International medical graduates (IMGs) constituted 32.9% of psychiatry residents in the United States in 2008/2009 (1). IMGs are a heterogeneous group in their cultural, linguistic, and educational backgrounds. Regarding the last, diversity of training experiences, suboptimal clinical exposure to psychiatry, and cultural attitudes to mental illness may affect the performance of IMGs in residency training. Because they fulfill an important role in teaching and clinical care, educational initiatives that facilitate the transition of IMGs into U.S. residency training are highly desirable. One such educational approach is the clinical observership, often conceptualized as a structured pre-residency experience geared toward familiarizing IMGs with the structure and process of delivering medical care in the U.S., and preparing them for entry into residency training.
Although observerships have become an increasingly common part of IMGs’ entry into U.S. medical education, little has been published on this topic (2, 3). Also, no recommendations specific to psychiatry have been published. This communication from the IMG Committee of the Group for Advancement of Psychiatry (GAP) intends to address this gap by outlining a practical approach that residency training programs can use to organize the content and process of an observership, with special attention to educational, legal, and ethical challenges. Reflecting on our own experience and others’, our goal is to provide observership programs with a roadmap that can be implemented and adapted on the basis of local needs and resources.
As defined by the American Medical Association (AMA), “An observership is a period of time spent observing clinical practice under the supervision of a physician-preceptor.” The AMA issued a document (4) to assist departments interested in developing observerships lasting from 2 to 4 weeks, without addressing issues pertaining to medical specialties. The AMA’s “Observership Program Guidelines and Evaluation Forms” suggests application requirements, learning objectives, preceptor guidelines, learner responsibilities, an organizational model, and Health Insurance Portability and Accountability Act (HIPPA) standards, and offers sample forms (4). According to the AMA, “An observership program may be established by any state or county medical association or interested group of physicians to assist IMGs who wish to observe clinical practice in the U.S.”
The terms “observership” and “externship” are sometimes used interchangeably; however, observerships are generally understood to include “observation” only and not involve direct patient care that may be part of an externship. As used in this article, observerships are U.S.-based programs available for IMGs to observe clinical care without providing direct patient care, the latter requiring a license to practice medicine.
Benefits of Observerships for IMGs
Observerships provide IMGs with a unique experiential opportunity in preparation for U.S. residency training. It is generally believed that time spent in a psychiatry observership will significantly strengthen an applicant’s chances of acceptance into a residency program. Also, an excellent letter of recommendation from an observership carries considerable weight with Training Directors (TDs). From the IMGs’ perspective, participation in several observerships increases their exposure to a number of programs and theoretically improves their chance of being highly ranked at the time of “the match,” or even securing a pre-match position. Another benefit of observership is as an opportunity to sharpen language and communication skills before taking the Clinical Skills Exam. Observers may also have the chance to participate in a scholarly/research project during the observership. Such experience, particularly if it leads to a publication, can improve the competitiveness of an IMG applicant for residency. In addition to benefits related to securing a residency position, there are numerous clinical and educational benefits that the observer can gain from this experience.
Benefits of Observerships for Departments of Psychiatry
Residency recruitment is one of the most challenging tasks a TD faces. To select fully-qualified candidates among the numerous applicants is a process fraught with pitfalls. Most TDs agree that only limited information about an applicant can be gathered on “interview day.” When an IMG observer spends extended time on a clinical service, there is an opportunity to come to know the trainee, their clinical knowledge, facility with the English language, cultural familiarity, and suitability to the training program, as well as to the field of psychiatry in general.
Benefits of Observerships for U.S. Psychiatry
Not all countries are able to offer adequate training in psychiatry (5). The observership in psychiatry provides an entrance-point for IMGs who wish to increase their knowledge and sophistication in an area of medicine that may have been given short shrift in their home-country. Observerships offer an additional level in the screening process of international applicants. Accurate letters of recommendation from observership directors provide substantive information for TDs. The more screening checkpoints there are, the greater is the likelihood that better physicians will be selected for residency.
It is our impression that psychiatry TDs prefer IMGs who have 6 months of pre-residency U.S.-based experience in psychiatry and, preferably, a primary-care specialty, such as internal medicine or family medicine. Unfortunately, only a limited number of programs offering these experiences exist. In part, this is due to increasing service requirements and growing funding constraints. Therefore, the question of what confluence of factors might persuade departments to invest faculty time in a voluntary pre-residency experience is legitimate. For an observership to become a successful undertaking, it should provide benefits to the department that has created it, beyond those to the trainees who will be investing their time and energy.
In the next sections, we outline the main aspects of an observership program—namely structure, application process, components of the educational experience itself, and program evaluation, along with ethical, legal, and practical considerations.
