How to decide where to apply? Things that applicants look for in their desirable US residency program.

Selecting which residency program to apply to is an arduous task.  How does one decide which ones among the thousands of residency programs in US should he or she apply to?  You cannot possibly apply to ALL the programs. While limiting the number of programs to apply to, also consider the fact that the costs go up considerably beyond 30 programs.

For example, if a medical graduate applied to 80 residency programs (this being the median number of applications submitted by an independent applicant in 2019), the cost of submission would be about $1800 (use the official residency fee calculator here). Also, it would be very difficult to interview beyond 12-15 programs because of travel costs, interview scheduling and your personal stamina.

It is very difficult to know how many programs to apply to without risking the chance of losing a potential interview by applying to fewer residency programs.  This becomes even more challenging for an IMG.

As discussed in my previous blog, independent applicants [that is US citizen IMG, non-US citizen IMG, or former US medical graduates] applied to a median of 78 residency programs as compared to 39 programs by US seniors. This is to say that, independent applicants had DOUBLE the number of residency applications as that of a US senior.

The NRMP data table provide information on how medical graduates decide to apply to a residency program and rank a program for matching. Here is a summary of the top 5 factors from the NRMP survey (ranked in order of importance):

1.  Desired location.  Location, location, location! This is the most important factor for applicants to decide which program to apply to. This comes as no major surprise as you will be spending three or more years of your professional life, living, breathing and working in a hospital. What is it about the location that is so important? Everything! Consider the safety of the neighborhood where you would be living and where the hospital is located, having family and friends in the area, cost of living, rents, climate, time spent on traffic, ease of getting to and from your workplace, activities for yourself and family such as restaurants or jobs for spouse, schools for children are some of the essential factors in deciding a location.

For example, a friend of mine chose not to apply to New York City even though he knew of the many IMG friendly programs in that city as he was turned off by the high cost of living, questionable safety and traffic difficulties. This is a very personal decision, but an excellent starting point as your start to narrow down the list of programs were you intend to apply.

2.  Perceived goodness of fit.  There is a lot of subjectivity in deciding whether a program is a good fit for you are not.  Some applicants prefer a small program that allows closer and more personal interactions with the teaching attendings as opposed to a much larger program in major teaching hospital where you maybe just a "person in a white coat". The goodness of fit is best assessed at the time of the actual interview day. A residency program with two or more IMGs is looked upon favorably by IMGs. So ask yourself if you will be happier in a program with 8, 20 or 50 residents.

3.  Reputation of program and academic medical center program.  Residency training at a reputable program is likely to increase your chances of landing a satisfying position after graduation, and more importantly helps you get into fellowship programs or academic careers. This is because of greater research opportunities in academic medical centers as compared to community hospitals.

Now this may be less of a concern if you choose to be in private clinical practice after residency graduation or are unable to get interviews because of your residency application (such as low USMLE scores, second or more attempts or long time since graduation). As alluded to in my earlier post on five reasons to pursue US residency training, training in an ACGME accredited program and obtaining board certification are adequate for one to have a thriving clinical practice. So, take it easy.

4.  Collegiality among residents and teaching faculty and quality of educational curriculum. This may be difficult to judge just by browsing through a website. Some helpful information to learn about a program include fellowship match rates or boards passing statistics. 

On the actual interview day, one should get a feel for the collegiality among residents. What is the morale of the residents? Do they look troubled at work? Are they willing to help each other out? Are many attendings approachable and easy going or are they malignant or aggressive? Do you think the program director would be a good friend for the next three years of residency (or even many years later)? 

Look for any teaching initiatives or changes in educational curriculum (such as academic half days or point-of-care ultrasound) that the program is proud of. Are the chief residents and faculty responsive to feedback from the residents?

You surely have heard of the highly prevalent burnout and emotional distress among US resident physicians. Choose to train in a learning environment where your colleagues can look out for each other and the faculty is approachable and helpful to you as a person and a physician. This is very important. You want to be training at a place that is comfortable to you but at the same time that does not leave you stressed and emotionally drained. Try to find out how the program is invested in your well-being.

