Clinical observation in the USA

Authors: Maaz Ghouri 

Publication date:  25 Mar 2009

Maaz Ghouri gives his experience and advice for junior doctors considering work in the USA

After the problems of Modernising Medical Careers, I was one of the doctors who left for the United States in pursuit of an American dream—little did I realise that it would change my perception of my career and my life altogether. I am an overseas doctor who came to the United Kingdom in 2003 hoping to train as a surgeon. The recent changes in training brought about by Modernising Medical Careers meant that many of my colleagues left for either the US, Australia, New Zealand, the Middle East, or for their respective home countries. I chose to move to the United States of America. Before starting a training programme in the US, it is highly recommended that you do a clinical observership, which is counted towards your United States Clinical Experience; having this under your belt increases the chances of getting into a residency programme of your choice.


Clinical observership in the US is similar to clinical attachment in the UK but it is much more strict and organised; overseas doctors are called international medical graduates (IMGs). You need to plan at least six months in advance for a clinical observership. Friends or colleagues who have already worked as observers are always a good source of information but help can also be obtained from the United States Medical Licensing Examination websites ( [Link] and [Link] ). These sites are excellent and can help you to interact with other doctors who are applying for observership programmes.


When you have made a checklist of all the hospitals you want to apply for, the next step is to contact the hospital. Make sure you choose a hospital that has a resident training programme in the specialty of your choice. Hospitals in the US have made observership a formalised form of hospital training. In a competitive specialty such as surgery, hospitals can charge you anywhere between $250 (£176; €191) a visit to $7000 a month, depending upon the hospital. The documents required for application are a copy of your degree certificate, your curriculum vitae, an immunisation certificate, travel and health insurance documents, a copy of your US visa (if already obtained), and a minimum of three letters of recommendation.

Obtaining a visa can be an issue if you are not a UK citizen. The visa usually offered is a B1, which is a visitor’s visa. Most of the international medical graduates are able to get a 10 year multiple entry visa but the average duration of stay per visit allowed is around three months. More information can be obtained from the US Embassy ( [Link] ).

Most of the hospitals offer the observership for a maximum of three months. So if you are planning to stay longer, it is better to contact different hospitals in advance in order to get a long stay approved upon arrival in US. When the hospital approves your visit, make sure you obtain an official hard copy letter of invitation with the details of approval. It takes an average of three weeks to two months to get the letter of approval from the hospital.

Arrival in the US

Immigration is strict in the US. The immigration officials will have a general idea about your visit but some of them can be a little difficult to convince. It is better to be prepared and carry all the official documents, such as your letter of invitation, certificate from the Educational Commission for Foreign Medical Graduates, copies of your degree certificate, and a doctor’s prescription if you are carrying any medicines in your hand luggage. When you have your clearance, you will be issued with an I-94 form, which is a very important document required for all official work in the US.

After you report to the hospital’s education office, you will be issued with an identity badge and a library card, and occupational health clearance may be required.

Life in the US

The two main issues faced by international medical graduates are accommodation and travel. It is wise to contact the hospital in advance and let them know of your accommodation needs. Most of the hospitals have accommodation for students and doctors on the campus. This is booked well in advance so you need to make contact early to avoid disappointment. It is generally advisable to live on the campus and close to the hospital if you are working late shifts and odd hours. Most of the hospitals offer free food for residents and observers, but if this facility is unavailable, then you are entitled to a hospital discount in the canteen. You need to contact the education office in advance to make use of this facility.

Public transport is not as good as in the UK unless you are living in big cities such as New York or San Francisco. You cannot apply for a US driving licence on a B1 visa unless your I-94 form has a stay permit of more than nine months. The cost of living is generally cheaper in the US, but again it depends on where you live. The cost of living in New York and California can be pretty expensive, especially when you are not earning. People in general are friendly and helpful. Most of the major credit cards are acceptable, but this is not the same with debit cards. Most of the major UK banks offer an international travel facility to their customers at a minimum fee. You need to contact your local bank in advance for more information about this.


The typical working day for a resident starts at 7 am (earlier for surgical and anaesthetic specialties). Usually the day starts with breakfast teaching or a meeting. Surgery starts at around 8 am. Surgical residents operate a lot more in the US than in the UK, and the average official working hours are 80 hours a week. When you are on call you work somewhere between 26 to 30 hours a shift.

As an observer, legally we are not allowed to scrub for the procedure or be directly involved in the care of the patient. This can be frustrating for some surgeons with lots of experience; there are, however, a few kind hearted surgeons who allow you to assist them, but their numbers are very limited. One way to impress your consultant is to read about the surgical procedure in advance and have a discussion in the operating theatre rather than simply watching the procedure. If you are from the UK, you are bound to be asked, “Is this how you would do the procedure in the UK?” or, “What is the difference you have observed in the practice of medicine in the US and the UK?”


The teaching programme is very well structured in most of the teaching hospitals in the US. There are daily breakfast teaching programmes and weekly grand rounds. This is a good opportunity to show and improve your knowledge and presentation skills.

There is a huge scope and importance given to research in teaching institutes. The consultants always have some research project available for students or observers to carry out. Research involving the care of patients needs approval from the Institutional Review Board (IRB) or the Independent Ethics Committee (IEC). Review boards usually make quick decisions. Having been involved in a research project or publication boosts your chances of selection into the residency programme match through the electronic residency application service ( [Link] ).

Have a meeting with your consultant in advance and discuss the aims and objectives of observership and how this fits into your career plan. It is wise to ask the attending (equivalent to a consultant) half way through the observership for a reference. In the US, a reference comes in the form of a letter of recommendation (LOR), which is a detailed description of a candidate including some details about the supervising consultant. It is better to ask the consultant in advance because it takes time to prepare and organise. Another reason to ask for a reference half way through the observership is that if the supervising consultant is uncomfortable about giving you a reference you can move on to another consultant.

My experience

My experience of clinical observership in the US has been wonderful. Apart from surgical experience, it was a great opportunity to learn about new cultures and practices. The people were very friendly and went out of their way to help me at difficult times. I believe it is possible to convert that American dream into reality provided you are ready for hard work and a little sacrifice. My investment in clinical observership was well rewarded.

Competing interests: None declared.

Maaz Ghouri fellow in cardiovascular surgery Texas Heart Institute, Houston, USA

Cite this as BMJ Careers ; doi: