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“Externship” doesn’t mean anything

July 26, 2011

“Externship” is a meaningless word.  I cringe at the word “Observership.”  As far as I am concerned, if you are a medical school graduate seeing patient care with an attending supervisor you are an observer.  There is a huge difference between observing and doing a clinical rotation as a student at a hospital in the US.  Rules on observers are in place to ensure compliance with state and federal laws and hospital accreditation standards as well as ensure the legal safety of observers, staff and patients.  Some programs do not consider your USCE as clinical experience unless you have done clerkships in the US as students or have done a PGY1 year in the US.

As an observer you don’t have malpractice insurance.  That is one reason that you cannot legally examine patients and a big reason why so many hospitals do not allow observers.  If you examine patients (even if your resident says its OK) and a patient complains, you are the one that will take the heat and likely asked to leave.   In the presence of a patient or in any patient care area, observers cannot not be asked or allowed to answer specific questions about a patient’s care or treatment, or otherwise provide medical or professional opinions.  The observer is permitted only to view patient care, and in some hospitals only with patient consent. Observers cannot have direct patient contact or provide any type of medical care.  Protect yourself and don’t cross the line.  Don’t write notes, don’t talk to patients, and don’t examine patients.  You never know when a patient (who is a lawyer) will say “and who is this?” when you are listening to his heart.  Your answer “Um, I’m a doctor from Antarctica and I’m just an observer and I don’t um have a US license to touch patients or um malpractice insurance to cover me if you decide to sue me…OK?”

I often see letters that inflate how much an observer has done.  Sometimes I have to look at the date of graduation and the date of the USCE to figure out if it was a student rotation or time as an observer.  I hate that.  The letter writers who laud their observer’s clinical skills are lying or they were foolish to allow an uninsured observer to touch / talk to a patient.  When I see these inflation letters I wonder about the judgement of the letter writers which reflects badly on the candidate (you).  Letters from a time of observation need to have the following statement: “Our hospital policy on observers forbids any patient contact so I am not able to directly comment on the observer’s clinical skills.”  The letters can and should comment on how much they liked you as a person and how good your English is.

Observer time does not allow you to showcase your organizational skills or clinical skills. Those are very important for program directors to know. Observer time is an opportunity to show off your knowledge base, your social skills and your flair for the English language.  These are also important for program directors to know.

Time spent as an observer can be quite fruitful.  Try to get observer time at IMG friendly hospitals were you can spend time getting to know the hospital and especially the program director.  If you are liked at that IMG friendly hospital, you will probably get an interview there.  Candidates that I know only got interviews at hospitals where they did observerships.

If you are lucky enough to have had time as an observer describe it in your application as “Observer at Man’s Greatest Hospital in the Hematology Department, July 2011”  and not “Externship in Hematology, Man’s Greatest Hospital, July 2011.”

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