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If you attend most U.S. medical schools, this is probably a topic you will never have to deal with. You may not even realize that there are such entities as “rotation agencies.” Your school, as required by accreditation standards, must be associated with a hospital in which students can later complete their clinical hours. More on this can be found on the LCME accreditation page. But for international medical students/graduates (IMS/IMGs) using medical rotation (third party) agencies is often a requirement.
For those of us that went to Canadian, Caribbean, or other foreign schools that plan on practicing in America, these agencies provide networking between schools, students, and preceptors. Our schools are often small and lack the networks and resources needed for University hospital affiliations. Not to mention the already competitive world that is academics life for medical trainees, this is one more stressor that may arise.
This is where the agencies come in. Though students can attempt to individually set up their dozen or so rotations, or externships, needed for graduation, it is much easier to simply use an agency that is able to form agreements with a wider range of teaching doctors (preceptors) in a wider span of cities and states.
My school uses an agency for the majority of rotations if you stay in the Chicago area. Many Caribbean-based medical schools have their headquarters in Chicago, Boston, and a handful of other cities. However, these affiliations between schools and agencies can be difficult to form as they each have their own agendas (which may or may not align with the students). After all, they are businesses.
UPDATE: Find our 2019 pricing guide and review of some of the most popular rotation agencies.
How They Work
For the most part, these agencies perform as you would expect. They receive individual students or groups from a school each term and begin to attempt to place them with doctors they have agreements with. Some of these doctors really care about teaching, while others may have various other reasons for taking on students. Depending on how many students they have, what courses are required (varies from school to school for cores, electives are up to the student), and what timeline they are working with there can be a lot of variability in a student’s schedule. Some students can take more time, while others need to cram in order to apply for the next Residency Match.
Then, depending on the number of preceptors the agency has developed agreements with, they get to work (often with the help of computer algorithms) to place each student in each rotation. This is probably not too difficult with a handful of students, but placing several dozen to several hundred on a rotating basis every few weeks (rotations generally last 2-6 weeks) can be quite the match-making game. There is almost no transparency on this process so many agencies claim to offer rotations in locations, but they are never available. This may be due to preferential treatment of some students, or they simply didn’t actually have the rotations to begin with.
In the end, the agency is a business. As such, they are going to do what is in their best interest. If they have an agreement with your school and receive numerous students on a regular basis, they may be more willing to step in when things don’t go as planned. If you are a lone student reaching out to agencies your school has no agreement with, you are on your own. And if a problem arises do you think they will take your side, or protect their longer-term income: the preceptor?
This is the predicament I found myself in…
*To read more about this, stay tuned for a future article regarding the troubles and tribulations that may arise.
Rules to Guide You
Why go through all of this, you may ask? Some students want to practice in a particular area, and it can benefit them to network with the local healthcare staff. Others want to be near friends or family. Or perhaps for a hopeful relationship that ends up going nowhere (ahem). Whatever the reason, there are a few steps I’ve learned that may help you better choose (if you have a choice) a safer rotation.
DON’T purchase all of your rotations ahead of time. If you have to pay for these extra rotations on top of your schools tuition, as is common, make sure to only pay for 2-3 at a time. I’d recommend one if you don’t mind having gaps in between, but most students just want to get it over with. They may try to sell you on the scarcity of a rotation and that they “go months ahead of time,” but this is often a sales pitch. It may be true in some cases, but you don’t ever want to pay too much ahead of time and lose your leverage later on. You may need it. Plus, you may find contacts through your rotations that will allow you to complete a rotation with them and not have to go through the middle-man, which is always cheaper. They used this scare tactic on me, and I regret it each and every day.
DON’T fall for the up-sell. Some agencies will give their rotations special titles, like: “verified” vs “non-verified.” These terms mean nothing to residency applications, despite what they tell you. They often just cost more. Now, if they can guarantee you more of a particular demographic of patients, such as more inpatient vs outpatient, it may be worth it. But make sure there is something in the contract stating they will reimburse you if a rotation is labeled “verified” or “inpatient” and turns out not to be. They often take their cues from whatever the preceptor put on their initial paperwork, and things often change afterwards with no reliable verification process.
I relied on my schools clinical department for the final word, though I did double check by calling the licensing board in the state I was interested in. Since neither was aware of this “verified” status, it seemed pretty safe to pass on the up-sell.
