Introduction

Welcome to my Expert Guide to USCE. In this guide, I will present (1) the best strategies for obtaining U.S. clinical experience (USCE) and (2) how to get the most out of your USCE. In doing so, I assume you are either an international medical student or an international medical graduate and your aim is to get into residency in the United States.

Definitions

For the purposes of this guide and the USCE Finder, I define an “international medical student” (IMS) as any student currently enrolled in a medical school outside the U.S. and Canada whose clerkships do not take place at U.S. hospitals. I define an “international medical graduate” (IMG) as someone who has graduated from such a medical school.

When referring to whether a residency program is friendly to IMGs, I consider a program to be not IMG friendly if it (1) does not support ECFMG-sponsored J-1 visas; (2) does not have any IMG’s currently enrolled in the program; and/or (3) has policies that are unfriendly to IMGs (e.g., requires 12 months’ hands-on USCE to be considered for the program).

For a program to be considered friendly to IMGs, it must support ECFMG-sponsored J-1 visas. The program’s IMG Friendliness score is then determined by the percentage of IMGs relative to total residents currently enrolled in the program.

What Types of USCE Are There?

There are various types of USCE. Generally, these differ in the extent to which the USCE is a hands-on experience and whether the USCE is open to IMS’s, IMG’s or both:

1. Observerships: Usually hands-off, though to varying extents can be hands-on; usually for IMG’s but can also be for IMS’s
2. Pre-Residency Fellowships: To some extent hands-on; for IMG’s only
3. Externships: Hands-on; for IMG’s, though could also be for IMS’s
4. Sub-Internships: Hands-on; usually for IMS’s but in rare situations can be for IMG’s
5. Clinical Electives: Hands-on; for IMS’s only
6. Audition Rotations: Hands-on; for IMS’s only, intended for those interested in pursuing residency at the host program

Which Types Are Most Valuable?

There are two views by which to determine which USCEs are the most valuable:

1. Hands-on: Among programs that require IMG applicants to have USCE, hands-on USCE more frequently and significantly meets this requirement. Hands-on USCE also provides the basis for stronger letters of recommendation (LORs), which are ones that are able to fully evaluate your personality and competence in the clinical setting.
2. Hands-off: Among programs that do not require IMG applicants to have USCE, having hands-off USCE is an advantage. Hands-off USCE also allows the applicant to meet the criteria of programs requiring USCE and permitting observerships to meet this requirement. Hands-off USCE also provides an advantage when it is hosted by a program where the applicant will be or is applying for residency, as it allows the program to get to know the candidate more extensively and in a first-hand setting.

If you are an IMS, you should prioritize hands-on experiences.

If you are an IMG, you should prioritize (1) IMG-friendly programs where you will apply and/or (2) hands-on experiences. Ideally, you will have a mix of both in your application.

These are highly coveted positions. The more you do to prepare a competitive application for them, the greater chance you will have of securing a position.

How to Get USCE if You Are an IMS: Using the USCE Finder

Start at least a few months in advance.

If you are an IMS looking for hands-on USCE (which, as I described above, is the only type of USCE you should be looking for), the first step is to determine whether your medical school participates in the AAMC’s Visiting Student Learning Opportunities (VSLO). Then use the USCE Finder to locate USCE as follows:

1. Choose your Specialty: Unless you are targeting a specific specialty, and even if you are, leave this blank. At institutions hosting USCE for IMS’s, you choose among a catalog of clinical electives once you are accepted.
2. Choose the USCE Type: Here, select Audition Rotation, Sub-Internship, Clinical Elective – VSLO, or Clinical Elective – Non-VSLO.
3. Choose the State: Given the ERAS Application’s shift toward using geographic preferences when applying for residency, you may wish to consider the geographic regions you wish to target with your residency application, and choose your USCE accordingly.
4. Optional: You can filter results by the IMG Friendliness score of the hosting program, if applicable.

In the list of results, read any notes that are provided. For example, some clinical electives require an affiliation agreement to be established between your medical school and the U.S. medical school hosting the elective. If there is not already an agreement in place, it can often be established.

If you are wanting to target a specific program where you will apply for residency, make sure it is a program where you will be a good fit as an applicant. You can do this by reviewing the program’s website using the link that is provided in the results list.

Then go to the application website using the link provided to view the requirements, which can include:

1. Fees such as registration, tuition and criminal background check
2. Step 1 and a certain minimum score (e.g., 104) on TOEFL
3. A recommendation letter from your medical school
4. Demonstration of financial ability to cover lodging, food, transportation and insurance expenses
5. Demonstration of an appropriate visa (which is usually B but can also be J-1 Exchange Visitor)
6. Your CV (make sure this is professionally prepared)
7. A statement or letter of intent

How to Get USCE if You Are an IMG: Using the USCE Finder

Start at least a few months in advance.

If you are an IMG looking for USCE, you can look for either hands-on or hands-off experiences. Depending on the specialty, there may be no or few hands-on experiences hosted by a program or institution available to IMGs.

Most hands-on experiences for IMGs, including hands-on observerships, take place in a private clinic, outside an institution’s strict regulations limiting the ability of an observer to interact with patients. The most effective (and cheapest) way to get a hands-on experience in a private clinic is to go to the clinic in person. Alternatively, use personal connections to obtain this experience.

