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USCE (US Clinical Experience) is a great value addition to International Medical Graduates seeking Residency in the United States!

Updated: March 30th 2011

Wednesday, April 4, 2007

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.

Search keywords to this article:

- "how is elective different from externship"

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Anonymous Anonymous said...

ayan said...

hey doc,
i still have not understood the exact difference between an externship and a clerkship. can an img avail of an externship in the us? if yes then please tell me how.
1:13 AM
Anonymous said...

dear doc,
do I still have to be a student to be able to get an externship?
5:36 AM
Digitaldoc, MD said...

If the externships are mentioned to be only for 4th year medical students - then yes, you need to be a student - but generally 'externships for IMGs' imply that you need to have graduated

for electives - clerkships, yes, you need to be a student.

Note that these definitions are generalized, you will not find the oxford dictionary defining these terms like that - they are sometimes interchangeable.
11:20 AM
Anonymous said...

dear doc,i have passed my final mbbs in india and preparing for steps.which usce, observerhip orexternship would be better for me to have a better chance in residency match.please do reply.
10:53 PM
Digitaldoc, MD said...

Since externships are more "hands-on" - they will help you more, but if you get only observerships, those are still better than having no experience at all !
6:07 AM
Anonymous said...

hi doc. im doing preceptorship with a multi-specialty doctor (pulmo and sleep) and an IM-primary care physician for the past 3 years while preparing for usmle.But unlike what you have described, i am allowed to "touch" the patient with or without supervision. and since most of the time they are delayed or late, im allowed to explain results and plans in detail. a few times, i see the patient from start to finish and just relay to the doctors my findings and discuss my plans. a lot of these patients are satisfied on how i took care of them that they opt not to wait for the docs anymore. where will this type of clinical experience fall: externship or preceptorship?
2:25 AM
Digitaldoc, MD said...

yes, that can happen - especially when the doctors confidence grows on you, while some places are strict about not allowing observers to touch the patients. About your question - its upto the physician, ask him if he would be willing to call it an externship on paper - if thats fine with him, go ahead and call it so :-)
3:12 PM

December 24, 2007 at 6:59 PM  
Blogger Abdullah said...

Hello Doc,

Great notes.

I am IMG and I have scholarship for Master and for residency training.
I got acceptance for Master of Anatomy at Case Western Reserve University for two years.
I planned after that to pursue training in Radiology.

After 2 years, I will complete 5 years since my graduation on 2005, Do you think it will affect my application.
How can I used this 2 years of Master to help my status for residency application.


February 21, 2008 at 4:55 AM  
Blogger Digitaldoc, MD said...

Hello Dr. Abdullah - congrats on your acceptance. To improve chances for any residency, the usuals are high USMLE scores, radiology research work and U.S. clinical experience (Observerships in Radiology at Case Western Reserve)- have tacked the general residency application strategies on Tips4Match Blog

Try to contact radiology faculty during your coursework to see what opportunities you can undertake during the course.

Radiology residency can be a pretty tough one for IMGs - like I covered here

February 23, 2008 at 1:54 AM  
Blogger dratiffarid said...

Im in Final Year MBBS in India and I intend to do my intership in States, which category will it come under? Will it be observership?
(Need to do the one that the Indian Board will accept as well)

Please help.

February 24, 2008 at 5:42 AM  
Blogger Digitaldoc, MD said...

Since you are a current medical student, you should be looking for electives/clerkships - which are better than observerships since they are hands-on experiences and not just watching

February 25, 2008 at 12:34 AM  
Blogger dratiffarid said...

I understood the part that an elective is better. But I'm half-way through my 8th semester and if I apply now for an elective, it will take time and I may get a chance only when I'm in 9th semester. At that point of time, I would want to concentrate on my Final MBBS exams.

So, I was wondering that after clearing my Final MBBS, if I could do internship in the US rather than in India, will it come under observership or which other category?

ANd I think I should apply before September, what do you think?

Please help.

