Country considerations
Placement considerations
Low-resource/developing country vs. high-resource/developed country
Budget
Visa and home office restrictions
Language
Time of year e.g. Monsoon season
Cultural experience
Opportunities for holiday
Particular specialty or ‘general’ surgery (often includes trauma and orthopaedics and paediatrics)
Advanced technology
Availability of resources
Other medical students (having to share opportunities)
Contacts known or recommended to you
It is useful to start your search for a placement with a contact. If you have a particular specialty that you wish to focus your elective on, ask a consultant in that specialty if they can recommend anywhere. Talk to FY1s about where they went – a personal recommendation beats any review you read on the internet. Most medical schools keep a list of past student electives with their elective reports – reading through these will give you a flavour of what options there are. Make sure you have an up to date copy of your CV ready to send with all enquiry emails as this may speed up the process.
When to Plan?
Start planning your elective as early as possible. Aim to start making contact with potential placements 18 months to a year before you will be going. Popular hospitals often get booked up well in advance and you may need several months to sort out visas, work permits and travel health.
Who to Go With?
If travelling abroad some students like to travel as a pair, but there is often no reason not to go alone, and you may find you get more out of the experience if you do so. If you do choose to go with someone else make sure you know them well – your friendship is likely to come under some stress during your time away!
Funding
If you choose to travel abroad you will need to start raising funds early as the costs can add up. Most medical schools will have some money available as small grants to those who apply for it – the best applications provide detailed proposals of what the elective will involve, including the possibility of research or audit. Local charities may also have some money available; they would usually expect a report or presentation on your return. www.money4medstudents.org offers practical advice on budgeting and also provides a list of contacts for grant applications.
Insurance and Indemnity
It is a good idea to take out insurance for your trip, and your medical school may insist on it. Check the small print and clarify that you will be covered for working/shadowing in a healthcare setting. Most countries do not require medical indemnity cover for electives, with the exception of Canada and the USA. Contact your medical defence union for advice.
Travel Health
Book an appointment at your local travel clinic at least 6 months before you travel – ask your GP practice for details of the nearest one.
When You’re Away
Keep a logbook. If you haven’t already signed up, www.elogbook.org is free and used almost universally amongst surgical trainees – there is no excuse not to use it and you will need it as soon as you start specialty training anyway. Record all procedures, even those observed – they will provide evidence of your commitment to a career in surgery at interviews in the future
Consider ethics. If you are going to be carrying out your elective in a low resource setting it is worth thinking about the ethical implications of your trip. Only work within the limits of your knowledge and technical ability. Make sure you know who your supervisors are and be sure to ask for help if you need it. Remember, the GMC’s Good Medical Practice [1] states that ‘you must work within the limits of your competence’. This is just the same when you are on your elective. Be aware that if you include experiences you’re not qualified for in your elective report, your medical school may decide to fail you on your elective for being unsafe.
Keep a blog. Your family and friends will want to know what you are up to – this can make it easier for people to relate to what you may be going through, especially if you have had new or difficult experiences. It will also give you a permanent record of your experiences
Take a break. Immersing yourself in a new setting can be exhausting. Plan some weekend trips to explore the local area, and if you can, try to fit some holiday onto the end of your elective to properly unwind before you head home
On Your Return
Remember to write your elective report or any other requirements that your university has for your elective. If you received funding from charities or organisations, make sure you send them a copy of your report too. They may have a meeting or event where you can arrange to give a presentation – this looks good on your CV as well.
Most importantly: enjoy yourself! Your medical elective is really a once in a lifetime experience so make the most of it while you can.
Useful Resources
www.lonelyplanet.com – country information
www.bma.org.uk/medicalelective – general advice for elective planning
www.money4medstudents.org – budgeting and funding
www.gov.uk/foreign-travel-advice – country specific advice
www.nathnac.org/travel – health and travel advice, country specific information, diseases and outbreak updates
Working and Training Abroad
An increasing number of surgeons are working abroad to gain experience in a different healthcare system and continue developing specialty surgical skills all over the world. Work taken abroad can count toward certification in the UK, but this must be agreed in advance by making an appointment with a regional postgraduate dean.
Salary and Support
Opportunities to work and train abroad can either be salaried or voluntary. This will depend on a number of factors including the hosting institution or organisation, whether there is a locally unfilled area of need and your level of experience. Aside from salary, you will need to consider what other support may or may not be provided such as pre-deployment training, allowances, accommodation, flights, insurance, pension payments, membership fees and journal subscriptions.
If you are planning to work as an unpaid volunteer, you may wish to consider applying for a travelling bursary. A number or charities and organisations offer such grants including the Royal Colleges, the Health Technology Assessment Programme, the Association of Surgeons in Training, surgical specialty organisations and commercial sources.
Timing and Training: When to Go?
If taken around the time of training you need to consider whether time spent abroad will be between training programmes or during a training programme. It is strongly advised by the postgraduate medical education training board (PMETB) to complete your Foundation Years one and two (FY1/FY2) before going abroad. Being accepted onto a specialist or general practice training programme is only open to those who have completed and been signed off for the two years of the foundation programme.
Between Training Programmes
Working or volunteering abroad is theoretically possible between FY1 and FY2 but you will need to consider the practicalities of retaining a place on the programme for the second year through discussion with the Foundation School Director. A more popular time to go away is following completion of foundation training before entering higher surgical training.
For specialties entered at Specialty Training year 3 (ST3) there may be an opportunity for working abroad following the two years of Core Training (CT1/CT2). This will not apply to the few remaining run-through training programmes. Taking time out between CT1 and CT2 is not recommended, although in exceptional circumstances may be granted.
