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Old 03-21-2014
Haggstrom Haggstrom is offline
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Iíd like to give some recommendations, followed by telling about my experience in searching for and attending a clinical hands-on experience in the United States, because I wish there was such a story out there when I was looking for it myself.

My recommendations are intended for those who are still students at any foreign medical school.

My recommendations

I recommend trying to contact university hospitals, starting at least year before the time you plan to be in the US, because deadlines for applications may be more than a year in advance in some cases. For example, I've seen some institutions essentially stating that applications need to be received by the previous academic year, so if you want to start an activity in June, and their academic year switches between June and July, then the application may need to be handed in by June in the previous year at the latest.

Also look up at an early stage what kinds of visa types are available for you when going to the US from your country to do clinicals.

A list of medical schools that offer electives to international medical students is found at the AAMC webpage (https://services.aamc.org/eec/students/index.cfm). If the link has become broken, then the listing may still be found by googling something like ďAAMC On-Line Extramural Electives CompendiumĒ. Last time I checked you could change the criteria under ďSearch Schools By:Ē, and thereby get to search by state, province or region, as well as specifically sort out the institutions that accept international students for electives.

I recommend beginning by systematically going through the electives pages for these institutions. Updated webpages for their elective catalogs should be found at the AAMC webpage. Otherwise, you can google each institution to find electives catalogs and contact information.

Still, acceptance of international medical students does not mean acceptance of medical students from YOUR university, because many instances of such acceptance are based on agreements between particular universities only. So you can expect to find your school ineligible for electives of many of these universities, but donít let it drag your spirits down.

If you donít find any proper electives or programs in the particular field you wanted, I recommend searching for electives or programs in somewhat related subjects.

However, if you haven't found any other means of getting a hands-on experience in the US by approximately two months before the start of your available period, and a future residency position is really important to you, then I think you may begin to consider contacting a third-party agency that arranges a rotation for you. However, such arrangements are costly (at over $600 per week for AmeriClerkships), and Iíve experienced myself that they can be delayed by weeks with short notice and that you may be placed in another field of medicine/surgery than the one you applied and payed for.

AmeriClerkships for example states that you can start your clinicals 4 to 6 weeks at the earliest after documentation has been presented, and this documentation mainly includes:
*Medical education record which shows that you attend or attended an approved medical school.
*Documentation that you can legally stay in the United States during the period of interest, and that also establishes your identity.
*Clinical Authorization Letter bearing the sponsoring institutional seal (if you're a medical student, extern or resident).
*Documentation of health or travelers insurance for the period of interest.
*Documentation of immunizations including: Hepatitis B, Tetanus, Varicella, Mumps, Measles, Rubella, as well as a PPD within 12 months (if positive, then negative CXR), and flu shot within 12 months
*Up to date curriculum vitae

Also, if you've let a third-party organization arrange your clinicals, plan so that you have at least 2 weeks as buffer time after the clinicals before you need to leave the United States, as I've experienced myself that once clinicals get delayed they can get VERY delayed and you don't want to miss days in the hospital that youíve payed so much money for.

My recommendation is also to not contact private practices for arranging clinicals Ė at least I didnít get a single significant reply.
My search for clinicals

As a background for my recommendations, I started to search for clinicals by looking at electives and rotations offered by various university hospitals. However, I didnít know about the AAMC webpage then, so I searched by each university hospital individually, which was a very slow process considering the low fraction of acceptance of international students from universities without established exchange programs.
When there was only about 6 months before my available period for doing a rotation in the US, I turned to private practices instead, and I wrote about 30 applications to different ones asking about an externship, even if I would pay any fees rather than demanding a pay from them, but got no offers. I think major reasons for not getting a reply was that I didnít send any information about what visa I would use, or what malpractice insurance I would have.
At that point I turned to third-party agencies, which I had already come across earlier. The first third-party organization that I came in contact with to arrange my clinicals was IMGPrep, which offered a 3 month hands-on clerkship program for $7,850. It seemed ok until I read one of the last paragraphs in their agreement:
"If IMGPrep cannot find an externship position that will accept you as an extern in their facility, within an agreed upon time, IMGPrep will refund all fees less a $500 deposit for work undertaken on your behalf."
This made me realize that it could be possible to keep such a business going by simply saying "sorry, we couldn't find any position for you" to everyone and still earn $500. I know the probability is still small, but it's still a considerably large amount of money and as an aspiring physician you don't want to waste time on scams. Also, if they were as good as they claimed themselves to be, they wouldn't need to have such a "deposit" at all. So this still made me suspicious enough to make an Internet search for some page comparing different third parties, and I came across this forum page for "What is the best Paid IMG Externship provider company?":
http://www.usmle-forums.com/usce-cli...hips-imgs.html
, and the "winner" was an organization called AmeriClerkships (with 107 votes), followed by IMG Prep (with 26 votes) and FMG Portal (with 18 votes). Thus, I contacted AmeriClerkships.
My experience with AmeriClerkships

