A medical elective is a period of study where medical students have the freedom to choose a specific area of medicine or a specialty that they are interested in and complete a placement in that specialty anywhere in the world. It is usually between 6-12 weeks and most students decide to go abroad.
Many universities have global connections with other university teaching hospitals and my university did with Johns Hopkins through their 'Twin Links' programme. This meant that my university covered any tuition and application fees associated with the process - which was a massive financial burden lifted (as Johns Hopkins charges around $5000 for clinical electives of 4 weeks length).
The application process in a nutshell
Whether you apply through Twin Links or not, the application for a clinical elective at Johns Hopkins is the same, the latter will just require you to pay the fee if you are accepted.
The Visiting Medical Students Program webpage provides all the information you need to apply to a clinical or research elective at Johns Hopkins University. I recommend a clinical elective over a research one if you are considering relocating to the U.S. as clinical practice trumps research every time when it comes to USCE and will be what they are looking for in your letters of recommendation. Clinical electives cost about $5000 as aforementioned, whilst research electives cost $500.
Applications are accepted on a rolling basis and students are encouraged to apply up to 6 months before the start of the elective (you won't see dates beyond 6 months, so you must wait until your elective period dates show up on the application system). The earlier you submit, the higher the chance you have of getting a place in the specialty you want. Even if you have been chosen by King's for the Twin Links programme, you are NOT guaranteed the specialty of your choice (I had to make about 4 applications until I eventually got one in something I wanted). They advise AGAINST emailing departments ahead of time, but I actually did email a short CV and email of interest to 2 supervisors I found in the elective catalogue (updates every few months so please make sure you're looking at the most up to date one) and the second got me a quick and smooth acceptance for my 4th application to the specialty I wanted.
What do I need to apply?
Resume/CV: The most important part. I recommend having a succinct 2-3 page CV in pdf form tailored to the specialty you want. It needs to be succinct and highlight achievements that are GLOBALLY significant and understood. I.e. Committee positions and random volunteering roles should be low down on your CV, most US clinicians won't care or know what GKT MSA is. They want to see what you've published and presented and all your academic awards. See my blog post on the anatomy of an academic CV. A copy of my exact CVs for different electives will be provided in my upcoming electives e-book.
Transcript: For King's students, this will be your HEAR or ROAR. Download and send to MBBS Stage 3 - as they will have to submit it on your behalf (the US does not accept transcripts from students themselves... weird I know but unfortunately, some students forge their transcripts). Contrary to popular belief, US clinicians do not care about transcripts as they don't see our marks as equivalent to their USMLEs and we are not graded on rotations. However, they do care about 'F's (fails) and gaps in education (i.e. years out for whatever reason, excluding intercalating as that is education).
Letter of Good Standing: For King's students, this can be found on Student Records as the Dean's recommendation letter. If you want to go above and beyond, you can also compile letters of support from your personal tutor and any clinicians in the specialty you want to do. I did this and it worked in my favour.
Immunisation requirements: Can be found here.
Visas
As a UK passport holder, I used the ESTA (visa waiver programme) to enter the US for my elective.
If you do not hold a UK passport or do not meet the eligibility criteria for an ESTA (e.g. you may have recently visited one of the 'forbidden' countries the US has listed), you will need a B1/B2 business/tourism visa. I would go for the combination if you're doing your elective + tourist activities.
What did I get up to?
Week 1: Rehabilitation Inpatient Unit
My elective began in the rehabilitation inpatient unit, where I observed the MDT collaborate to enhance outcomes for children facing neurological challenges from both traumatic and degenerative conditions. I followed patients from their admission, participated in morning rounds, and attended their various therapies, including speech and language, occupational therapy (baking and making chocolate-covered pretzels!), and physiotherapy in the state-of-the-art gym.
Weeks 2-3: Neonatal Development Clinic and Neurodevelopmental Disorders (NDD) Clinic
At the NDD clinic, I conducted consultations and neurological exams on children with conditions such as cerebral palsy, ADHD, and autism.
I spent time in the neonatal development clinic, where I engaged in tracking developmental milestones by playing with babies. This experience underscored the importance of early intervention and the joy of working with the youngest patients!
Week 4: Epilepsy Monitoring Unit
In the epilepsy monitoring unit, I learned to read and conduct EEGs, understanding their critical role in diagnosing and planning treatment for epilepsy.
Specialty interest add-ons
Fortunately, I had a very hands-on supervisor who wanted to make sure I got exposure to everything I was interested in. So she got me involved in 2 niche extra clinics:
Prenatal Exposures Clinic: I gained insights into the impact of exposures like lead, opioid, and alcohol use on foetal neurodevelopment. This experience highlighted the importance of prenatal care and education and revealed how the US healthcare system's limitations can restrict access to essential services for certain groups.
Neuropsychiatry Clinic: Neuropsychiatry focuses on mental disorders in patients with nervous system damage. I saw many children with cerebral palsy and met my first pediatric catatonic patient, which spurred me to follow up with research on catatonia and the use of lorazepam with the team.
Where was I based?