DO make sure that your preceptor is affiliated with a hospital system: Even if they are doing private practice, they can have privileges at a local hospital. Hopefully your school will have restrictions on this already, but if not be careful. Your paperwork, which will be needed for residency applications, will remain at the affiliated hospital and is easily accessible when the time comes. Hospitals deal with this type of thing frequently, and are pretty conservative when it comes to throwing away ANY potentially important records (plus a lot of it is digital now). If the preceptor is not affiliated with a hospital they may go out of business, lose your paperwork, or rely on the agency to maintain records (believe me, they often can’t maintain their own, let alone yours!).
Sometimes agencies don’t want to be cut out of the mix and won’t let your school set up direct agreements with the hospitals. They will, however, allow a three-way contract between the school, agency, and affiliate hospital (as happened in my case) since the school may require being involved to some degree. This is for your protection, so if the agency is too afraid to disclose their preceptor/hospital information to your school, they likely won’t lift a finger to help you if there’s a problem down the road. I have heard stories of students unable to apply for the next Match because of issues with paperwork. Don’t risk it.
DO make sure the agency provides adequate notice. Notice of your next rotation and location is important. After months of trying this outside the safe umbrella of my school, I have dealt with many issues. I had rotations canceled and changed last minute 3 times (in 4 months); rotations being moved ; supposed inpatient rotations turn out to be outpatient; and generally find out about 2 days before what rotation I will be going to and where it is. It’s really beneficial to have adequate time to review the important material related to that rotation ahead of time. If you are also in a constant state of residential flux (AirBnB must love us students), you may require a little more time to get settled and to study.
You may get the (partial) lie about it taking weeks to months to set up rotations and the agency must just send you where ever there is a free spot. To a degree, this is true. It can take a few weeks to process paperwork…initially. Their ability to randomly change the order of your rotations on a whim (as is my experience) leads one to believe theirs more fluidity than being admitted. The likely issue is that they may not actually have the rotations they have promised. Or they failed to file paperwork until last minute. I have confirmed with several hospitals that it only takes 1-2 weeks for them, but each will be different. So, if you cannot get a guarantee at least a few weeks in advance be cautious.
*You may also want to know what the maximum number of students a preceptor will take is. Though the agency likely won’t tell you how many are in each currently, they should be able to divulge that at the least. Then you can know if you should expect to be alone, or have a dozen other students crammed around a table each day.
DO price match if at all possible. I found out that I was paying one agency several hundred PER WEEK! For what? After their initial placement of you into a rotation, which consists of filing a few pieces of paper and waiting for a response, they are pretty hands off. For my rotations in Colorado, I had no other options. The other agencies I had reached out to did not have connections in the state. However, when setting up some of my own rotations (long story) I discovered that there was a huge discrepancy between what I paid through the agency compared to what was charged for ones I found (which was covered by the school tuition). Though each preceptor negotiates their own weekly charge with the agency, it seemed that they were still making several hundred extra each week. As has been a huge scandal in medical circles lately, this is similar to the hidden truth behind physician locum tenens companies. I found out about this initially from Docs Outside the Box podcast. Little to no transparency doesn’t make for a very honest and fair process.
DO (and this may be the most important one) make sure the agency has a process in place for disputes. I don’t mean a “here’s our complaint form online you can fill out”, but a legitimate, in-writing process on how disputes will be handled. You need to know who will be involved, how far they will take it, and what your options are if things don’t go your way. For instance, though we all hope this never happens to us, and it seems pretty rare from my experiences and research, make sure that a discriminatory teacher’s poor grade can be disputed.
The absolute worst thing in using these agencies is not the uncertainty, the extra cost, and the disorganized fashion they may be run. No, the worst could be a vindictive preceptor that, for whatever personal reason it may be, decided to make a choice that can ultimately ruin your life. Yes, a failed grade may eliminate any hope you have of becoming a licensed physician. Something this important should not be left to chance. If the agency has nothing in writing about how this will be settled, just say no (or run screaming!).
Unfortunately, if you are picky about a particular rotation, state, or city (as I was) you will likely have few options. And being desperate, or careless, can lead you into a world of hurt. If your ultimate goal is just to soldier on and get through your rotations, I’d suggest not rocking the boat. Stay where you are, if at all possible, and finish everything within your school. If you decide to reach for the stars (or at least a state/city you would like to increase your odds of residency in), heed these words. They may save you a lot of time and money, and maybe even your career.
If you have any experiences in this realm, positive or negative, feel free to post them below or share on our facebook page. You can also sent in an anonymous email if preferred via our contact page.
