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Letters to the Editor

Postgraduate Clinical Observerships for International Medical School Graduates: Time for Regulation

Mavani, Niraj K. MD; Xu, Shuai MD, MSc

Author Information
doi: 10.1097/ACM.0000000000001152
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To the Editor:

Thirty-seven percent of individuals entering the residency Match in 2013 were international medical graduates (IMGs).1 Data from the Educational Commission of Foreign Medical Graduates show that more than 90% of IMGs report some type of U.S.-based clinical experience before successfully matching—the most common experience was a clinical observership conducted either at a hospital (40%) or a private physician practice (25%).2 Observerships should be regulated as a component of graduate medical education (GME).

Currently, clinical observerships remain completely unregulated. Although the American Medical Association IMG Section has published guidelines on observerships and offers a voluntary listing of programs on their Web site, there is no direct oversight. An Internet-based search showed that academic centers, community hospitals, private practices, and medical associations all offer observerships. There are also several for-profit broker services. The range of advertised experiences and costs are highly variable. Some programs cost $0 to observers while others charge $5,000 per month. The length of these experiences varies from a few days to several months.

The clarity of outlined goals of each observership program also varies greatly. The majority of observerships do not clearly describe potential experiences or learning objectives for candidates. Furthermore, for-profit services market observerships as mechanisms to improve a candidate’s likelihood to match. One for-profit service guarantees a letter of recommendation after the paid experience.

Currently, there are initiatives to ensure that foreign medical schools meet the standard of U.S. medical schools accredited by the Liaison Committee on Medical Education.3 Potential policy changes to regulate observerships as a component of GME include mandatory listing in a central registry. Observerships should incorporate clear curriculum goals to ensure a meaningful exposure to the U.S. health care system (e.g., exposure to an electronic medical record). In the absence of direct patient contact, observers should be evaluated on their clinical skills using standardized patients or simulations. A clear conflict of interest statement should accompany recommendations derived from paid experiences. Finally, the fees collected by institutions with observerships should directly reflect the cost of administering the program. These policy suggestions would ensure a richer experience for future IMG residents who represent a significant and important proportion of the future U.S. physician workforce.

Niraj K. Mavani, MD
Categorical medicine resident, Department of Medicine, Presence Saint Joseph Hospital (affiliated with the University of Illinois College of Medicine), Chicago, Illinois.

Shuai Xu, MD, MSc
Dermatology resident, Department of Dermatology, McGaw Medical Center of Northwestern University, Chicago, Illinois; [email protected]


1. National Resident Matching Program; Educational Commission for Foreign Medical Graduates. Charting outcomes in the match: International medical graduates. 2014. Accessed January 28, 2016.
2. ECFMG Certificate Holders Office. IMGs in the 2013 Match. 2013. Philadelphia, Pa: ECFMG; Accessed January 28, 2016.
3. Eckhert NL, van Zanten M. U.S.-citizen international medical graduates—a boon for the workforce? N Engl J Med. 2015;372:16861687.
Copyright © 2016 by the Association of American Medical Colleges