Clinical electives are an opportunity for international medical graduates (IMGs) to gain exposure to the clinical aspects of neurosurgery. Subinternships are similar to observerships but involve more hands-on experience. Observerships do not include hands-on clinical experience, but they do allow an IMG to observe and understand clinical practice in the United States. For IMGs, observerships and electives are great opportunities to network and find potential mentors.

The first step for scheduling an elective is to find out the school’s policy for electives. Some international medical schools provide their students a certain amount of time during medical school to perform away rotations. You can use this time for doing an elective/subinternship in the United States. If not, determine if you can use any official break time as an opportunity to perform an away rotation.

If you have an electives office at your medical school, someone there can also help you understand your options. Because the policy of every medical school is different regarding clinical rotations in the United States, a good idea would also be to get in touch with any seniors who might have done any type of elective in the United States.

Once you have the prospective dates for performing an elective/subinternship, it is important to perform a thorough internet search on the institutions which have electives available in neurosurgery during those dates. Perform this search well in advance, because most institutions stop accepting applications several months before the scheduled dates of the elective. Make a list of those institutions and start applying as soon as you can. When applying, keep in mind the following factors:

• Budget: Different institutions have different tuition and application fees for an elective month. You will have to be mindful of your budget. If you write to the electives office and cite genuine hardship, the fee might be waived or reduced, but this is rare.
• United States Medical Licensing Examination (USMLE) requirements: Certain institutions, such as the Mayo and Cleveland Clinic, only consider applicants who have already completed the USMLE Step 1.
• VSLO options: Find out if your medical school participates in the Visiting Student Learning Opportunities (VSLO). If it does, you can apply to several institutions through this useful portal.
• Affiliations: Some international medical schools have an affiliation or agreement with a medical school in the United States for electives/subinternships. Be sure to check if your medical school has any such agreement in place and if they apply to your US medical school of choice.
• English proficiency requirements: Some institutions will also require IMGs to take an English proficiency exam, such as the TOEFL (Test of English as a Foreign Language), to be eligible for a rotation.

Make a list of the institutions that offer electives for your available dates. Then, screen them on the basis of your criteria and budget, other requirements such as USMLE status, and any other considerations you might have.

Once you have a list of institutions for which you are eligible to apply, submit your application as soon as possible. The application will require several documents to be verified by your home institution. A list of these documents will be available on each US medical school’s website. Make sure to apply to several institutions, because elective spots are filled very quickly. Of particular note is that the deadlines for elective applications are unforgiving.

To perform a clinical elective in the United States, you will need a visa, unless you are a US citizen or green card holder. Once you receive your acceptance letter for the elective, you can then apply for a visa. Most places require a B1/B2 visa, for which you can apply; the institution will specify if a different type, such as an F1 visa, is required. For the visa interview, you will need to bring in the acceptance/invitation letter from the institution(s) in which you will be performing rotations.

Be excited and happy at this amazing opportunity. You will be spending a lot of time and money on this experience, so be sure to put forth your best effort. Arrange safe accommodation for yourself before traveling. Medical students use different ways of finding rooms to sublet, such as using rotatingroom.com, Airbnb, and groups on the Facebook. Try to find accommodation as near to the hospital as you can, or try to find accommodation that is near to a transport spot such as a train or bus station.

An away rotation is like having a month-long interview at a neurosurgery residency program. Your performance during the rotation is crucial for getting a strong letter of recommendation at the end of it, as well as an interview invitation from the program; remember that laziness and/or unprofessional behavior can ensure that you do not get either. As an IMG, it is also important for you to keep in mind that, assuming you do well during the rotation, the people you meet here might be able to help you with finding a research fellowship later.

Thus, it is extremely important that you remain vigilant throughout the rotation. Electives/subinternships at various programs are slightly different from each other, but the following aspects will always be similar. For further information, also see the Subinternship Chapter.

Everyday around 4:00 to 5:00 am, the neurosurgery team will perform patient rounds. Make sure to be there before the round starts, and it is best to be the first one to arrive for the rounds. You might be required to make lists for the team and update them before the round starts. Ask your intern what will be required of you for the morning rounds, and perform the tasks assigned to you well and on time, preferably before the senior residents arrive.