5.  Work-life balance (or work-life integration).  Again this is specialty specific. Find out if the program encourages or even actively participates in out-of-the-hospital social gatherings and activities such as the events found in my hospital. Look on Twitter or Youtube. Get a feel for the kind of documentation responsibilities while you take care of the patients. Also, look at the number of electronic medical record systems (for example, a VA hospital has a separate EMR system if you also round in the VA hospital or clinic). While this should not be a deal breaker, it is best to be fully aware of the extra effort you may need to put in.

TWO additional points to be noted:

1. Salary and benefits are very similar in all residency programs. This should not really be a consideration when choosing between ACGME accredited programs.

2.  For IMGs and those requiring visas, visa sponsorship is of the highest priority (if you need a visa and the program will not offer you one, there is no way for you to work in that hospital). Visa sponsorship would be an important starting point for IMGs as they narrow down their list.

That’s all for now. Hope you like this blog. I would love to hear your thoughts and comments. Join the mailing list for the blog or my facebook groups and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

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!

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The ONLY reason why you should FOREGO your dream of US residency training

In a previous blog, I discussed five reasons why aninternational medical graduate (IMG) should seriously consider pursuingpostgraduate medical education in US. But what might be absolute contraindication(s) i.e. are there some reasons one should totally give up the thoughts of US residency training?

After a lot of thought and search, I could find just one potential problem: Having a cause for the state medical board to not authorize you to practice medicine would be this sole reason.

So having a criminal history, being involved in litigation or a medical malpractice case, irregular behavior on the exams, history of drug or alcohol use jeopardizing your ability to practice, being dismissed or withdraw(n) from medical school, medical school not being in the world directory of medical schools, multiple attempts at USMLE (maximum 3 attempts for my state of VT https://www.fsmb.org/step-3/state-licensure/) are serious red flags.

Here is another blog post with more details. 

Any information pertinent to the above needs to be revealed to residency programs (in ERAS) when you apply and to the state medical licensing bodies. If you have any of these red flags, you really need to weigh whether it is worth applying to a US residency training. 

Psychiatric or physical disability is something that you cannot be discriminated against and need to provide the information to residency programs and the medical boards. 

Other factors below are not insurmountable: 

1.  1. Specialty choice: maybe you were an orthopedic surgeon, ophthalmologist or neurosurgeon in your home country and looking to be one in the US. If you choose to pursue a competitive specialty (as in my previous blog post), you would just need to be prepared to go through a long steep road with many bumps and have the resilience and patience to ‘stay the course’. You would really need to strengthen your portfolio through research, publications, networking. I personally know two general surgeon IMGs who after trying for a few years to get into general surgery, then chose to pursue internal medicine residency and move on with their lives. This might work for some and not for some - you need to decide.

2.   2. Need for visas: yes this does make it onerous to get interviews and match, but again you need to buff up your portfolio as best as you can through research, clinical observerships etc. Some get lucky to marry and have a spouse with US citizenship that opens a lot of doors for their careers.

3.      

4.   3. Low score on USMLE or a second attempt: What are your chances of getting into a US residency? Again, this is not an absolute contraindication. Some just are not good exam takers and still do very well. 

So that’s it – I would love to hear your thoughts and comments. Join the mailing list and check out www.ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

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!

Opinions in this blog are solely of the author and Ed4Med LLC and not the employers or affiliations of the author. 

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FIVE reasons to pursue US residency training.

I was once asked in an interview (for a faculty position!) as to why I chose to train in the US? That question took me for a surprise as it forced me to reflect upon the choices I made in my graduate medical education.

The following five reasons would satisfy any interviewer or friend or family questioning you and your intentions to pursue US residency training:

1.       Advanced and cutting edge technology, medications and procedures available to you as a resident. Training in India, I was very proud of my diagnostic abilities such as making a diagnosis of pleural effusion even before a CXRay was obtained. But that’s being half a doctor as disease management is an equally important skill to learn to be a superb clinician. A great example is point-of-care ultrasound that is revolutionizing medical practice and has generated a huge interest in educational research.

