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Warning from California on “Externships”

November 5, 2011

I see letters from individual physician offices lauding the practice of an individual who has done an “externship.” As I have stated before “externships” are meaningless. Program directors are smart people and they know that these letters and experiences are not very worthwhile.  A letter from a private physician office is suspect in many ways.  First off, the physician has most likely been paid by an agency who received money from the extern.  The letter written in support of the extern is biased as the physician is paid on behalf of the extern.  Even if the physician states to the extern otherwise, the letter is a formality.  I have never seen a critical letter from a private physician’s practice of an extern’s performance. I have seen critical letters from physicians in hospitals where IMGs do observerships. Remember, the ideal US clinical experience (and only useful clinical experience) is a clinical rotation in the US at a university hospital while you are a medical student or Non-ACGME Clinical Fellowships or training programs.

Any physician who allows an extern to do anything above what a high school educated medical assistant can do is assisting in the unlicensed practice of medicine. The unlicensed or unauthorized practice of medicine occurs when an unlicensed person does something that is part of the legal definition of “medicine.”  Florida Statute § 458.327(1)(a) makes “[t]he practice of medicine or an attempt to practice medicine without a license to practice in Florida” a felony of the third degree. My personal physician has a medical assistant who takes my blood pressure and asks me how my shoulder feels. That is the extent of what a medical assistant does. She most certainly does not do a physical exam on me. Anything beyond blood pressure measurement and “chit-chat” may be the unlicensed practice of medicine. The unlicensed practice of medicine puts the physician the extern is working with and the extern in a potentially compromising situation. A physician who allows an extern to do more than a medical assistant may violate state licensing provisions. A residency program that “requires” you to do an externship may be unknowingly encouraging you to practice medicine without a license. The California Board of Medicine has issued a warning to physicians who allow externs to see patients. (See “Don’t assist the unlicensed practice of medicine.” on page 5) The AMA also has a post on their website on the issue where they highlight that both the supervising physician and the IMG can face sanctions.

Unfortunately, there is a great deal of misinformation regarding this topic. Ten years ago the concept of an extern did not exist. Companies saw a potential market to exploit IMGs to gain experience in the US when observerships became scarce. These companies charge big money to place IMGs in doctor’s offices.

So where does one get US clinical experience?  Here is a up to date list of observer opportunities. There is a great post on US clinical experience by MLE and Residency tips called types and opportunities for USCE.  Further, some hospitals have Non-ACGME Clinical Fellowships or training programs that one may be eligible for. Examples of such programs can be found here and here.

While I realize that not everyone can travel to the US as a student I see plenty of applications where individuals have delayed their medical degree to come to the US and do elective rotations as students.  I hope this message reaches those who are thinking of doing training in the US early in their thought process so they can plan to do US rotations while they are still students.

The views expressed in this post are those of Kenneth Christopher, MD and do not necessarily reflect the views of Dr. Christopher’s employer Partners HealthCare.

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