thse data very favorably as it indicates to me that IMGs are very much still desirable by US residency programs. So, as an IMG, you still have a great chance to have a successful match in a US residency program especially if you have a stunning portfolio and stellar interview performance.

Fourth question: As a follow-up to the last question, why are there fewer IMGs applying into US residency programs?

The reason for this trend is not entirely clear, though one can speculate that visa difficulties encountered by IMGs from certain countries, improving standard of living and possibly medical training in other countries or need to be close to family in home country are possible reasons.

Fifth (and last) question: Which countries do IMGs come from?

I was unable to find very recent data from Educational Commission for Foreign Medical Graduates (ECFMG). From available 2014 NRMP data, ECFMG reports that "Not counting United States, India contributed the highest number of IMGs to the Match, followed by Pakistan. Other countries with more than 100 applicants in a category include
Canada, Nigeria, China, Iran, Iraq, and Egypt."

In conclusion, YES, 2020 is a great year for medical residency training in US. IMGs need to stay updated with any changes in visa/immigration rules that could affect their ability to travel and train in US.

That's it in this blog. Please leave your comments and questions below and do join the mailing list to receive the latest blog posts. All the best!

Before you go: Here's your golden opportunity to have your voice heard. Write down your ONE question regarding your US residency program application, personal statement, interviews or anything that has been bothering you and keeping you up at night. You can reply at the end of this blog or post a message at my Facebook page.

The top 10 popular questions will be featured on my next blog posts at https://ed4medllc.blogspot.com/ and the winners will receive a coupon each for a FREE practice interview at Ed4medus.com ! Put those thinking caps on and hurry up!

“If You Are Working On Something That You Really Care About, You Don’t Have To Be Pushed. The Vision Pulls You.” – Steve Jobs