BASICS: Electives, Clerkships, Externships, Observerships, etc

So what exactly is the difference between Externships, Observerships, Clerkships, Electives, Mini-Residency, Sub-internships, etc. ?

They are various types of USCE terms that you will come across scattered all over the Internet and USMLE forums. Though I have already clarified the differences on the Tips4Match blog, I guess it's a good idea to put the food where the mouth is ;-) I mean, placing that info on this blog exclusively meant for USCE.

Before we begin, let me clarify that these terms are explained here in the context for International Medical Graduates.

1. CLERKSHIPS or ELECTIVES: In most cases, the terms 'Clerkships' or 'Electives' are clinical rotations granted by US Medical schools to medical students. Note that I said students and Not graduates. This implies that you need to be still enrolled in the 4th year of your home-country medical school while applying and will be doing part (one to three months) of those 4th year rotations in the US. Such rotations, besides being accepted by the US Medical school, also needs a "NOC" - No Objection Certificate, from the Dean of your own medical school or University.

Note: The term '4th year medical school' is often referred to as internship year in some places like India. While in the USA, an Intern is the First year candidate in any Residency program , also called PGY1

Experience-wise, Electives are like doing a medical school internship in another hospital which gives a good hands-on experience, you are allowed to do physical exams, touch the patients besides histories, case presentations and lab-result followups. You are not held liable for errors because of your student status.

Once you graduate out of your Medical school you become an "IMG" for US purposes and you no longer qualify for Electives / Clerkships in the USA, (unless you re-enroll in a US Medical school - Yeah, some rich fellas do so). Instead, IMGs can avail of the following kinds of USCE.


You do the same thing as an externships, except that you are still a 'medical student' - not a medical graduate.

2. EXTERNSHIPS: Externships are clinical rotations for International Medical Graduates that give a solid hands-on experience working as a resident under supervision. You do almost everything that a PGY1 resident does except that your medical notes need to be approved by a resident or attending and you will not have the authority to write orders and prescriptions.


Often an externship spans a single department, while a sub-internship or mini-residency may be longer over several specialties.


3. OBSERVERSHIPS: An Observership or shadowing (Sometimes also called as a preceptorship) means exactly what the english word means - to see and note without touching the patient ! In most cases they consist of attending morning rounds, seminars, student lectures and attending case presentations. You cannot touch the patients and perform physicals.



Some places may also call Externships as or a Sub-internships or a Mini-Residency, but the terms are not always strictly externships. Likewise, at times, when a program says "externship" it may actually mean an Observership - so it's upto you find out beforehand, the nature of the rotation.

Thus, Externships, Sub-internships, Mini-Residencies, Clerkships or Electives are considered true USCE since they give you 'hands-on' clinical experience, whereas Observerships or Shadowing only give you a chance to be a passive observer without being allowed to touch the patient.

Sometimes a program may explicity mention that Observerships do not count as USCE ! For example, the University of Michigan psychiatry residency program at Ann Harbour. An example of a "Mini-residency" is the Mt. Sinai Mini Residency Program at Miami, Florida, in 13 Specialty areas (300$ per area) . For registration, Info and contacting - Click Here


Be advised that in terms of importance for getting considered for a Residency position :

"Hands-on Experience is Better than Observerships"

Q. Doc, I only got an observership - no externship. Am I doomed ?

A. Agreed that an externship is better, but having an observership is still better than having nothing at all! There are thousands of IMGs without any of these..


Q. What Visa Can an IMG do an observership / Externships on ?

A. Any Visa....Yes it can even be a visitors Visa AS LONG AS as the Observership or an Externship DOES NOT pay you. Any USCE that PAYS you (Like a visiting scholar's position or a paid sub-internship ) would need either an J1 (more common) or a H1 visa to be sponsored by the hospital. At times, the specific Program may need a specific visa type like a student visa, visitors visa, etc. and they will provide a supporting visa letter for the same.


Q. Requirements for USCE ? Do you need USMLE Steps for Observerships/Externships ? ECFMG Certified ?

A. There is no formal American policy on this - but hospitals may have their own internal demands. It's best to find that out when you contact the guys. As a sample, Click here to check out the requirements of the Baylor Neonatology Observership program. And have a look at USMLE step 1 requirements for the IMG requirements for clerkship at the Mayo Medical Schools. Usually for an externship, most programs may need you to be ECFMG certified, since you do similar stuff as a resident would, while requirements are usually less stringent for Observerships since there is no patient-touching involved.

To reiterate and irritate ;-) : There are no universal policies on these and you must endeavor to find those out via emails / phone.




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