Mark Wilson gives some tips on planning your elective at a top US medical school

The United States needs little introduction. It is big, expensive, and alleged to be one of the best--although it comes a rather low 37th in the World Health Organisation's ranking of health systems. It is widely quoted that although Americans spend 11% of their gross domestic product on health care, 30 million people cannot afford fees or insurance producing a huge disparity between the rich and poor. There are four sources of health funding:

• Patient fees
• Private insurance
Federal funded Medicare insurance for elderly and disabled people
• State funded Medicare insurance for families on low incomes

As stated in this month's elective report, there are often wrangles between what is best for the patient and what insurance companies are willing to pay for. In my experience, if you do a trauma elective, you might see an accountant as part of the trauma team.

However, if it's high tech medicine you are after, the United States is the place to find it. There are 126 medical schools (listed at www.medicstravel.org) and most of them give information on how to apply for an elective. But the cost can vary from being free--one will actually give you a grant to come to them--through to thousands of dollars.

Visas

Many students can get by with just the visitor's waiver that tourists get on the plane--this allows a stay of three months. However, officially, you need a J1 visa, which costs £30. There are good reasons for getting the visa--some large institutions will need to see it before they give you a security pass--and security is tighter than ever. If you get caught without one you could jeopardise your chances of ever being allowed to work there in the future. They have a premium rate visa information line on 0891 200 290 and a rather extortionate £1.50 a minute line that gives you the privilege of talking to an American on 0991 500 590. You can visit the embassy, but you will need an appointment. Dress smartly, join the queue at the crack of dawn, take letters from the hospital you are going to, and prepare to be interrogated. Some students have also been asked to get medical tests, for example a chest x ray and hepatitis B titres. Check with your destination.

Cost

As mentioned earlier, the cost of an elective varies dramatically. Harvard (www.med.harvard.edu) currently charges $2650 (£1665; €2370) for a four week elective. Some students have said it is worth every penny, but others have found it a bit of a rip off. Medical schools can also charge hefty prices for accommodation--Harvard charge $700 with no linen.

Other medical schools are equally expensive. Take Pittsburgh Medical School, for example. Quoting from their web site, there is a non-refundable application fee of $50 and tuition fees of $2100 for 4-8 weeks. They then estimate monthly expenses--including rent at $595--to total another $1074. You have therefore spent $3224 and not even bought your airline ticket.

But there are unofficial ways around these fees. Look at the websites of your destination, find someone who does the specialty you are interested in, and write to them directly. They may say apply through the university or you may be lucky. If they will sign your forms for you, you may not have to bother the university--although do check as you may have to provide things like your own insurance. Other universities are not nearly as expensive as these two and you can always apply directly to hospitals.

Indemnity insurance

You must ensure that you are covered to do your elective in the United States. It may be that your current provider will cover you, in which case get written confirmation. If not, either your destination will be able to provide cover or they should be able to recommend a broker.

Travel insurance and vaccinations

For your own safety, travel insurance is vital. The bills from even a minor procedure can be huge. Make sure you are covered. No vaccinations are needed other than those for working in the UK. Hepatitis B vaccination is essential. However, check with your destination regarding the need for occupational health clearance.

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