February 25, 2008 at 6:38 AM  
Blogger Digitaldoc, MD said...

You cannot do the whole med-school internship year in the US - only 3 months of it and thats called 4th year electives- which is what is usually done by MBBS students. it would be 9 months of internship in your own school and 3 months in the US. Look up the clerkships/electives mentioned on this blog..most of them will not allow more than 12 weeks (3 months)

Plus that will after your final year MBBS exams too.

Note: Do not confuse your medical school internships with the PGY1 year of residency in year, which is also called as the 'intern' year..which is AFTER completing medical school and getting it thru the residency match program. In the US medical school internships, as MBBS students understand - is not the term used, they are called 4th year electives instead

February 25, 2008 at 2:42 PM  
Blogger Amol said...

hello doc,
I want to ask that out of subinternship & elective clerkship. which is better. i am getting both of them, so which of them should I take for which i have more credential in my cv when i apply for residency.

February 26, 2008 at 11:44 AM  
Blogger Digitaldoc, MD said...

The term 'mini-internship' can be used to mean hands-on in some places and only observerships in other. So, confirm with them and Choose the one with more hands-on experience and which gives you more letters of recommendation (that is more that one physician preceptor)

February 27, 2008 at 6:48 AM  
Anonymous Anonymous said...

Dear Digidoc,

I'm an IMG and i'm hoping to apply for this year's match
I did 2 monthes of electives, 6 months of observeship and a step two score of 97 however my step 1 score is quite low 82
do you think I have a chance to be accepted in one of the top residency programs in internal medicine as harvard, CC, johns hopkinns, UC irvine??
and if not how can I boost my chances??
please answer

March 6, 2008 at 7:11 AM  
Blogger Digitaldoc, MD said...

At top places, besides good scores, research & publications are highly desirable. With good clinical experiences already on your resume, you could invest next in some research work at University programs.

At the same time, do not simply aim for 'top programs' rather make sure you know what you wanna do after your residency - like an area of expertise or a specific fellowship, and try to seek information on programs that are best known for those specific goals.

March 6, 2008 at 9:09 AM  
Anonymous Anonymous said...

hello digital doc,

i am in 3rd year of medical school in India .I am going for an observership
program with Penn State cancer institute in department of biochemistry and molecular biology.
I need to ask you that when i shall be applying for residency in some other program like internal medicine,will this experience be of some value in my resume.

March 21, 2008 at 8:03 AM  
Blogger Digitaldoc, MD said...

Hello, while that will certainly be a great addition to your resume, a clinical observership might help you more. Molecular / Biochemistry experience will certainly help for pathology applicants, since thats a fellowship option after pathology residency.

But, with this experience you will have a strong chance at clinical electives during your final year medical school, which will certainly make matters easier for internal medicine, along with the other usuals like good scores, applying with scores ready on 1st Sept. for a given application season

March 21, 2008 at 8:25 AM  
Anonymous Anonymous said...

Dear digital doc,I`m an "intern" in an indian college,so that leaves me the option of applying for both a clerkship and an externship right??(after i finish internship of course)...Which one of the two is more desirable and which one is harder to get and why?I`d appreciate it if you could clarify this for me..Thank you

March 28, 2008 at 9:34 AM  
Blogger Digitaldoc, MD said...

Hello, a clerkship / elective during internship is more desirable to trying for externships later for the following reasons:

1. there are lotsa formal elective programs designed in US medical schools that accept foreign medical students - while externships are more of informal try-an-try till you find and convince a doc thingie

2. electives will appear on your medical school transcript - externships will not

3. since electives are during your medical school internship itself, it makes getting USCE earlier on your Resume and you could have a good shot at residency directly after medical school (provided you complete Step 1 and Step 2 CK by then) rather than having to wait another year to get externships and observership in US.

4. Since electives are formal programs, many schools will offer to provide for J1 / F1 visas (some will still want you to get your own visitors visas) - whereas observerships and externships are usually done on visitors visas with higher rejection chances than formal educational experiences like electives.

