How to navigate US electives post-pandemic

I started my elective at an O&G outpatient clinic in San Antonio in Texas. It was a very small clinic with only one doctor and a handful of nurses and administrative staff. The doctor I was shadowing specialised in reproductive endocrinology and fertility medicine and after the first day of being there, I was bored and knew I wouldn’t want to spend six weeks there. So, I asked around the hospital and managed to organise two further placements within the six-week block. My supervising doctor was okay with me doing so- as long as he knew where I would be and generally what I was doing as he was the one that would be signing me off at the end of the placement.

I ended up doing a week at that O&G clinic, two weeks in internal medicine (a week in endocrinology and diabetes), two weeks in emergency medicine and a week at the free community clinic that was affiliated with one of the hospitals. Out of all the placements I did, the most interesting and rewarding by far was the free community clinic. It was run by volunteer doctors, mostly family medicine physicians (the equivalent to GP’s in the UK) who gave up their time to treat uninsured patients.

The world of medical insurance, drug reps and generally just the American healthcare system is such a minefield. I had tried to read up a bit about it before my elective, but it turned out to be so much more complicated than I thought. There are so many insurance companies and so many different insurance plans that its honestly hard to keep up with conversations about insurance and most clinics had a designated team to arrange billing etc. Certain clinics will also only accept certain insurance providers too.

Here’s a whistlestop tour though the most useful nuggets of information:

Most people are registered with a family medicine doctor (equivalent to a GP in the UK).

They will look after most of your healthcare needs and will refer you on to a specialist if they think you need one. Even if you are insured, at every appointment with your family doctor, you pay a fee, called a “co-pay” (around $30). However, you don’t necessarily need a family doctor and you can self-refer to specialists. If you see a specialist, that co-pay can be up to $200+ depending on the physician and the location.

Insurance is so confusing, and I can’t claim to even begin to understand so I won’t try to explain.

Basically, the general gist is that if you have insurance, that’s good but you still have to pay and if you don’t have insurance, that’s bad because you also have to pay but more than you would have to pay if you DID have insurance.

Then there’s Medicare and Medicaid.

Medicare is for anyone over the age of 65, or on dialysis, or with a chronic mental health condition. It covers 80% of the costs of inpatient stays, outpatient appointments and prescriptions. Most people will have a secondary insurance on top of Medicare which pays for the other 20%. Medicaid is for anyone that falls below the poverty line. Generic medications like aspirin, metformin etc. can be prescribed and picked up at certain pharmacies for $4 with a GoodRx card.

At the free clinic, the doctors would prescribe a 90-day supply so patients could get three months of medication for 4$. The cost of patented medications depends on your insurance. In the endocrinology clinic, one of the doctors was obsessed with Ozempic (semaglutide) which is $810

At the internal medicine (endocrinology) clinic, there were drug reps that would bring starbucks, donuts, mangonadas…

…like a mango slushie but with chamoy sauce – look it up if you’ve never heard of it before… and free LUNCHES along with their medication samples. Every morning, the team would decide where they wanted lunch from that day, everyone would give in their orders and the drug rep of the day would magically arrive at lunch time with everyone’s food. They would then spend the lunch hour discussing and selling their product to the doctors while the medical scribes, technicians, students etc. went off and had a full uninterrupted one-hour (!) lunch break.

I generally think I was treated really well as a medical student.

Americans love British people, and everyone was obsessed with my accent. A lot of the doctors were very interested in hearing about free healthcare and how the NHS works and the differences I had noticed between the two healthcare systems. Overall it was such a great experience, and as difficult and annoying as it was to organise, I would 100% do it all over again for the experience. The US doesn’t allow doctors to work there without doing all the conversion exams and residency etc. whereas most other countries will accept doctors from all over the world so it really is a once in a lifetime opportunity to go and experience the healthcare system there without actually working.

Start looking into institutions etc. as early as you can. A lot of the big hospitals want applications to be sent in nine months to a year in advance. So, leave yourself at least that much time as they often need immunisation records, medical school transcripts, a letter of good standing etc. from your university which can take some time to organise and send through. Almost all of the US institutions were closed to international students when I was first looking into electives (Yale has recently opened its doors to internationals but is charging ~4000$ per 4 week placement and that was just way out of my budget). I knew I was interested in O&G so I started looking up O&G doctors online and emailing them explaining my situation and asking if it was possible for them to take me on as an elective student. I also included a line that said if they didn’t have space in their own clinics, if they could forward my email on to anyone that might be able to help. If you have connections (know literally any physicians in the US), contact them first because they’re most likely to want to help you if they know you.

If you’re looking things up online you might start to get advertisements for those companies and they can seem like a good idea. I met a lot of international students on commercial placements from those companies while on my elective and almost all of them had bad experiences in very small hospitals and clinics and the general view is that they’re not worth the money and don’t give the extra support that you might think they would by being part of a large corporation.

Flights, accommodation, VISAS, tuition, and administrative fees start to add up so quickly. Also, most places in the US you’ll need a car to get around and under 25’s have to pay an insurance fee on top of care hire and regular insurance costs! I thought I’d be okay with public transport but after a couple of days I realised I desperately needed a car and ended up hiring one anyway.

This might mean deadline extensions or extra help might be available to you. Your university should also be able to provide a Step 1 exemption letter stating that you have the equivalent pre-clinical knowledge for institutions that request it.

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