I spent most of my time at the Kennedy Krieger Institute and even visited their school for children with neurological conditions. Be prepared to travel to different sites depending on your specialty. JHU does NOT provide accommodation to elective students so myself and some other UK elective students (Twin Links) found an Air B and B nearby. However, areas around the hospital are NOT the safest (towards the end of the elective, we opted to get a car as there was no grocery stores nearby and Uber costs were racking up).
I had great networking opportunities with other US medical students and my supervisor, the program director of neurodevelopmental disabilities. Neurodevelopmental disabilities (NDD) has been recently recognised as a specialty in the US. Training in neurodevelopmental disabilities allows board certification in 3 specialties, including pediatrics, neurology with special qualification in child neurology, and neurodevelopmental disabilities. Although a niche field with a slightly longer residency program (~5 years), it was great to get an insight into the range of opportunities available in the States where you can be dual+ specialised, which is not currently possible in the UK.
Johns Hopkins is situated in Baltimore, Maryland, a city with its own unique cultural and socioeconomic landscape. According to recent census data, over half of Baltimore's population is Black or African American. About 95% of the population has health coverage, with most on employee plans and around a third on Medicaid, the public health insurance program for low-income individuals.
There is stark socioeconomic deprivation in Baltimore, which was particularly relevant in pediatrics. Many children faced multiple challenges, including poor living conditions, unstable homes, and financial difficulties, all of which impact their health and well-being.
Achievements and expectations
Students on my rotation had to deliver a 45 mins presentation on a topic of their choice to faculty with 15 mins questions. It was intense and is essentially an audition for a residency position at Johns Hopkins. All of the residents, attendings and program directors attended and filled out matrix sheets on aspects of my performance - it was formal and a bit scary but extremely helpful.
I achieved an ‘honors’ grade for my rotation, significantly influenced by this presentation. This grade is shared with King's and may be mentioned in your letter of recommendation if your supervisor agrees to write you one. Posterior fossa syndrome, characterised by mutism following brain tumor surgery in children, was particularly poignant as I followed two children with it - a 5 year old and 13 year old. Observing the differences in neurodevelopmental manifestations between these two ages was fascinating and highlighted the profound impact of early language development disruptions.
Grades/evaluations and expectations can be found on their webpage. Read through this and adhere to it. You are being observed when you step into the hospital up until the time you leave.
Overall, if you're a person who is willing to go above and beyond and likes a challenge, the US elective is going to be an enjoyable learning experience for you! If not, it will be a drag and you won’t get a lot out of it.
Did sitting Step 1 before my elective help me?
The short answer is yes. US med students may be rotating with you and will be used as a direct comparison for your final evaluation/grade. Having Step 1 under my belt was something I was able to use in conversation with residents/attendings to prove 'commitment' to matching (if you are planning to relocate) and I saw patients with the conditions I had studied. Sitting Step 2 would have been even better because you then have an idea of US diagnostic tests and treatment - however, studying for finals should suffice. Fortunately, most of the UK diagnostic tests and treatments are the same as the US which is an advantage! I would not do any specific extra reading or studying before going (maybe just brush up on your specific specialty if you're a bit rusty), I think finals and OSCEs are enough. I did not do any specific studying for the elective itself (apart from Step 1).
Final thoughts
UK vs US healthcare: The USA spends three times as much per person on healthcare compared to the UK, and doctors often battle with insurance companies to ensure patients receive necessary care. Encountering cases affected by socioeconomic deprivation and insurance issues underscored the harsh reality of healthcare disparities in the US. It's a reminder that doctors must advocate for systemic changes to ensure equitable access to care, especially for children.
Resident vs attending lifestyle: Attendings live the lifestyle we see on social media, residents do not. It showed me that delayed gratification wins yet again. You have to be willing to go through rigorous training with relatively poor pay for the work you're doing... no matter what country you're in. Short and intense = US. Long and more balanced = UK. The US has a greater earning potential by far compared to the UK, and doctors also have a lot more autonomy. In terms of clinical acumen, I'd say both countries have fantastic clinicians but there is a greater emphasis on research in the States, so I felt doctors were more ahead of the curve and willing to try cutting-edge treatments. They were definitely more able and willing to teach too.
Patients as 'customers'/'clients': Patients in the US typically split their care across multiple providers each year, which can complicate continuity of care. Hospitals run like businesses, focusing on their brand and satisfaction rates, with doctors often having online ratings and business cards.
US medical culture: You need to be engaged, excited and keen about whatever specialty you're doing as I felt there was no room to be 'half-assed/half-prepared'. Compared to the UK, I felt they also expected me to have one specialty already confirmed as they 'match' into a specialty rather than a foundation training post which still rotates through specialties like we do.
Finally, have fun, be engaged, be willing to learn, and go the extra mile and you'll have a truly fulfilling and enriching experience. This blog post was mainly aimed at King's College London students but can be applicable to all.
Demystified: planning your dream elective - The steps to finding and funding elective opportunities across the world with examples
Full details and examples of my applications to Johns Hopkins and my other 2 electives in the States will be shared in my upcoming e-book on 1 September 2024.
I will also share some of the applications I made to other countries like Australia, Brazil and Cuba which I unfortunately turned down to focus my efforts on the States as well as all the funding opportunities on offer.
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