Hope these are enough pointers to explain why I feel electives are a better bet than externships for internationals :-)

March 28, 2008 at 5:01 PM  
Anonymous PRABHAT said...

hi,sir.presently doing internship from i eligible for elective? .i replied to a hospital ,they said that interns are not eligible.i explained them that internship in india is 5th year and i am still a student, but they said that" No, interns are not eligible. After your intern year you are allowed to practice medicine, which is like our residency program."

April 4, 2008 at 8:24 AM  
Blogger Digitaldoc, MD said...

hgmm...looks like they confused the PGY1 residency year (called intern year) with what you meant - try not to use the term intern - rather say 4th year medical student (4th year as in 4th academic year, which cud be 5th calendar year)

April 4, 2008 at 11:54 AM  
Anonymous Anonymous said...

I have just finished my internship in march 08' after mbbs in india. To what programs can I apply to... am I eligible for clerkships? I will mostly receive my degree in march 09'.
Please help.

April 16, 2008 at 8:17 AM  
Blogger Digitaldoc, MD said...

If you are no longer a current medical school student, you will not be eligible for clerkships / electives - observerships, mini-residency, externships and research positions are what you can apply to.

April 18, 2008 at 1:34 PM  
Anonymous Anonymous said...

i am a final year medical student.i recently completed my electives ta mount sinai mediacal school, new york.
all i wanted to know was that is a month of elctives enough for future.i got two LOR too.
and yes, how can one get OBSERVERSHIP.

September 10, 2008 at 9:45 AM  
Anonymous Anonymous said...

Please. I am an international medical graduate looking for externship how can u help me.

September 14, 2008 at 8:19 PM  
Anonymous sprinter said...

Hi digitaldoc,
I have done a clinical clerkship in summer just before final year of my medical school.I have been given a confirmation of acceptance for this clerkship where it is mentioned as clinical elective.Although this does not appear in my transcript.You mentioned above that one difference between elective and externship is that the first,in contrast to the second,appears in transcript.So how should I mention that at the time of residency application:elective or externship?Thanks in advance.

October 6, 2008 at 11:25 AM  
Blogger Digitaldoc, MD said...

Your medical school transcript should show the elective, if not you can request your office to do so, since it was part of your medical school years. Plus on ERAS, do mention that as work experience too - yes, as a elective/clerkship - or whatever term was used by the place where you did it...note that the definitions are not strictly official and might at times be used interchangeably

October 13, 2008 at 11:45 AM  
Anonymous Anonymous said...

hello digital doc, i m presently doing my internship in INDIA which i will be completing in March'09...i have a visitor's visa for 10 years to USA...i want to know which one will be better for me,externship or observership? and can i persue it on my visitor's visa? i will be really thakful if u can clear my doubts...thank you.

December 12, 2008 at 6:07 AM  
Anonymous Anonymous said...

Hi digitaldoc,

I want to apply to the MSMC miniresidency program at Florida.

They say that applicants' USMLE scores should be above 80 on both step 1 and 2. Unfortunately my step 1 is 79 and step 2 is 81.

Do you think that hiding my step 1 score and just sending the step2 ck score and step 2 cs pass result could cause any problem during the rotation?
They said that applicants don't need to have passed both the step 1 and 2 for applying to their programs.

And, does this program accepts applicants on the first-come basis or on the USMLE score basis?


January 2, 2009 at 3:06 AM  
Blogger scorpion said...

Hi digital doc,

Can u please tell me does lor loses value as time passes?

For example will LOR obtained in 2009 work for applying in sept 2011???

June 6, 2009 at 8:07 AM  
Blogger Digitaldoc, MD said...

I would say keep LORs not older than a year - though I used one of my LORs that was 2 years old..but the rest were all 'fresh'

June 8, 2009 at 3:57 AM  
Anonymous Anonymous said...