Structure of an Observership Program
Training experiences for IMGs in U.S. psychiatric observerships differ from one another. Some programs have several “sub-rotations” (i.e., inpatient service, psychiatric emergency room, etc.), whereas others assign the observer to one attending, whom they follow for the duration of the program (shadowing), or assign observers to one unit/service for the duration of the experience, with exposure to several attending psychiatrists. Although, currently, the duration of observerships differs by program and is determined by each department’s resources, needs, and strengths, we strongly recommend a duration of several months—ideally, 5–6 months. The longer experience we recommend should ensure a higher level of acculturation to U.S. psychiatry and a greater likelihood of benefit to the trainees.
The Observership Application Process
We recommend that psychiatry observerships restrict applications to those who are ready to apply for residency training and have passed the U.S. Medical Licensure Examination (USMLE) Step II. The observership applicants should be required to present the same credentials for review as they would have for a residency application.
The Electronic Residency Application System (ERAS) used by TDs for residency applicants not only transmits transcripts, letters, and so forth, but also checks legal history and can follow up on alleged unethical behavior (6). These services are not available to the Observership Director. However, the ECFMG Credential Verification Service (7) will confirm that the applicant is a graduate of a medical school listed in the International Medical Education Directory (I-MED). The USMLE transcript provides an applicant’s complete examination history. Requiring that applicants be ECFMG-certified signifies that the applicant possesses basic fluency in English and has attained an established level of medical knowledge and clinical skill.
An applicant’s curriculum vitae may not demonstrate any international training in psychiatry. Lack of overseas experience should not be assumed to reflect an applicant’s lack of interest in psychiatry. In some countries, there may not have been an opportunity for any training in psychiatry, or it may have been limited to a mere 2 weeks, whereas, in others, medical students are required to specialize very early in their training. More reliable data, when available, are the types of U.S. experiences that applicants have already completed.
Personal interviews should be an integral part of the observership application process. Attention to the applicant’s level of acculturation (i.e., verbal and nonverbal communication, proficiency in English, cultural awareness, etc.) is needed. Techniques developed by various programs to assess these skills include testing the applicant with a clinical vignette or with a writing task that demonstrates level of grammar, conceptualization skills, and psychological-mindedness. Opportunities for informal interaction with residents or other related clinical staff provide additional feedback.
The AMA’s Observership Program Guidelines do not mention didactics and appear to explicitly exclude them:
An observership program is not (emphasis added) intended to fill gaps in clinical knowledge or training; it is meant to familiarize and acculturate an IMG to the practice of medicine in an American clinical setting, and provides an introduction to American medicine as they will experience it in a hospital-based residency program.
Unlike the AMA’s Observership Program Guidelines, we recommend that observerships in psychiatry have, as a goal, to include didactic teaching. The goal of psychiatric observerships is to prepare trainees to enter their PGY-I year familiar with U.S. medicine, along with the knowledge of basic psychiatry and experience that will allow them to function on a par with U.S. graduates.
Common teaching dilemmas include whether or not observers should or can be absorbed into ongoing didactics. Should didactics be planned especially for observers, and does the department have the resources for that? Should the teaching responsibilities be assigned to attending psychiatrists or to residents? Which topics should be in the curriculum? What impact, if any, will the presence of observers have on various departmental events (grand rounds, trainee seminars, rounds, etc.)? As an example, The Jamaica Hospital, New York Observership program included 21-week, 1-hour seminars; a foundations course in general psychiatry, a seminar introducing the bio-psycho-social model, training in interviewing skills, and an introduction to evidence-based medicine and medical literacy. Four staff members devoted 1 hour/week to the didactic program. In making these decisions, departments should be guided by the resources available to them.
A list of core competencies that we believe could be used as benchmarks for both designing and evaluating observership programs in psychiatry are presented. We group them under the general Accreditation Council for Graduate Medical Education (ACGME) (8) core-competencies with an understanding that the competencies are attained on a developmental ladder, and taking into consideration that observerships are pre-residency experiences.
The following principles should guide the organization of observerships:
An observership is not residency training; the benchmark of a successful observership should be, at minimum, the knowledge and orientation level of a medical student at the end of his or her clerkship.
The focus ought to be enhancing cultural competence and familiarity with hospital functioning.
All legal and regulatory safeguards must be followed.
Observers must not be exploited to provide inexpensive labor.
A successful completion of the observership should result in an invitation for interview.
Core Competencies for Observerships
Recommendations of competency areas and specific knowledge, skills, and attitudes are listed in Table 1.
TABLE 1.Learning Goals for IMGs in Psychiatric Observerships
| Add to My POL
|Patient Care||Medical Knowledge||Practice-Based Learning and Improvement||Interpersonal and Communication Skills||Professionalism||Systems-Based Practice|
|Psychiatric Interviewing||Basic Syndromes and Nosology||Evidence-Based Medicine|
|• Being able to observe interviewers will help the observer in grasping basic concepts of effective interviewing.||• IMG observers should become familiar with the major psychiatric diseases classification, using the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR) (99).Psychopharmacology and Therapy|
• Becoming familiar with commonly-used psychiatric medications in the U.S.