During Specialty Training
There are several opportunities for breaks during specialty training, which are highlighted in Table 30.2.
Table 30.2
Options for breaks during surgical training
OOPT – out of programme training | Usually 1 year, up to three negotiable with Programme Director Prospective approval from GMC compulsory Counts towards training Requires educational supervisor and completion of assessments as in UK |
OOPE – out of programme experience | As OOPT but does not count towards training Most voluntary/humanitarian work falls into this category |
OOPR – out of programme for research | Usually MSc/MD/PhD |
Career break | Break for reasons unrelated to surgery e.g. competing in sport at high level |
If you plan to work abroad during specialty training, you need to consider whether it will count towards training or whether your time away will be additional to your UK based training. If the training abroad is relevant to your chosen specialty and allows equivalent acquisition of the required knowledge and skills then it may be suitable for an OOPT and if so will not lengthen your training. The post must be prospectively approved by your Programme Director and the GMC prior to starting.
Out of programme years are not permitted within the first or final year of a training programme and applicants must have received an ARCP outcome 1 for the preceding year. At least 6 months’ notice will be required, although a year is preferable.
Further information on OOPE/OOPT can be obtained from the relevant Local Education and Training Board (LETB) websites and the ‘Gold Guide’ to postgraduate specialty training in the UK [2].
Preparation
Preparation must be started early. Speak to others who have experience of working overseas and visit as many agency websites as possible to gain a broad understanding of the options available.
Discuss your plans early with those people that will need to know and ultimately may be responsible for sanctioning your leave. These include your Programme Director, employer, educational supervisor/departmental manager and, of course, your family.
Be clear on which professional bodies you will need to register with abroad, what paperwork will be needed and when. Consider your personal visa requirements especially if you are a non-UK/EEA national as spending time out of the UK may affect your immigration status with regards to qualifying for indefinite leave to remain in the UK (see UK visas and immigration policy).
Returning to the UK
Consider your plan for your return to the UK. Ideally, ensure you have a job to return to or at least be familiar with the application process if intending to seek a training or substantive post. It may be necessary to return to the UK for interviews during your time away; it is unlikely that telephone or video conference interviews will be offered for UK training programmes.
Pensions
If you are a member of the NHS pension scheme, you will need to consider how any potential break in service will affect your contributions. Some organisations offer to maintain your NHS contributions whilst you are working with them abroad, e.g. the Red Cross.
GMC Registration and License to Practice
When working abroad, you will have the option of whether or not to maintain GMC registration and if so whether to maintain a license to practice. Remaining registered enables a doctor to demonstrate a continued position of good standing, is an acknowledgement that your primary medical qualification allowed entry onto the UK medical register and means you will not need to go through the process of re-registering in order to work back in the UK which can take up to three months and incurs a fee. An annual registration fee is payable in order to maintain registration.
A doctor registered with the GMC but not working in the UK can choose whether or not to maintain a license to practice because this only applies to UK practice. If you relinquish your licence when leaving the UK to work abroad, you will have to restore it before working back in the UK. For more information on GMC registration, license to practice and fees, see the GMC website at www.gmc-uk.org/doctors/index.asp
United States of America
It is common for international graduates to move to the United States of America (USA) for training and practice. Due to the competitive nature of this move, completing all the steps to secure postgraduate training in the USA can be challenging, especially when balancing this with the completion of university and Foundation Training.
Training programs in the USA are becoming increasingly competitive for international as well as local medical graduates, with over 21,000 international medical graduates (IMGs) applying for residency programmes in the USA in 2014 [3]. In the same year, general surgery was the 5th most popular specialty program for international graduates. To enter a training programme it is mandatory to demonstrate that any medical education obtained elsewhere matches the standards of safe medical practice in USA.
Before applying to residency programmes, graduates must obtain an Educational Commission for Foreign Medical Graduates (ECFMG) [4] certificate, which is achieved by passing a series of tests which assess basic scientific and clinical knowledge, and ability to interact with patients. Once certification is obtained, an IMG can work in clinical environments and participate in patient care.
The ECFMG certification is obtained after successfully passing the United States Medical Licensing Examinations (USMLE) [5]. There are a total of three exams to be passed, namely the USMLE Step 1, Step 2 Clinical Knowledge (CK) and Step 2 Clinical Skills (CS) (Fig. 30.1). There are many books available to guide you through the USMLEs, and many UK students will choose to take USMLE Step 1 during early clinical years.
Fig. 30.1
Process of certification in the USA for International Medical Graduates
Residency Applications
When an ECFMG certificate has been achieved, an online application is completed and residency programmes hold interviews. There are a number of factors that make a strong application:
USMLE Scores: Completion of all steps with outstanding scores is the vital aspect of an application. Scores higher than 220 in USMLE Step 1 and 2-CK, are considered to be respectable scores. USMLE Step 2-CS results are reported as a pass or fail. Additionally, the number of attempts to pass the exam also affects the application. Multiple attempts to pass an exam even with a good score are not favourable.
Work Experience: Voluntary, elective and clinical experience in the field of application demonstrates the interest and dedication to the specialty. This makes the application strong and attracts more interview calls. Additionally, any type of clinical experience gained in the USA is beneficial. This can be achieved by completing electives in the USA as medical students, since medical students do not require USMLE to perform clinical work. The added advantages of a USA clinical elective include building a network of contacts, gaining recommendation letters, increasing understanding of the USA clinical system and assessment of the residency program for a future application.
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