United States Clinical Experience (USCE) 101

United States Clinical Experience (USCE) is considered an important aspect of an IMG’s residency application in the US.

[Disclaimer: This post is based solely on the author’s personal experiences and views.]

Beginning on the first day as a first-year resident, an IMG will be a practicing physician who will be independently shouldering the responsibility of a patient’s care.

The idea of USCE is to familiarise oneself with the healthcare system that is different from the one that we’ve been trained in during medical college.

(USCE in any department is counted toward one’s application. However, it is preferred that it is in one’s field of interest.)

It is important to look at USCE as a learning experience and not merely a means to get Letters of Recommendations.

(Most programs require 3-4 letters, you can use letters from your home institution too but the ones that are from the US are valued better. Waived letters, ones which are directly uploaded by the attendings to the ERAS website, are also valued more.)

Let’s get the jargon right!

• Rotations: Loosely translates to ‘postings’ in India. A third-year American medical student is required to complete their core (compulsory) rotations in the departments of Family Medicine, Internal Medicine, OBGYN, Neurology, Psychiatry, Pediatrics and General Surgery.
• Electives: ‘Postings’ again, but ones which are undertaken by the fourth-year American medical students by choice in their fields of interest. If a student undertakes a second rotation in one of the core- rotation subjects then it is called an ‘advanced rotation’. If the elective is in a subspecialty (‘super-specialty’) department then the student is considered a Sub-Intern (a student who will be independently caring for 2-3 patients just as a first-year resident – an intern does).

As a final year medical student, you can also apply to these rotations through various University’s international visiting medical student programs.

These are very highly valued and provide you with hands-on learning opportunities with a structured didactic curriculum.

Note: These rotations are open only to final year medical students. The terminology gets a little tricky here and can result in some miscommunication. A final year medical student in the US is someone who is traditionally in the fourth year (MS4) of medical school, which is the same in India. However, considering we have a 5.5-year program with an internship year as a prerequisite to graduating, it is better to refer to ourselves as a final year medical student while we’re in the US and NOT as an intern. An intern in the US is a first-year resident.

• Externship: These are rotations/electives that are not undertaken in the home institution. In the US, some medical students take up ‘away-rotations’ at different institutions from their own and ‘externship’ is probably an international medical student’s version of it.
• Observerships/ Shadowing: During an observership or when you’re shadowing someone, you are not directly involved in the care of the patient and will only be a silent observer. This is probably the most popular way to gain USCE as an international medical graduate. This is probably not valued on par with rotations/ electives and is also poorly valued in the case of students applying to surgical programs.

Where can you get USCE?

1. University Hospitals with international visiting student programs. Best bet: Check out this post on Electives without Step 1 scores and Electives with Step 1 scores for a comprehensive list of places you can apply to.

2. Community Hospitals with residency programs that accept IMGs (Usually only observerships): A common way to get an opportunity is to send out cold emails to the attendings listed on their websites. Forbes’s article on writing a cold email was a helpful resource in drafting those emails. It may not be the most efficient way but every effort counts.

3. University adjunct professor’s private clinic (Usually only observerships): Cold emails or contacts.

4. Other private clinics (Most claim to be hands-on but are usually observerships): Cold emails, contacts, and agencies.

General tips to consider during the application process

1. Read the requirements mentioned on the websites thoroughly and try to apply at least 6-8 months in advance. Most applications are great these days and so it’s also a matter of the available spots. Don’t take rejections personally.
2. Most hands-on opportunities require you to get liability insurance. Here are some services that you can use (Neither The Indian Medical Student nor the author is affiliated with these companies):
   • Academic Medical Professionals Insurance Risk Retention Group, LLC
   • Marsh USA
   • IPB Insurance
   • Willis Towers Watson Insurance
   • MDU Services Limited
   • QBE Insurance
3. Some rotations through agencies can require you to get liability insurance even though you may not be directly involved in patient care. Consider confirming with them if it is needed and it could save you some bucks.
4. Consider gaining at least 3-4 months of USCE if you plan to apply for a primary care specialty (Internal Medicine, Pediatrics, Family Medicine) and complete at least 5-6 rotations of USCE if you plan to apply for a surgical specialty.
5. If you will be rotating at a combination of different places – private clinics, community hospitals, and university hospitals, then I recommend that you schedule them in that order. This will help you be better prepared for your University rotations, where you can impress your attendings with not only your subject knowledge but the ease with which you integrate into the team. After all, good University LORs are always highly valued.

I hope this helps! It is needless to say that one’s performance during the rotation and relationship with the attendings after the rotation ends is just as important towards one’s success. Please leave any questions below and I will be happy to answer them. All the best! 🙂

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This post has been written by Dr. Anmol Patted who is a medical graduate from KAHER’s Jawaharlal Nehru Medical College, India. She is aspiring to be an OBGYN. You can ask her questions in the comments section below.

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