Having access to diagnostic tests in labs and radiological studies, medications, consultation services and, most importantly, having the patients closely follow-up with you to see the effect of your recommended treatment offer unparalleled learning opportunities. I can confidently say that as a doctor in training, this is one of the most important reasons for US residency training. You could also say to your interviewer as to how you loved these aspects of residency training in US that you were exposed to during your observership or clinical rotation.

Patients love what you do as a resident and appreciate your time and effort to talk with them. This results in many of them following through on your recommendations and follow-up appointments. Access to wonderful educational resources such as Uptodate through your residency program to get the latest information and learn the practice of evidence based medicine is an amazing perk in US residency training so that you are not in the dark.

No health care system is perfect. Yes, medical care may not be beneficial at times and occasionally brings up ethical and moral dilemmas. Wouldn’t it be great to be exposed to how experts handle these challenging circumstances? Physician burnout is a serious concern worldwide and electronic medical records may have a role in impacting well-being. Numerous initiatives to address burnout are being studied and implemented to improve well-being and for the first time, a survey of US physicians found a decrease in burnout, that to me is a very encouraging finding.

2.       Residency training in US is regulated and standardized. ACGME is the authority that ensures high quality of residency training and oversees the programs and residents. Important policy changes such as duty hour changes for residents and monitoring feedback from residents are under the purview of ACGME. ACGME accreditation of a program ensures that an internist, for example, can competently suspect MI or CVA at the end of residency training. This means that one can train in essentially any ACGME accredited program and come out as a well-groomed physician to practice medicine or surgery.

3.       ABMS (American Board of Medical Specialties) certification is recognized both nationally and internationally. After completion of residency training, the newly minted attending needs to take a certifying exam such as ABIM board certification for internal medicine. Many hospitals in US, especially teaching hospitals, require ABIM certification to ensure well qualified doctors in their staff in their efforts to maintain high standards of clinical care.

4.       You become a high-income earner after graduation. Now don’t say this to your interviewer as you are not really in the medical practice to make money (you should be in business or real estate if your intention is to make money). But, it’s hard not to think about financial returns of your hard work especially in the current climate of financial uncertainty. The nature of your specialty practice, location, type of practice and a host of other factors decide your take home pay. The bottom line is that from a financial perspective, you will do very well as a US trained physician. Even during residency training, you get paid around $60k per year that allows you to take care of basic expenses (esp if you have minimal or no loan).

5.      Numerous doors open for your after US residency training. While many choose to pursue fellowship or start clinical practice in a private or academic setting after residency, there are numerous exciting opportunities in research, industry, teaching, administration, leadership, MBA, MPH and even non-clinical careers such as medical writing, expert witness and many others that become available to you.

US residency training is very much admired and respected internationally and ABIM certification is even recognized in other countries such as Singapore and the Middle East. Some IMGs have personally decided to return to their home country to contribute and enhance the medical practice.

That’s all for now. Hope you like this blog. I would love to hear your thoughts and comments. Join the mailing list for the blog or my facebook groups and check out Ed4medus.com to learn more about personalized services to help you get into a US medical residency program.

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!

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Is getting into a US residency program becoming more competitive for US and international medical graduates?

Have you every wondered whether it has been getting more difficult lately to get into a US residency program? What's the data to support or refute this statement?

To answer this question, lets look at NRMP data (below)

The notable findings in this report are as follows:
1. The length of the ROL (rank order list) in Table 1 for the filled PROGRAMS has been steadily increasing from 9.24 (in 2002) to 13.12 (in 2019) rankings for one position i.e. in 2019, to successfully MATCH one applicant into a residency position, a program had to rank 13.12 candidates for that position. 

What does this mean? Clearly there are more residency positions than before (see my blog titled 'Is 2020 a good year for medical residency training in US?') so more rankings per position cannot be explained by a decrease in the denominator. 

