The Difference between Clerkships, Observerships, and Externships

US Clinical Experience (USCE)

US clinical experience (USCE) is a clinical and/or hospital based working experience in specific specialty fields like medicine and surgery.  It is one of the most important experiences a person must have on the application for US residency.  As a medical student or graduate, you must have seen the terms clerkship, observership and hands-on clinical experiences come up again and again.  These are all terms that are related to US clinical experience or USCE.  This is of utmost important for international students and graduates (IMGs) who want to get relevant USCE and LORs (letter of recommendation) in their pursuit of a match into a US residency position.

While American students are very familiar with the different terminologies in USCE, usually international students remain confused about differences in such terms.  This article is meant to clarify these terms individually to give a clearer picture on the overall types of experience that can qualify as USCE.

First, you must know the importance of US clinical experience?  Why is it so important?  What aims or objective does the experience carry?  When referring to USCE, typically the experience makes you:

  • Well oriented in the field
  • Become skillful and have professional behavior
  • Comfortable being expected to serve patients with great care
  • Professionally evaluated by a physician based on a US healthcare grading system, showing  you can have good communication with other health professionals and most importantly patients
  • Become oriented with the day to day experience involved in the specialty
  • Network with physicians in the field that may be relevant to the specialty

S0. USCE is not only just an experience and integral component to your application; it is a strong edge for you to get networking opportunities leading to a potential US residency.   It is most beneficial for the IMGs who apply for US residency, who had no previous exposure to the US healthcare system or US medical education.  Those applicants having strong USCE are considered as most compatible by the program directors and ultimate decision makers on residency applicants.  Remember, these directors see thousands of applicants per year, IMGs must use every edge possible to stand out.


Why the USCE is so much important for IMGs/FMGs and international medical students?

We all know that medical curriculum is different in every country.  So, those students who are not Americans often face great confusion and issues when they apply for their further medicine studies.  US clinical experience helps these students to deal properly with the protocols and procedure that are performing in US and acclimate them to the not only curriculum differences but cultural differences and international student may face.  Moreover, it s the best and strongest way to become a strong applicant for US residency programs.

For practical purposes, you can have two types of USCE

  • Hands-on clinical experiences
  • Non hand on clinical experiences

Precisely speaking – hands-on clinical experiences are the most valued ones by residency program directors and decision makers.  These typically involve teaching or university- based hospital experiences that serve best clinical experience to the students. These experiences can also be gained in community hospitals and clinics via physicians clinical associated to the teaching staff faculty.  The students are in direct contact with the patients, learn how to take patient history, learn the best professional skills, and gain exposure to Electronic Medical Records (EMRs).  Usually, this category refers to clerkships/electives and externships.

On the other hand – non hands-on clinical experience refers to shadowing-only or observership experience.  Though this term is historically probably the most widely known referring to clinical experience in the international medical community, the emphasis on this type of experience has waned over the years due to no direct patient interaction.  One can understand the position of a residency program director, who would want the student to have proper prior training, which literally every US medical student competing for the same spots already has in-built into their medical education.  Lately, program directors are not even accepting observation-only, shadowing-only, or observership programs as clinical experience at all.  It then behooves the international applicant to gain as much relevant hands-on experience by any means available to them.   While we understand the importance of hands-on, we also realize some observership opportunities carry affiliations to prestigious institutions and/or offer the only option some students have available to them because of a wide variety of constraints.  Thus, sometimes this experience can be- good for those international students, who face problems in finding externships but have say very high USMLE scores to offset.

Now let’s discuss these main categories in more detail:

  1. Hands-on clinical experience include all clerkship/elective rotations for students and externships for graduates.

Medical school rotations: (clerkship or elective)

  • This includes generally – the elective or clerkship. Here we will discuss in special reference to clerkship:
    • These rotations are arranged in US, while you are in a medical school.
    • Can also be organized via a third party and credited by the home school
    • Many universities also offer a type of exchange program for credit by directly applying for their clerkship program (varies widely)
    • Many visiting student elective and clerkship experiences can be found as well
  • These rotations include interaction with patients, didactics, and improving the communication and professional skills
  • These rotations typically follow a curriculum set forth by the affiliated US medical school
  • If available for credit at your home medical school, these rotations offer the best opportunity to save time and avoid red flags on your residency application later on because of not staying clinically relevant

Externships for graduates

  • These experiences include didactics and direct patient care services
  • Improves best communication skills and enhance professionalism
  • Almost all types of this experience involve tuition or enrollment fees
  • It is the best way for an international medical graduate (IMG) to strengthen their application for US residency due to both the opportunities of earning a letter of recommendation (LOR), clinical evaluations, and/or US certificates of completion
  • Best way to make various contacts with physicians, doctors and other health professionals. 
  1. Non hand- on clinical experiences refer to observer ship.
  • Purely observation or shadowing based education
  • No direct contact with patients
  • You must have good observation skills so that you might be able to see how the physicians look after the patients
  • The experience can be often free but also paid
  • Many universities offer paid observation only programs directly
  • The disadvantage – you are not strong competitor of US residency and may not form good contacts with other health professional
  • This experience is not considered too appreciable among USCE and often discounted by program directors you are trying to impress

 USCE – the value and importance

  • USCE is very essential for foreign and international medical students and graduates.  If you are an international student and you don’t have USCE – you should attempt to gain as much as possible before applying to residency to earn LORs and even all the way before interview season to stay clinically relevant in your field of study
  • USCE enables a student or graduate to become their best at communication and professional skills, which can also benefit you later with USMLE Step 2CS
  • You have the chance at networking and forming many contacts with US physicians – this helps you a lot in getting letters of recommendation and oftentimes research opportunities as well
  • The greatest benefit of having USCE is that you are able to understand and be exposed to the US health system, which is the biggest issue and disadvantage faced by the international medical applicant to residency


In conclusion– USCE is very important for every medical student and even more for the international medico.   Whether you are an American or not and especially for IMGs – you must have as much residency relevant USCE for the best residency application possible!