To the Editor:

International medical graduate (IMG) physicians play a critical role in the US health care system. Nearly 1 in 4 physicians practicing in the USA today is an IMG [1]. Additionally, IMG physicians are more likely to enter primary care specialties to practice in underserved or rural areas. Therefore, IMGs play a significant role in alleviating physician shortages. The specialties with the highest number of actively practicing IMGs include internal medicine, neurology, psychiatry, and pediatrics [1, 2].

Once accepted into a US residency program, many IMG physicians require unique support as they navigate life in a new country and medical system. Psychiatry specifically presents unique challenges due to the central role that language and culture plays in treatment [3]. For example, a physician trained in the East may struggle within Euro-American models, which place a great emphasis on individualism. Previous investigations into IMG physicians’ coming to North America for residency speak to the importance of helping them gain comfort and knowledge of the US system in order to make their residency period successful [4]. Postgraduate clinical observerships may provide an opportunity to facilitate this process prior to pursuing residency in the USA [5].

As part of our educational outreach mission, our department established a new observership program aimed at international medical students and recent graduates seeking an opportunity to learn and gain experiences in psychiatry in the USA. Applicants may choose between a 1-month clinical experience and a 4–6-month research placement.

Interested applicants are asked to fill out an online application with letters of recommendation along with a personal statement describing what they wish to gain from the obsesrvership experience. Candidates also complete a video interview. Those selected into the program pay a $2000 administrative fee and are registered at the hospital as a volunteer. A portion of this fee is used to support educational activities for the sites that participate in hosting the observers in addition to offsetting the costs of administering the program.

While most observers report during their video interview that they are planning to apply for US residency training, at least 25–35% of our observers describe other goals for this experience: bringing back new knowledge and insights to their local communities. As part of the program, they are hoping to learn more about work with specific patient populations and/or clinical treatment settings that do not exist in their home country. These specialized settings have included, for example, the adult consultation-liaison service, a pediatric psychiatry clinic, a pediatric special needs clinic, and a psychiatry clinic for lesbian, gay, bisexual, and transgender individuals.

During the 1-month clinical observership, each student spends 1 week on four different clinical services, including an inpatient unit, the comprehensive psychiatric emergency program, an outpatient clinic, and a final week in a specialty setting designed to satisfy the student’s personal interest. This rotating system allows for increased exposure to different psychiatric settings and decreases the burden on any one clinical service. Our program only hosts one clinical observer at a time; thus, only 12 physicians are able to take part in the program each year.

The clinical observer is only allowed to observe and meet with patients together with a supervising physician and attend clinical meetings. Observers are not allowed independent clinical responsibility and do not have access to the electronic medical record. All observers are invited to attend didactic classes with our residents and departmental grand rounds. In addition, observers are often provided additional support in activities such as résumé building and personal statement writing in preparation for the residency application process. If requested, a letter of recommendation for residency applications is provided.

Since January 2018, the program has received 210 inquiries of interest. As of February 2020, 28 applicants were accepted from 35 completed applications. Fourteen participants completed the clinical observership program (each from a different country) before the program was unfortunately put on hold in March 2020 due to COVID-19. It reopened in the fall of 2022.

Anonymous follow-up surveys of both clinical observers and host faculty were conducted as part of ongoing program evaluation and improvement efforts. The institutional review board reviewed these surveys and determined they did not meet the definition of human subjects research.

In the spring of 2021, 10 of 14 past clinical observers completed an online survey. Participants felt the best parts of the observership included the range of psychiatric services seen, mentorship, experienced faculty with high teaching skills, and the option to attend the didactic classes with the residents. Areas participants felt could be improved included having access to patient charts, more teaching on the clinical services, having the residents better understand the role of the observers, and having access to the medical library. Eleven clinical observers were known to have applied to US residency programs (three did not apply). Of these, five matched, two did not match, and the results of the last four are unknown.

Eleven faculty members involved in hosting observers also reported several benefits of the program: ten faculty members indicated it was cultural exchange, nine felt it increased diversity, eight enjoyed the cross-cultural teaching, and seven felt it contributed to the understanding of global issues in psychiatry. One faculty member noted that the program “allows observers to get acquainted with our systems of care, the content and culture…[and] they bring their experience to our setting for us to learn from them.” Another commented that a benefit of the program was for observers “to establish relationships with clinicians in the U.S…[and] to draw talented, skilled and more diverse individuals to our local and, more broadly, U.S. training programs.”

Postgraduate clinical observerships offer an opportunity to integrate IMG physicians into the US medical system. The results of the program support the feasibility of creating an observership program and suggest that participation may be a useful steppingstone in the US residency application process, as well as providing unique experiences to foreign trainees seeking to broaden their education. These programs also provide a bidirectional opportunity for cultural exchange.