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I am a 2nd or 3rd year medical student who wants to do electives in USA, How do I get started

A junior year medical student trying to make sense out of many phrases and jargons that you dont understand? Or a senior medical student who has no time to waste and wants accurate guidance on right time? Or a graduate who wants to evaluate possible options for opportunities to acquire US clinical experience.

This page is the right one for all of you who seek to educate themselves with the basic knowledge of electives/USCE related 'things' and gives a clear picture on why you should have US hospital based clinical experience as one of your accomplishments to boast in your CV. This page will also orient you by providing a bird's eye view on how the 'system' works, and will roughly guide you with enough knowledge so that you can formulate your specific goals.

If you are already familiar with most of the facts about matching a residency position in a medical specialty in USA, then you can skip to the next section of your choice from the navigation bar on the left side.

In this article I have laid out some basic details to give an overall understanding on what you need to do if you wanna train in USA for further carrier specialization (assuming that at this point you know absolutely nothing about it to start with). After that I have co-related those details to help explain the importance of acquiring US Clinical Experience (USCE).

If you are starting from a scratch, then probably the only thing that you know for your self right now is that you wanna do your post graduate medical training in USA after you graduate from your medical school. This immediate post graduate training is called Residency. If you are able to complete this post graduate training, and you want to train further in addition to your residency, then that additional training is called Fellowship. Example: lets say you spent X years in your medical school and graduated, then you did three years of your training in General Internal Medicine, following this you further trained for a year or two in Cardiology in USA. In this example the three years of your general internal medicine were your residency training while the additional 1 or 2 years in Cardiology were your fellowship.

However, there are a couple of things that you need to do before you can be considered eligible to apply for a residency in any specialty in USA. The minimum requirements of which are to pass a series of exams called 'United States Medical Licensing Exams' or USMLE. If you are a foreign medical student, the organization that conducts these exams is Educational Commission for Foreign Medical Graduates or ECFMG, this organization does not conduct USMLE for US medical students, another organization named NBME does the same job for them. So now you know an additional fact that not only you are required to take USMLE, but US medical students also take these exams and you will be competing against them on similar parameters. You can visit their websites for additional information.

About USMLE and ECFMG CERTIFICATION: Altogether there are 3 exams :

USMLE Step 1: It is an 8 hr long Computer based theoretical exam with clinically oriented MCQs, testing subject matter from Anatomy , Physiology, Biochemistry, Pathology, Microbiology & Immunology, Pharmacology, Behavioral Science and Biostats in variable proportions. By most students, this exam is considered the toughest out of all three. More information on USMLE Step 1 can be explored by reading through the Content description & general Information booklet. You will need Adobe Acrobat Reader to view the file.

USMLE Step 2: This one's a slightly complicated story. Unlike Step 1 that tests your knowledge on basic science, USMLE Step 2 evaluates your clinical knowledge and skills. By 'clinical' I mean specialty related subjects like surgery/medicine etc that require direct interactions with the patients. You study these subjects during the later years of your undergraduate medical training.

USMLE Step 2 is further subdivided into 2 components:

  1. Clinical Knowledge (CK): It is a 9 hr long exam similar in pattern to Step 1, but ofcourse is based on clinical subjects (see below). More information on USMLE Step 2 CK can be explored by reading through the Content description & general Information booklet. You will need Adobe Acrobat Reader to view the file.
  2. Clinical Skills (CS): It is an 8 hr long PRACTICAL exam evaluating your clinical skills relating to patient interactions, such as History taking/Physical exams. It also tests your english speaking capabilities. This exam can only be taken in USA and unlike CK and step 1, there is no score to this exam-you only have to pass it. More information on USMLE Step 2 CS can be explored by reading through the Content description & general Information booklet. You will need Adobe Acrobat Reader to view the file.

For both CS and CK, the exam subjects are Internal medicine, Surgery, Pediatrics, Obs and Gynecology, Psychiatry and biostats. Remember that both exams are independent and separate from each other and even though they are referred to as components of Step 2, there is no aggregate score or anything.

Once you graduate and have your degree issued to you (which your medical school verifies to ECFMG), and you have cleared Step 1, CK and CS, you are then ECFMG CERTIFIED. Note that USMLE Step 3 (see below) is not a requirement for ECFMG certification. Becoming ECFMG certified is the minimum requirement to apply for a medical residency training program in USA. It does not guarantee that you will be able to secure a residency position.