First of all, Thank you so much for this is truly helpful....Now my question...I am currently enrolled in a medical school in China, it is my 4th year next semester, I need to apply for USMLE but I was concerned about my scores in Medical school. Is it going to be difficult for me to get a surgical residency in the US if I have 2 D's on my transcript, one in Physiology, and one in Biochemistry...all my other scores are good. Also, in order for me to get into the surgical program what do you think I should be aiming for on my USMLE step 1 and 2? ....thank you once again.

June 28, 2009 at 3:46 AM  
Blogger Digitaldoc, MD said...

If you have the ability to achieve a USMLE score based on what you aim for, why not aim for the ultimate 99 ? Higher the better for any specialty. With concerns about poor performance in Medical school, high uSMLE scores are especially important to you. Besides scores, for a competitive field, you will also need your time your steps well to give you time to get some US clinical experience as well, so work on proper planning is very critical to you. Check out the NRMP match planner

June 28, 2009 at 7:41 AM  
Blogger jalsomina said...

I am biology grad from US and currently finishing my 4th year medical school in my country, Egypt. I will volunteer for some research work this summer in California and I thought it would be a chance to do an observership or elective or anything extra that would be of benefit on my C.V and future when I apply for residencies in US hopefully after I graduate after 2 more years. What do you suggest I do to make use of this summer time in US. P.S: i worked as nurse aid when I was studying in US.

June 28, 2009 at 12:10 PM  
Blogger Digitaldoc, MD said...

Yes, US clerkships / electives in the field of your interest would be a great idea. Research, in addition, would help for competitive fields like Radiology, derm, ortho, anesth. I assume you are a US citizen, if that is so, then to keep your matching chances high, you should apply more to programs that do not sponsor visas !

July 1, 2009 at 7:10 AM  
Blogger prashanth said...

hi sir ... i am doing my final year mbbs ( medicine , surgery , ped, og ,,,etc... )in chennai , india . my final year will end on feb 14, 2010 . my results will be on march 20, 2010 . by hearsay . i came to know that my college deans dont have the habit of sending its students for electives to other countries or hospitals during house surgeon time . but still can i try for elective in that 1 month holiday between final year end and starting of house surgeon . but do i need to guive my final year mark sheet for electives because results will come only in march , by that time i want to be in electuives .. or can i just take leave during the first few weeks of house surgeon an do elective . .and extend my house surgeon by the no. of days lost ... am i allwed to do electives just before house surgeon ....

July 9, 2009 at 2:57 AM  
Blogger chill said...

before applying for electives do we have to email the elective-coordinator??? in that case what we need to mention in our mail??

July 16, 2009 at 7:33 AM  
Anonymous Anonymous said...

First of all, Thank you so much for this is truly helpfull
I'm a medical student from Jordan
I want to ask if a clinical experience at a private hospital with has a teaching program(residency program)considered helpfull ? also my supervising phyiscian is consisting that it wii be an externship rather than an elective !!!
also what is beteer an observership at a university hospital or an externship at a private hospital ??
thanks :)))

October 10, 2009 at 12:03 PM  
Blogger Kashi said...

hey digitaldoc, ur doin a grrr8 grrr8 job here for IMGs. Thx 4 tht..
Im takin my 3rd year xams nxt month. Here in pakistan we have 2 pass four academic yrs plus one year of housejob aka internship (its not PGY-1). Tht makes it the 5th academic year. Em plannin 4 step 2 CK nxt year in october and then step 1 in the nxt cming year. When xactly shud i apply 4 clerkship in US 4 residency match? I mean shud i apply for the 4th year or 5th year? Cuz i read smwhere on ur site tht LOR shudnt be more than a year old. What does that mean? Also a humble suggestion that you may make a blog 4 the average total expenses for doin clerkships or observerships in US. I ll post my expenses when em thru the whole process.. Thx bro in anticipation !

November 25, 2009 at 7:52 PM  
Anonymous Anonymous said...

love u digitaldoc doing gr8 job here

March 7, 2011 at 8:01 PM  

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