If it is a hands-off experience, make sure it is at a program/hospital with a residency in your desired specialty. If it is outside such a program/hospital, make sure it is a significantly hands-on experience that will give you a strong letter of recommendation.

For all USCE, make sure it is one that offers the opportunity to get a letter of recommendation from the experience. (Some opportunities will give only a certificate of completion.)

Using the USCE Finder, look for hands-on or hands-off experiences as follows:

1. Choose your Specialty or Sub-Specialty
2. Choose the USCE Type
3. Choose the State: Here, you should choose states that correspond with the geographic regions you will be targeting with your residency application.
4. Optional: You can filter results by the IMG Friendliness score of the hosting program, if applicable. Please note: If you are restricted to a certain geography (e.g., you are living in Chicago), then you can still apply for an observership at a program that is not IMG friendly by mentioning this in your letter of intent.

In the list of results:

1. Read any notes that are provided. You can also click on the link to view the program, as well as the link, if available, to any application information.
2. Some programs will have a specific process to follow for applying for the USCE. Others will not provide specific instructions.
3. There are programs that offer observerships to IMGs but do not actually accept IMGs into their programs.
4. Even if a fee is not listed, there may be fees for registration (up to $300) and criminal background check (up to $150).
5. Particularly for the USCE opportunities charging a fee and ones that are marked “DLA Verified,” these are highly competitive. You may achieve better results applying for the ones without a fee listed and that are marked “Verification Pending.”
6. “DLA Verified” means either (1) the department or (2) the institution is confirmed to offer observerships. This does not mean you are guaranteed to get an observership here. The discretion remains up to the department to permit the observership.

Keep in mind that in specialties other than internal medicine, if the program is not IMG friendly, they are unlikely to offer an observership.

If you are going to apply for an observership in a program that does not sponsor visas, do this because of geographic preferences (and communicate your understanding that the program does not sponsor visas).

For USCE opportunities that do not provide specific instructions, and even if they do, and for all those that require to first secure a faculty sponsor, you should prepare to send:

1. A brief letter of intent as your email. With your letter of intent, take the point of view that you need to compel the person to action. Focus on why you are targeting this particular program for your observership, what makes you a strong fit for the program (make sure to check the program’s requirements) and your intention to apply to the program in the upcoming match cycle.
2. State what type of visa you have and that you already have it, if you can.
3. Your professionally prepared CV.
4. Keep in mind that USCE opportunities may require you to have Step 2 and English proficiency. Provide your Step 2 score along with Step 1 and TOEFL or OET results.
5. USCE opportunities may require you to be ECFMG-certified.
6. Demonstration of financial ability to cover lodging, food, transportation and insurance expenses (you can simply make a statement to this effect in your letter of intent).

When reaching out to a program to inquire about USCE, you need to consider that this is part of your interview for the program. All communications with the program, regardless of the purpose, must be considered as part of your application to the program.

In the State of New Jersey, you need to be a current medical student to be an observer.

Should I Pay an Agency to Get Me an Observership?

While there are several agencies to whom you can pay a fee as an IMG to get you a USCE opportunity, it is important to keep the following in mind:

1. While sometimes you can end up with a good experience, the agency often does not clarify nor delineate the clinical access/privileges you will have as an observer.
2. You can sign up for a rotation thinking you will be getting an experience at a teaching hospital, only to find yourself at an outpatient office with no hands-on patient involvement.
3. While you may get a letter of recommendation, it is often from a template in which few details are changed from one candidate to the next, making them easy to spot by program directors.

How Do I Get the Most out of My USCE?

One of the top goals for the USCE, from the point of view of the program director at the program where you will be applying for residency, is to give the program director the opportunity to get to know you better.

This can come from having worked with you directly in the USCE.

It can come from a strong letter of recommendation written from a significantly hands-on clinical experience.

To get the most out of your USCE:

1. Show your passion for the rotation, specialty.
2. Even if it is hands-off, get involved as much as possible.
3. Show up early and leave late.
4. Research cases daily and ask insightful questions. If the attending assigns you material to read, read that material that same day and show up the next day with questions.
5. Find opportunities to give at least one presentation on a relevant topic or case, even if informally to a small group.
6. Treat the experience like one long interview: Be professional, friendly and outgoing, to everyone.
7. Look to help wherever needed.
8. Look for any opportunity to make connections, expand your network.
9. Before asking for an LOR, make sure you've earned it. When you ask for an LOR, ask the recommender if they can write you a "strong" LOR.

If you are in the U.S. and limited to where you can go geographically, and you cannot get an observership in your area, either at a hospital or in a private clinic, try volunteering at the hospital, ideally one with a residency program. A “volunteer” experience can often be better than an “observership,” as “observer” roles are often restricted.

How Do I Make My Application Competitive?

I cannot stress this enough: These opportunities are highly coveted. Think about the thousands of candidates who want them. How will you set yourself apart?

Passing Step 1 on the first attempt and high scores on Step 2 and the TOEFL or OET exams will make a difference. What will also make a difference is ensuring your application is a strong one.

Here are services we offer that can help:

1. Letter of Intent Editing & Feedback
2. CV/Resume Editing & Feedback
3. Letter of Recommendation Editing & Feedback
4. SOP / Personal Statement – Various Services

We also offer services for:

1. MSPEs
2. ERAS Applications
3. Application Review & Strategy
4. Interview Coaching

The bottom line is: If you want USCE, you can get it.