In my opinion, the above data suggests that nowadays programs are ranking more applicants as the program directors feel that applicants now have more choices to pursue at different programs and locations. So, to improve the chances that a program will successfully match the number of applicants it needs and that there are no unfilled positions, programs are betting more i.e. ranking more applicants. 

To throw a wrench in this line of reasoning, the data reports states that 'NRMP advises applicants and programs to include all acceptable choices on their rank order lists. A longer ROL in no way affects the chances of matching to choices higher on the ROL.' I think this is a way of asking the programs to continually improve the quality of residency education to get the most and best suited applicants.

2. The length of ROL for the applicants is even more interesting. Again, the data tables 2 and 3 in this report show that the length of ROL for matched US seniors increased from 7.96 (in 2002) to 12.91 (in 2019). That is, a US senior is now ranking more programs than before. 

In my opinion, the above finding is a clear sign that matching into a US residency program is now MORE competitive. Other data to support my above conclusion is the fact that unmatched applicants had shorter ROL and ranked close to half the number of programs as compared to matched US seniors (6.90 for the former and 12.91 for the latter as in table 3).

Data for IMGs is not provided in this report. One could extrapolate from the 2019 data (tables 2 and 3) that if the average length of ROL for the entire matched applicants was 11.22 and the average length of ROL for the matched US seniors was higher at 12.91, then on average, independent applicants (US medical graduates, DO, US IMGs, non-US IMGs) had shorter ROL and ranked fewer programs. 

It is a no-brainer that if you rank fewer programs, you have less chance of matching. But why would one rank fewer programs? Are independent applicants more confident of matching as compared to US seniors? I don't think so - in my opinion, independent applicants are less preferred i.e. ranked lower when compared with US seniors and likely had fewer interviews. I certainly hear this in regards to non-US IMGs whom I have interacted with during observership (see my earlier blog titled 'Observership - what is it like in an academic hospital?').

The following figure from NRMP supports my above speculation. It shows that independent applicants applied to more programs than US seniors, but interviewed less and ranked fewer programs than US seniors.

To summarize, YES, it is getting more competitive for both programs and applicants to have a successful match and this trend has greater impact on IMGs. 

I wish I could give you better news, but the take home message is that 'strengthening your resume, scoring well on the exams and having a stellar interview performance at every program you interview are your best shot at beating the crowd'. 

Go to www.ed4medus.com to learn more about personalized services offered and find out how Ed4Med LLC can help you get into a US medical residency program. 

I would love to hear your thoughts. Please join the mailing list for the latest blog posts and leave any comments or suggestions in the box below. You can follow me on Facebook and Twitter. All the best - Ed4Med LLC.

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!

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Which specialties do not participate in the NRMP match?

Almost every residency specialty gets its residents and fellows through the NRMP match. There are three exceptions: Ophthalmology, Plastic Surgery and Urology have their own match process. 

Two things to note:

1. These are 2nd year residency positions. You would still need to have 1st year residency (also called internship) position in medicine, surgery or transitional year through NRMP.

2. The timelines for the match for these three specialties is different from the rest that go through the NRMP. Have a look at the links below to get the most updated information. In general, the match results of Ophthalmology and Urology are released sooner than the NRMP match results in January of the year of training; while the match result of Plastic surgery is released later than the NRMP match results in May of the year of training.

The San Francisco match is the matching program for Ophthalmology and Plastic surgery.

The American Urological Association runs the residency match process for Urology applicants.

Each specialty has its own rules and timelines so I would recommend that you go the official websites linked above. All the best! 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 for images on top of webpage: https://www.aao.org/image.axd?id=c11407ed-24ab-471a-9ebb-619c7817f531&t=636806584464830000 (Ophthalmology) and http://www.ststephenshospital.com.au/sfimages/default-source/default-album/dr-john-yaxley2105bfa38c1c6e33af17ff0000fca4f5.jpg?sfvrsn=0&MaxWidth=400&MaxHeight=&ScaleUp=false&Quality=High&Method=ResizeFitToAreaArguments&Signature=F844C4C19FB692BC51218119F105153A0E11A672 (Urology)  

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!

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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/