• Observers should develop some basic appreciation of the relevance of psychological therapies in patient care.Learning by Doing
• Observers can make recommendations to their mentors as to medications, treatment strategies, etc.
|• Observers can be asked to do literature searches and write a paper on a topic of interest. Literature searches, computer literacy, and evidence-based medicine improve the IMG’s knowledge-base, clinical reasoning, and understanding of the concept of “life-long-learning.”Case Formulation|
• Formulation using the bio-psycho-social model, as well as opportunities to present a case.
|• Practice writing of notes orients to the different types of documentation necessary in psychiatry: (i.e., the content of the Emergency Room note, the case history of the newly-admitted patient, the follow-up note, the consultation request, etc.)Learning by Doing|
• Observers can be asked to write a “chart note,”a separate from the chart. Writing the note helps the trainee to distinguish what is relevant, organize the material, and convey information in a coherent, organized, “medical” fashion such that other healthcare professionals will understand it.
|• Many professional practices like those related to boundaries, autonomy, and confidentiality, have strong cultural components. During their observership, IMGs should become familiar with professional and ethical standards that guide the practice of medicine in the U.S. (1010)||• Observers should be introduced to the different levels of care available in psychiatric treatment in the US. Also, they should develop a basic understanding of the various systems of care that may be a part of the patient’s treatment.|
Once the goals and objectives of the training program have been articulated and the methods of learning and clinical experiences established, evaluation tools for an observer’s performance need to be developed. These tools provide feedback to the observer and information for the final evaluation that will be written by the director of the program.
In order to maintain the integrity of the program and its value to residency TDs and current and future observers, the final letter of recommendation should provide both honest and accurate feedback and contain specifics as to the nature of the training experience and the participant’s performance.
The Problem of “Observer Status”
Despite observers’ self-identification as clinicians, their roles in the hospital are not those of physicians, but of observer-volunteers. Faculty members model professional behavior with patients; their reflections and questions during patient evaluations and at rounds broaden the observers’ experiences. Patients, however, have the right to refuse an observer’s presence during their care. Observers should be introduced clearly as such and patient permission sought. On the other hand, learning theory tells us that adults learn by doing. If the programs’ goals are to make IMGs more competent psychiatric physicians, the central dilemma becomes how to make them active learners. Each program will need to answer the question in its own way. Specific suggestions are included in the following section.
Adaptation Issues for Observers
In their decision to come to the United States, IMGs undergo a series of losses (11): there is the loss of accessibility to a natural network of support and the loss of lifestyle; and they must think in a language that is not their own. Some may discover that they have come to a country where they are not necessarily welcome and must deal with discrimination and racism (overt or covert). They face economic challenges and are frequently supporting a family and pursuing their education while working at menial jobs. Because they were qualified physicians and likely of high social status in their home country, they may have very high personal expectations and hence difficulty adapting to the learner role. Some IMGs have already been practicing psychiatrists who may not find it easy to shift back to being a trainee.
In the hospital, IMGs are adjusting to new cultures, new systems, and new environments (12). Cultural differences include issues related to gender, hierarchy, and power (13). The IMGs’ knowledge-base may be different, and they may have acquired different learning skills, techniques, and expectations in medicine. They face cultural differences in how patients view healthcare providers, differences in approaches to patient care, in professional relationships, and so forth. Although cultural adaptation may be a challenge for some IMGs, in the globalization era that we live in, many IMGs have experienced elements of U.S. culture in their home countries. Also, some IMGs are U.S. citizens who received their medical education abroad and are thus well acquainted with U.S. culture.
Faculty should be sensitized to the fact that IMGs are qualified practitioners who are in observership programs because they need to upgrade certain skills not required in their previous practice, but who also face more personal stressors than the average U.S. trainee.
It should be noted that cultural issues might not only arise from the observer’s side, but also from the supervisors’ side. Examination of this topic is beyond the scope of this article.
Ethical Concerns in Establishing a Program for IMGs
Observers will typically view themselves as vulnerable. Observers know that successful completion of an observership will significantly enhance their chances of securing a residency position. Potential for exploitation exists. Examples include perceiving observers as “physician-extenders,” who will provide services without remuneration; one of us (DS), for example, was apprised of a case of an observer who had been asked by a resident to type the resident’s case conference report. Another ethical challenge is charging fees for the observership as, on one hand, departments incur costs related to the education of observers, while on the other, there is a risk of commercializing the observership experience—with further risk of financial exploitation.
