Discussion
To our knowledge, this is the first study to provide aggregate data regarding the characteristics of VMS programs and participating students at US and Puerto Rico medical schools. Important findings were that most medical schools have VMS programs, the most popular rotations are in internal medicine, demand outweighs available positions, and eligibility and evaluation standards are inconsistent within and between institutions. About half the programs allow international students; this result is consistent with data on the AAMC's "Extramural Electives Compendium" Web site, which lists 117 US medical schools with VMS programs, of which 47 (40%) allow international medical students to do visiting electives and clerkships at their institutions [9]. (Notably, the AAMC's "Extramural Electives Compendium" Web site does not present data regarding VMS programs in aggregate; these data were abstracted manually and compiled by one of us [PSM].)
The most commonly reported reason for having a VMS program is to recruit residents. This finding may help explain previous research showing that approximately half of all fourth-year US medical students participate in electives and clerkships at institutions other than their own medical schools [1-5] and also supports advice that medical students should pursue visiting electives and clerkships to enhance their chances of securing residency positions at the host institution [7,8]. In fact, most visiting medical students are in their fourth year and therefore are likely contemplating their residency training options. Indeed, the survey respondents ranked "desire to do a residency at our institution" as the most important reason visiting medical students choose to do electives or clerkships.
A majority of VMS programs require substantial clinical experience. Consequently, most VMS programs are limited to third- or fourth-year students. In addition, most VMS programs require fluency in English, documentation of immunizations, and completion of United States Medical Licensing Examination (USMLE) Step 1; some have additional requirements. These findings suggest that VMS programs make an effort to ensure that visiting students have skills and educational levels comparable to their own students, which enhances the visiting clerkship experience for the students, faculty, and patients. Another possibility is that VMS programs "screen" prospective visiting students to accommodate only those who might be competitive for residency programs.
Nonetheless, VMS programs may not recruit students as effectively as they hope to. Only 1 VMS program guaranteed interviews to visiting medical students. Furthermore, we found substantial variability in the effectiveness of VMS programs at recruiting residents and former visiting medical students who make up first-year residency classes at the respondents' institutions ranged widely (range, 0-76). Moreover, a previous single-institution study showed that students who participated in VMS programs were not more successful in obtaining their first choice of residency than students who did not participate in VMS programs [11].
At the time of our survey, more than 80% of VMS programs required paper applications and less than 10% required online applications. Since then--during April 2008--the AAMC launched the Visiting Student Application Service (VSAS), which is an online application service for VMS programs at US medical schools. To date, 63 US medical schools with VMS programs use the VSAS. This system, however, does not allow students to enter information related to clinical experiences, upload letters of recommendation, or enter USMLE Step 1 scores. In addition, potential international visiting medical students cannot use the VSAS [15]. Our survey findings suggest that updating the VSAS to allow it to upload the aforementioned information would be desirable to most VMS programs.
A majority of respondents reported that visiting medical students were evaluated no differently than their own medical students. Only 5% of programs reported using only their own evaluation forms for visiting medical students, 52% of programs reported using only the students' home institutions' evaluation forms, and 32% reported using both. It is likely, however, that medical schools evaluate students similarly (eg, knowledge, presentations skills, professionalism) and that overlap exists among the schools' evaluation forms. Nevertheless, in our experience administering a VMS program that accommodates about 350 visiting students per year [12], completing home institutions' evaluation forms can be logistically complicated. Given the large number of medical schools that have VMS programs and the large number of visiting medical students who participate in them, a standardized evaluation form for visiting medical students might be desirable.
All the respondents reported challenges related to maintaining a VMS program. One common challenge was insufficient numbers of elective and clerkship slots, possibly because most institutions give their own medical students priority for electives and clerkships. In addition, accommodating visiting students strains educational resources, including faculty availability. Furthermore, some electives and clerkships are more popular than others. Respondents to our survey listed general internal medicine and internal medicine subspecialty clerkships and electives, orthopedic surgery, and emergency medicine as the most popular among visiting students. Therefore, VMS programs might consider ways to expand availability for these electives and clerkships and determine reasons why some specialties are not targeted by visiting students.
Our study has a number of limitations. First, only 59% of medical schools responded to the survey and nonrespondents may have had unique perspectives on their VMS programs that would have influenced the results. However, there were no significant differences between the responding and nonresponding schools regarding the percentages of VMS programs listed in the AAMC's "Extramural Electives Compendium" Web site, 2007 medical student enrollments, or 2007 US News & World Report rankings, thereby adding validity to the results. Second, we examined the perspectives of VMS programs, not the perspectives of actual visiting medical students. The survey respondents' impressions that medical students participate in VMS programs primarily to secure residency positions should be confirmed in future studies by surveying actual visiting medical students. Other reasons medical students participate in VMS programs might include evaluating an institution or residency program and comparing it to others, enhancing knowledge and skills, observing alternative practice styles and systems, and the enjoyment of travel [11]. It is also possible that US and international medical students participate in VMS programs for different reasons. All these medical student perspectives should be further explored.
Finally, our survey did not assess variables that predict success among visiting medical students, which would be especially informative to medical schools with VMS programs that have limited clerkship slots and other resources. Furthermore, although a prior single-institution study [11] showed that students who participated in visiting electives and clerkships were not more successful in obtaining their first choice of residency position than students who did not, schools nevertheless claim that the primary reason for having a VMS program is to enhance residency program recruitment. Thus, the relationship between participating in VMS programs and securing residency positions needs further study.