First and foremost, it’s important to evaluate the reasons for pursuing a clinical elective in the US. Personally, I had been set on completing my specialty training (residency) in the US since my third year of medical school, and an elective was an excellent opportunity to gain first-hand experience of working in the US healthcare system to see if it was the right fit for me.
I also have relatives and family friends living in New York and wanted to be able to see them while seeking educational opportunities. Moreover, having US clinical experience (USCE) is almost a requirement for applying to competitive specialties as an international medical graduate, and most programmes specify this on their website. This exposure also allows applicants to build connections with established physicians in the US and gain letters of recommendation, which are another requirement for applying to US residency. For the aforementioned reasons, I was inclined to perform a clinical elective in the US, specifically New York City.
I found myself in a fortunate situation in which my medical school had affiliations with two ivy league institutions: Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center and Weill Cornell Medicine, Cornell University. I underwent an internal application process comprising of short-answer questions assessing my motivation to pursue an elective at these institutions and attended a short interview with faculty at my medical school. I wasn’t too hopeful due to the fierce competition for these elective places – over 50 applicants for two places at Weill Cornell – however I was pleasantly surprised not long after to discover I had been selected.
My experience
My elective experience was rather unique. I opted to do a combined elective in neurocritical care and neuro-ophthalmology. I have been intrigued by both neurology and ophthalmology for a long time and wanted to get a broad experience to help me better understand these fields. I ended up spending two weeks in neurocritical care at the Weill Cornell Medical Center, New York Presbyterian Hospital and the remaining two weeks at the Weill Cornell Israel Englander Department of Ophthalmology.
My elective officially started on the 7th of April, but I landed in New York a few days earlier to get settled in and deal with some logistics, namely getting my accommodation keys, groceries for the week, in-state immunisations and collecting my ID card and hospital access badge. I was also keen to explore New York City before getting sucked into the long working hours and six-day working weeks, so arriving early gave me a nice period of time to enjoy myself before starting my clinical elective.
Having had no neurology placement and only five days of ophthalmology placement in medical school, I was extremely nervous to embark on such a hyper-specialised elective. Although I was initially nervous, the experience turned out to be the most transformative of my entire medical education. From day one, I was warmly welcomed by the ophthalmology team at Weill Cornell and had the privilege of learning from exceptional and compassionate clinicians who soon became mentors. I quickly adapted to the workflow, became proficient with Epic – the best electronic medical record system I’ve used so far – and grew into a confident, contributing member of the healthcare team.
"It was an honour to be part of such a dedicated and passionate team"
During my time at the department of neuro-ophthalmology, I had the opportunity to immerse myself in a fascinating field that lies at the intersection of two of my most favourite specialties: neurology and ophthalmology. As a final year medical student, my role was much more hands on than I had anticipated, and I was encouraged to engage actively with the clinical team and patients throughout my time there.
Since neuro-ophthalmology is primarily an outpatient subspecialty, my day typically started a bit later than other inpatient specialties. We had attending-consultant-led morning conferences between 7–8am most days of the week, where attendings talked about interesting and clinically relevant issues in the field. This was followed by morning clinic. I would arrive early to review patients’ charts, look up relevant cases and review recent neuroimaging or previous ophthalmic records. I then shadowed the attending neuro-ophthalmologist and residents during patient consultations and tried to learn as much as possible, which involved asking lots of silly questions! After building rapport with the attendings and gaining their trust, I was tasked with leading the consultations and examinations for most patients, with the attending supervising and jumping in to fill in gaps. This enabled me to step out of my comfort zone and really start thinking about the patients’ problems and possible aetiologies. However, these patients often had complex presenting complaints – sudden vision loss, diplopia, ptosis or visual field defects – that required a thorough history and neuro-ophthalmic examination. I would sometimes miss important parts of the history and examination, but having the attending there to step in and teach me enhanced my learning tremendously.
One of the highlights of my rotation was learning to perform focused examinations, such as assessing extraocular movements, pupil responses and visual fields by confrontation. I was taught how to use the slit lamp, direct and indirect ophthalmoscopy, and tonometry. I also used prism bars, maddox rod, red lens, lancaster test and cover test tools to elicit interesting findings. The attendings and residents took the time to ask me to interpret visual field tests and discuss possible differential diagnoses, which really pushed me to think systematically and critically.
I also enjoyed learning to correlate imaging findings with clinical signs in conditions like optic neuritis, idiopathic intracranial hypertension and compressive lesions. This was truly eye-opening and fundamental to the work of the neuro-ophthalmologists.
Afternoons typically included didactic sessions, case-based discussions or grand rounds. These provided a great platform to engage in fruitful discussions concerning pathophysiology and management of conditions like papilledema, cranial nerve palsies, visual pathway disorders and rare conditions, such as serratia marcescens-induced endophthalmitis. I was surprised and genuinely impressed to see how teaching was prioritised, even for residents who had a busy clinical schedule.
Throughout the rotation, I was impressed by the thoroughness, precision and empathy of the neuro-ophthalmology team in treating patients with life-altering conditions. The attendings often spent extra time with patients to address all of their questions and concerns and never rushed to dismiss the patients.
Beyond clinics, I had the chance to explore academic opportunities, including attending journal clubs and learn about exciting research projects running within the department.
One of the biggest benefits of working in an academic institution is the ability to partake in ground-breaking research. Since I was only there for two weeks, I couldn’t meaningfully contribute to big projects, however, I offered to help with case reports on the interesting patients I encountered.
Conclusion
This elective not only strengthened my interest in neuro-ophthalmology but also gave me a realistic glimpse into the American healthcare system and academic medicine. It was an honour to be part of such a dedicated and passionate team and witness the importance of teamworking and intellectual curiosity in driving clinical excellence.
Undertaking an international elective can be expensive, so it is recommended that you start planning early and save accordingly for the expenses associated with travelling, accommodation and tuition fees. Here is a list of scholarships and bursaries that you can consider:
- Royal College of Physicians and Surgeons of Glasgow Medical Elective Scholarship:
rcpsg.ac.uk/awards-and-scholarships
medical-elective-scholarship - Royal College of Opthalmologists’ Awards:
www.rcophth.ac.uk/events-courses
scholarships-awards-prizes - RSM Prizes for Students:
www.rsm.ac.uk/prizes-and-awards/prizes-for-students - The Royal College of Surgeons of England Elective Prize:
www.rcseng.ac.uk/standards-and-research/
research/fellowships-awards-grants/
medical-student-awards
Declaration of competing interests: None declared.
Acknowledgement: I would like to thank my mentor, Dr John Paddock, MD, for going above and beyond to take me under his wings and teaching me so much about his wonderful specialty of neuro-ophthalmology!