In the operating room (OR), observe everything intently. Things will be both similar to and different than the OR’s work at your home school. Do not feel overwhelmed. Always introduce yourself to the OR staff; tell them you are a visiting student, and politely ask if you can attend the case.

You should also introduce yourself to the resident(s) and attending neurosurgeon covering the case if you have not met them or discussed the case with them before the surgery. You do not want to be the unknown person standing in the way and hear the attending physician ask, “who are you?”

Always ask when you do not know something, but only when appropriate; do not cut off anyone while he or she is speaking, regardless of whether the person is an attending physician or a nurse. Please see the Operating Room Etiquette chapter. Ask someone, such as a scrub nurse, to show you how to scrub in (even if you know how to scrub in and have done it several times before; there will be slight variations from place to place).

Grab your gown and gloves or inform the scrub nurse of your gown and glove sizes before scrubbing in. After scrubbing in, start by observing. You will gradually be allowed to do more hands-on work. Do not consider any work given to you by the team as unimportant. Being asked to do work is a good thing, so do not say “no”; it means the team considers you a part of it. If you do not know how to do something, ask, and then do it.

When asked a question, never lie in your reply. If you have not seen a patient’s charts, it is better to admit it than to make up values and patient history. Try to make a log of the cases you see and review them.

You may have 1 or 2 clinic days scheduled (there can be more or less, depending on how the rotation is structured). Wear conservative, professional clothes to clinic. Be punctual, show interest in the work, and be at your best behavior with every single person.

Also, try to schedule clinic with any attending neurosurgeon from whom you later want to request a letter of recommendation. During your rotation, remember to be polite and courteous to everyone, including the interns, residents, attending physicians, nurses, OR staff, receptionists, other medical students, etc (ie, everyone you encounter).

An observership is a nonclinical experience during which you can spend time in a clinical setting but will not gain hands-on experience. Despite the fact that they are considered nonclinical experiences, you will still interact extensively with the neurosurgery team (residents and attending physicians.)

As an IMG, you can apply for an observership after you graduate from medical school. You can formally apply for them through the official websites of the medical school(s) in which you are interested. Alternatively, you can apply by e-mailing an attending physician/faculty member at an institution and explaining your interests and why you would like to do an observership there.

The process for applying for observerships is less exhaustive than that for subinternships, and the dates are more flexible. Typically, an observership can last from a few weeks to a few months. An observership is a great opportunity to demonstrate to a program the kind of candidate you would be.

Before starting an observership, set some goals for yourself, such as getting a strong letter of recommendation from the program, getting an interview in the future, networking and finding a mentor, or all of the above. Be mindful of these goals during your observership. Similar to an elective, an observership is the same as a month-long interview at a program. Hence, be vigilant throughout. If you are looking for a future research fellowship, you can certainly discuss it with the people at your observership, and they might be able to help you in that endeavor.

Near the end of any type of rotation, you will typically be expected to give a brief 10- to 20-minute presentation to the entire neurosurgery department on a topic of your choice. Some programs require a case presentation on a case you observed during the rotation itself, although most of them expect it to be a presentation on one of your own research projects.

This presentation is an excellent opportunity to shine in front of the entire neurosurgery department and leave a lasting impression. Lack of preparation for this presentation can also leave a lasting negative impression of your performance during the rotation. During the last week of the rotation, you will typically meet one-on-one with the neurosurgery department chairman, and you might also meet with the program director. These meetings are a great opportunity to reflect on your time in the program and to seek any feedback regarding your future career prospects.

It is a long-standing tradition in the United States to ask the neurosurgery department chairman for a “chairman’s letter of recommendation” at every program for which you perform a rotation. This letter is signed by the chairman and essentially summarizes your entire performance in the program, usually citing specific feedback from the residents. The away-rotation chairman’s letter is highly valued in neurosurgery residency applications, and having a glowing recommendation such as this would tremendously strengthen your application for any neurosurgery residency program.

Contributors

Ahmed Habib, MD

Aida Kafai Golahmadi, BS

Ayesha Quddusi, MD

Saad R. Alghamdi, MD

Victor E. Staartjes, BMed

Vittorio Stumpo, MD

DOI: https://doi.org/10.18791/nsatlas.v13.4