Another point thats worth mentioning at this point is that you can take any of Step 1/CK/CS exams in any order while still being a medical student provided that you have completed 1st two years of your basic science undergraduate training at your medical school. You dont have to be a Graduate to take USMLE.

If you are a 1st, 2nd or 3rd year medical student, it is highly recommended that you seriously consider taking step 1 BEFORE graduation and start planning right about at this point of your carrier ! I will explain it below as to why it is so important, but for now just swallow this important fact and remember it !

USMLE Step 3: Step 3 is the final component of the USMLE exams. Its usually considered the least important of all three steps. This does not necessarily means that it is easy. Even though its not part of a requirement for ECFMG certification, which means that most residency programs do not expect you to have taken the exam at the time of application, but having scored decent on it along with ECFMG certification can certainly make your application competitive in the eyes of the residency program director. Favorable visa outcomes (e-g H1 visa) if desired, require that you Pass Step 3 at the time of application.

This exam tests the same subjects as CK but lays greater emphasis on advance patient management. It is a 2 day exam and can only be taken in USA. Some US states require you to have completed 1st year of your residency training before you take it, others dont. To appear for USMLE Step 3, it is a requirement that you are already ECFMG Certified. More information on USMLE Step 3 can be explored by reading through the Content description & general Information booklet. You will need Adobe Acrobat Reader to view the file.

Step 3 is neither conducted by ECFMG nor NBME. Another organization named Fedration of State Medical Boards or FSMB is responsible for processing step 3 applications.

Any step component cannot be repeated to improve score once passed, atleast for 7 years from the date you appear for that exam, but you can re-take either if you fail. All three steps must be completed within a 7 year period from the start date of your first exam (which may be Step 1 or CK or CS).

At this point if you feel like you wanna know the meticulous details about the application process for step 1, CK or CS, dont resist this temptation- Go for it ! and read through the ECFMG information booklet to cash this enthusiasm.

Having said all this, the story of ECFMG certification and 'related things' like step 3 is now complete. To summarize, you now know what hell ECFMG certification is and that its the minimum requirement to apply for a residency position.

The word minimum Naturally suggests that there are ADDITIONAL COMPONENTS to a residency application as well. The second most important application component after your USMLE scores is US Clinical Experience or USCE. Depending on the preferences of specific institutes or type of specialties like Surgery, it may even be more important than your scores. Dont believe me? why dont you take a look at the University of Massachusetts General Surgery residency application requirements webpage that asks for USCE of atleast 6 months.

What exactly is USCE ? It is basically a clinical work experience gained from working in a US based hospital. It is in it self a broad term. Click here to learn about types of USCE, and then come back to this page again !

Believing that you actually did what I suggested, I asume that you now realize that Electives/Clerkships are the most respected and Valued form of USCE. The biggest limitation is that you cannot do electives after you have graduated and the greatest tragedy is that many students come to realize this fact when they are either very close to their graduation or they have graduated already, rendering them ineligible to apply for electives. This also means that years of your student life are very precious and must not be wasted.

Thats not just it ! Another big hurdle is Step 1 requirement by most famous reputed Universities/Hospitalsn that require you to have your USMLE Step 1 result in hand before they will consider your application for an elective rotation at their institute. Take a look at what Mayo Clinic (America's 2nd best hospital) requires you to have accomplished before you apply for an elective rotation at their institute.

Note that all places do not have a step 1 requirement, and most such places that dont, charge substantial fee. Example Harvard asks for around $4000 for 4 weeks of elective, Yale University charges a similar amount. But if you have taken Step 1 you can do 4-6 months of electives at different places that are equally good like Mayo clinic and the Cleveland Clinic for similar expenditure.

So here's the gameplan. For residency you need USCE, for USCE you need to do electives, for electives you need to take step 1 before or atleast during final year of your medical school, and if you are really serious about it, you need to start planning NOW because USMLE Step1 is one Big A** Exam for which you need to work really hard if you wanna score high !!

Good Luck, hope you enjoyed reading this article.


Jahanzaib Idrees



Last updated September 2010