Being foreign to the U.S. medical system and away from their usual support networks, observers may not know what their rights are or fear retribution if they speak up. At this time, there is no agency like the ACGME to oversee the observership experience. The observers’ rights, privileges, and responsibilities should be addressed early in the creation of an observership program and delineated in the program’s Observership Manual of Policies and Procedures.
Legal Considerations for Programs
Observerships are a relatively new phenomenon in higher medical education. Despite the fact that there are several websites (i.e., ImgFriendlyList.com, usmletomd.com/usce/, eamtar.com) that include information for IMGs seeking pre-residency experiences, there is no legal definition of an “observer.” There are also no educational standards for these programs, no certifying agencies for the programs or their graduates, and no affiliation agreements between the home country of the observer and the U.S. programs. There is also variability in malpractice coverage for observers: whereas some programs provide coverage under umbrella policies for volunteers, others provide no insurance coverage.
Despite these concerns, there is a grass-roots effort (Table 2) to orient and teach IMGs in U.S. hospitals before their residency training. How best to protect our patients, hospitals, and the IMG trainees?
TABLE 2.Challenges and Recommendations for Residency Programs to Implementing Observerships
| Add to My POL
|Health status||• Have hospital clear medically IMG before s/he sees patients.|
|Patient confidentiality||• Introduction to HIPAA regulations should be an essential part of the orientation program. Observers must understand that they must adhere to the HIPAA regulations. They should sign a form documenting that they have read and understand HIPAA regulations.|
|• Confidentiality is paramount; as observers will participate in bedside discussions, patient-oriented conferences, and have access to patients and patient information.|
|Visas||• The observership director will need to become familiar with the various visas and the privileges each extends.|
|• The IMG is responsible for obtaining the appropriate visa.|
|Legal status||• Despite the “trainee,” nomenclature, the observer’s legal status is that of a volunteer.|
|• Careful orientation of IMGs to the observership, and the legal limits of their activities is required.|
|• Observers should be registered with the hospital’s volunteers department and have the rights, protections, and limitations that come from being a volunteer. These should be documented in the program’s Policies and Procedures Manual.|
|• All legal issues must be clearly and explicitly articulated for both the IMG and members of the clinical staff and recorded in the program’s policies and procedures manual.|
|Supervision||• There is no unsupervised direct patient care by an observer. A licensed physician must be present.|
|• Close oversight and supervision are needed throughout the observership.|
|Patient care||• Observers must not document in the medical record, cannot sign any charts, and may not write orders.|
Develop a detailed Policy & Procedures Manual. Describe the duration of the program, the schedule, educational activities offered, evaluation methods, criteria for completion of the program and those for premature dismissal, policy for appeal (if any) prior to dismissal, policies for illness, lateness, time off for interviews, dress, etc. for distribution to the faculty and the trainees. Be prepared to make changes to these policies as new needs develop.
Prepare a document to be read and signed at orientation that indicates that the observer has been accepted only to the observership and indicating that they have been oriented to the program and to HIPAA regulations.
Help observers maintain the integrity of the observership experience. At orientation, inform the observers that you will inform any future residency TD if an observer accepted to a residency program does not complete the observership. Have the observer sign and date a form that they have received this notification.
Help staff maintain the integrity of the observership experience. Explain clearly to observers and staff that the observership is an “educational” activity. Observers are not to be used for administrative or service chores.
The agenda of all observers is acceptance into residency. With the match and the scramble in March, observers are either elated or miserable, and not focused on learning during the month of March. We recommend that rotations end before the match and begin sometime after the match.
Training is an experience that is enjoyed by most supervisors, but it is also a potential drain. The length of an observership is determined by the program. Supervisors should have 1–2 months when they are free from supervising observers.
Some residency programs will accept observers into their residency before the match. We recommend that the observership director be willing to speak with TDs as necessary but not to write a final evaluation until the observer has completed the program. Develop a policy as to whether other faculty members will be involved in writing letters of recommendation.
Remain attentive to cultural issues. Trainees and international faculty come from home countries that have their own cultural norms/fears/stereotypes. Try to remain aware of current conflicts in the news that may affect staff and trainees. Be aware of the possibility of covert or overt conflicts and prejudices between trainees and between faculty and trainees.
In this article, we have attempted to provide a viable structure for programs to deliver a comprehensive observership experience that benefits the observer, the hospital, and the healthcare system at large. We acknowledge that this framework may not suit every program, and considerable adaptations may be necessary, based on individual programs size and resources.
Drs. Hamoda and Sacks contributed equally to this article and are hence co-1st authors.
This article is from the International Medical Graduate Committee of the Group for Advancement of Psychiatry. Dr. Hamoda was supported by the Dupont-Warren and Livingston Fellowships as well as a Harvard Medical School Fellowship as part of the Eleanor and Miles Shore Fellowship Program.