I enrolled in an 8 week clerkship in OB/GYN in Michigan, which cost $5600. The clerkship was claimed to be an obstetrics hospitalist one featuring a teaching hospital and attended by a teaching hospital affiliate, starting in June. I enrolled and paid in February, thinking it would be safe to do it long before the start of the clerkship. However, one month before it would have begun I got an email saying that the attending physician I was originally planned to follow would not be able to have me there, and that they were looking for an alternative one. I was asked whether I would like to change location to Georgia instead for ease of finding an attending physician, or continue to be placed in Michigan. For various reasons I wanted to have my rotation in Michigan rather than in Georgia, and I had already arranged for accommodation and flights, so I chose to continue to be placed in Michigan. I booked a flight to be at the site a week before the planned start of my clincals, and a return flight to return home two weeks after I was expecting to have the clinicals completed. The trip there went smoothly, but I didnít hear about any new site for my rotation. The expected start date passed, and it wasnít until seventeen days after the originally start date that I received an email stating that I was confirmed to begin, and that I was to show up at a nearby location at 11 am. I showed up at that location and time and met the doctor, but only to be informed that it wasnít about starting my clinicals but only to have a short interview, after which the doctor said that he was unable to have me there until he had received further information from AmeriClerkships that I was appropriately covered for any instance of malpractice. Also, the site was a clinic providing infertility treatment, and was not a hospital providing OB/GYN service in general, which I had applied and payed for.
At this time, I seriously doubted that AmeriClerkships would find a clinical location in Michigan, so I told them that I would accept being located at another site, even if it was more than 50 miles away.
After 3 weeks had passed since the date I was originally scheduled to have begun my clinicals, I was informed that I could begin in Chicago, starting after 3 days at the earliest. I didnít want to miss another day of my available time before having to return home, so I accepted it. It was a bit difficult to find a proper place to stay in Chicago in such short notice, but I eventually managed to find one.

AmeriClerkships themselves claim to have a 97% follow-through rate on scheduled start dates (stated in the agreement), but I don't know about the evidence behind that number, but I've experienced that when there actually is a delay, then it can be really substantial. AmeriClerkships didnít refund my for missed clinical time or rebooking flights.

Other major disadvantages I find with AmeriClerkships are:
*The part of their agreement that says that you may be located anywhere within 50 miles of your desired location, and you have the right to know the zip code first at 7 days prior to clinical start date, and the exact location and name of your attending physician first by 3 days prior to the start date. I assume they have this rule to avoid the instance of participants and physicians making their own agreements, thereby leaving AmeriClerkships redundant. Still, this rule makes it very complicated to properly arrange for accommodation and other practical matters.
*The part of the agreement (and its practical implication) that attending physicians shall supervise their clinical trainees for a minimum of 5 to 6 half-days per week, and that it can be done in any combination of half or full days. My schedule consisted of a total of approximately 90 hours per month, which with a cost of $5600 for 8 weeks corresponds to an hourly cost of $35, which must also be viewed in the perspective that there were four clinical trainees following the doctor, and only one at a time could take a medical history or perform a physical examination. Of course I used the free time to study as well, but I could just as well have hade that free time in my home country. In total, here were only 32 patient encounters that I got to perform personally. Each patient encounter took about 15 minutes, so in effect I only had about 8 hours of actual active clinical time Ė for a price of about $680 per hour.
*Phone calls to your clinical coordinator (which essentially is your sole contact with the organization) are replied by voicemail about 90 percent of the time. On the other hand, you usually get a reply by email within a few days.
*You are not in control, and has relatively little information about the situation compared to when applying directly to hospitals, which may be detrimental to the process. For example, if I had been in contact directly with clinical sites in Grand Rapids I may have suspected at a much earlier stage that it would take long time to find one at all, and then I may have switched to Chicago at an earlier time.

Also, the rotation was divided between mainly three locations, with a transport time of a bit more than an hour from one place to another by bus or train.

On the other hand, what I like about AmeriClerkships is the friendly approach by their clinical coordinators, and I've often received emails when it should be evening or even night in their local time, indicating that they dedicate even those hours to you. Also, my impression is that they may still be the best (or least bad) among third party agencies for arranging clinicals.

Taken together, I like every person I've been in contact with at AmeriClerkships, but I dislike the entire system of third part arrangements of clinicals.
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