Types of USCE and How to Apply

So, you've heard that US clinical experience (USCE) is important to match to a competitive US residency, but you have no idea where to start?

I created this guide to hopefully answer all of your questions regarding USCE. I was inspired to do this because there are several important things that I found out on my journey that just aren't talked about online when I did my research about 2 years ago. Two important notes to start off with:

  • There are essentially 2 types of US clinical experience: electives, observerships. I will discuss what they are, and how to apply to them.
  • The main purpose of USCE is to get a letter of recommendation (LOR) from a US physician. You need 4 of these to apply to residency.
2022 update - USCE spreadsheet This spreadsheet is absolute gold. It's a pretty comprehensive list of >200 US clinical experience opportunities across the US, complied by the USMLE Sarthi team. Elective rotations are critical to your US application, so make sure to check it out and see if you can find something.


Electives are what most people refer to when they say USCE. You have 'hands on' interactions with patients. You have responsibilities similar to a US medical student, taking patient histories, write patient notes, presenting cases. Electives are considered the best type of USCE.

Why are electives the best? Put yourself in your attending's shoes. If the student with you is examining patients, writing patient notes, and speaking professionally to patients you will be able to write them a fantastic LOR.

This is all great, but if there was one thing I wish you could take away from this post, it's this:

You must be enrolled in a medical school to do a formal elective!

This is not so much a problem for many Indian IMGs, as they get a whole year off before they graduate to do electives (intern year), but for many other IMGs we do not have that luxury.

Some programmes require STEP 1 score or TOEFL, but something that caught me out personally is 'core rotations':

You must have completed what American schools call the 'core rotations': family medicine, emergency medicine, internal medicine, OBGYN, paediatrics, psychiatry, and surgery

How to apply: 6 - 12 months in advance go to the website of the institution that you want to rotate at, find the page 'visiting student electives', look at the department page for the specialty you are interested in. Find out the requirements, and then apply online. If you know programmes that have accepted international students before that is even better.

Note: Most programmes have now moved to VSLO, which means your medical school must eligible for to do those electives.


Observing or shadowing a physician means you cannot have any patient contact. Generally this means no history taking, no patient examination. You may be able to present a case and participate in discussions with the physicians, but not patients. Most programmes will not consider this USCE, though it may still be useful to flesh out your CV.

How to apply: Go to the website of a hospital and find the contact details of a physician, send them a nice email asking to shadow them, STEP 1/TOEFL not usually required. This can be sorted out in a few weeks if you're organised.

  • Include: USMLE score, your specialty interests, when you want to observe, ECFMG certification, CV, vaccination records (check this in advance)
  • make it short - doctors do not have time, they will not read a long email


Technically there is a third type of USCE called externships, however I believe they should only be a last resort, if you have already graduated and want some hands on clinical experience.

They are run by companies that claim to be able to provide you with hands on clinical experience, for a substantial fee. I have heard that they run a middle ground between electives and observerships in terms of clinical contact, however I cannot vouch for any of them.

Some of my colleagues have had success with a company called AMO opportunities, but be extremely careful here. A friend paid the full thouds

How to apply: just research companies by googling US clinical experience externships.

If you got this far, thanks for reading such a long post. I hope it was helpful to at least someone out there! If you guys have any specific questions the fastest way to reach me is via twitter DMs 🐦Subscribe for future newsletters on the IMG journey. Cheers!

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