Not just watching: Defining core competencies for international medical observers

International Medical Graduates (IMGs) play a vital role in addressing the US physician shortage, yet many begin their American Clinical Journey through observership that often lack formal structure or defined learning goals. This perspective proposes a competency-based framework to transform observerships from passive shadowing into purposeful educational experiences. Drawing from the Accreditation Council for Graduate Medical Education (ACGME) model, the authors outline seven adapted competencies: Medical Knowledge, Communication Skills, Reflective Learning, Systems Awareness, Cultural Competence, Ethical and Professional Principles, and Initiative and Engagement; each with observable behaviors to guide learning and feedback. Implementing this framework in a hospital medicine observership program enhanced both faculty teaching and learner engagement, fostering reflection, professional growth, and a sense of belonging among international observers. As states explore alternate licensure pathways for IMGs to meet national workforce needs, defining observership competencies offers a timely, equitable, and scalable approach to preparing globally trained physicians for practice in US healthcare systems.