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Types of US Clinical Experience

This page will help you clearing concepts about various basic terms that you probably already have or will come across in your 'learning' expedition on US Clinical Experience (USCE).

US Clinical Experience (USCE): It is a US hospital based working experience in a clinical specialty like Surgery/Medicine. When you claim that you have USCE, you are expected to be well oriented and skilled with routine functioning of a US hospital. It includes general skills like interacting with patients (history/physical), inputing their records into the electronic system, coordination with nurses and staff, and a general sense of hospital working.

For practical purposes, you can obtain 2 types of USCE.

1- Hands on Clinical Experience

2- Non-hands on Clinical Experience

Hands on Clinical Experience : This is the 'Real' or 'full bloom' type of clinical experience. It has all the traits of USCE described in the definition above. The key to' hands on' is 'Patient contact'. Depending on whether you are a student or a graduate you can obtain it in shape of either a Clinical Elective/Clerkship/Sub-internship (see the individual definitions given below to know about minor differences) or an Externship respectively.

- Clinical Elective : A clinical elective is an optional away rotation that a final year medical student can do outside the hospital of his/her parent institute to gain Clinical Experience. It can be at your home country and it can be at any other country in the world, but if your ultimate aim is to apply for a residency in USA, then your elective in a US based hospital will be most valuable in your Resume.

For example if you are a final year medical student at Harvard Medical School and you are doing your rotation in General Surgery at Massachusetts General Hospital (which is a hospital affiliated with the Harvard University), then this is not a clinical elective, BUT if you try to do an away rotation in a specialty of your choice, say Vascular Surgery at the Cleveland Clinic (a hospital not affiliated with Harvard), then that clinical experience will be a clinical elective. Remember this example I will use it again below.

Electives are most frequently 4 weeks in duration- can be shorter or longer. Note that Research elective (see below) is a different form of elective in which there is no patient contact and is not considered USCE. Some instiutes like Johns Hopkins does not accept International students for clinical electives (unless your institute has a direct affiliation with Johns Hopkins) but do accept them for Research electives (Click here for more details).

From my personal experience, any elective experience is only a window of opportunity for a student to build contacts with famous US doctors and obtain Letter of recomendations (LOR) to support your residency application. It is your chance to prove your potential, caliber and passion to your attending. There are only a BASIC set of skills that are expected from a medical student, and you are evaluated based on your ability to adapt quickly, Iq, common sense, interpersonal skills, overall general knowledge, Confidence, ability to define your roll in a fast paced environment, multitasking, and your functionality to adjust as part of a team interms of how much others can rely on you to get their job done. The easier you will make work for them the more they will like you. No one evaluates you on how much knowledge you have, but on how much you are able to retain/reproduce on what they teach you and how much you refine it from your self study.

- Clerkship: It is a compulsory medical student clinical rotation that is part of your curriculum (for this reason sometimes also referred to as core clerkships) at the affiliate hospital of your parent institute. US medical students do clerkships as part of their 3rd year requirement, but for most international medical students Clerkships are part of their third ear as well as 4th year ward rotation.

In the Harvard example above, if you are a medical student at Harvard medical school, and you do your rotation at Massachusetts General Hospital (Harvard's affilate) then that rotation is an example of a clerkship.

practically there is no difference between electives and clerkships in terms of clinical experience and because of this reason some institutes even use the word 'Clerkship' interchangably or essentially for the same meaning as 'elective'. Example Mayo Clinic uses both terms clerkship and elective to describe their general surgery rotation.

- Sub-internship: It is the most superior form of USCE that an applicant can have (in my opinion). The learning opportunity is immense at the level of a medical student. Its the same as an elective except that the level of responsibility is more and one added distinctive feature is an on-call participation with your team. This means that you spend the whole/most part of night with your team in addition to your day rotation. I like Sub-Internships the most because they give you the Maximum possible opportunity to spend more and more time with your team/attending, and you have all the time in the world to learn and they have a greater flexibility of time to teach you stuff compared to busy day time. Plus, traditionally the US doctors like it alot if you spend extra time, they take it as a proof of your commitment. Sub-internships are very useful if you desire a future residency in a Surgical specialty. You should always prefer electives that have in their discription 'student functions as an intern' or is titled sub-internship per se. Some good examples of Sub-I offering places that I can think of right now are Mayo Clinic, Yale University, Case Western Reserve University, University of California San Diego, University of North Carolina. As you dig down deep into the list you will still find quiet more of them.

All of elective-Clerkship-Sub-I are undertaken for accademic credit (which means it will contibute towards your degree and you will be evaluated at the end of your rotation), another important fact that makes them more valuable.

- Externship: It is a relatively rare specie of USCE with a lot of application requirements that if available to a Graduate is considerd hands on and better than an Observership (see below). As a general rule, any postgraduate training that involves patient contact will require you to be ECFMG Certified (for more details read through getting started). This form of USCE is inferior to elective/clerkship/Sub-I because there is no gaurantee that the training is supervised- in other words you are on your own.

Most institutes/hospitals do not offer externships. Some that used to, do not any more, and very few do offer still, but conditionally depending on your contacts. Another diference is that sometimes they are paid. Some hospitals use externships as 'cheap' labour to manage their overwhelming workload. They are not done for accademic credit which makes them less valuable than former types of USCE described above.

Non-hands on USCE and other terms: The most popular example is an "Observership". The difference from hands on is that this type of clinical experience is limited due to "no or minimal patient contact." Not in my opinion, but Clinical Research may be considered an example of non-hands on USCE by some.

- Observership: The reality is: It's least respected, better than nothing type of USCE that a graduate can undertake to fill in for the blanks of USCE in his/her resume. Thats what most program director's think. However, in my opinion, Observerships can be considerably resourceful depending upon your ability to make use of them and who you work with (especially if you were able to secure one via contacts). At the end of the day all that matters is what someone is willing to write about you in the letter of recomendation and that intern depends on how much your efforts made them like you.

The biggest drawback that an Observership has is 'minimal or no patient contact.' The good thing is that they are relatively easier to find, have greater chances of acceptability, and have less vigorous application requirements. Regradless, there are sill a lot of things that you can do while being an 'observer'. For example: You can project an intelligent image, help as a team member, make things easier for your attending, discuss cases to full detail, voluntier for more work, do powerpoint or case presentations. You can still do everything that a student can do except for a physical exam, that too if your attending likes you so much that he lets you do that-you can ! All that is more possible if there already is not a student on that rotation. So you see practically "its not just better than nothing type of a thing" But rather still a door of opportunity that can be very benificial. I have never done an observership, but I have seen observers when I was on rotations, and I could easily make things what I personaly thaught others could have done to highlight their presence. Your attitute is what makes the difference, because most of the times you decide what more you can do and what you want to do. In USA people are just so nice that they are never a hurdle in your way as long as they find that you are helpful. If you participate in your observership with a preset mind that 'you are just an Observer and you can barely do anything under that status'. Then its applicable for you how 'rumorously' people define Observerships. You have to find work for yourself thinkin of ways how you can help your attending, and trust me if you can do that then it can reward you better than an elective can. Be resourceful of whatever opportunity you have. Earn their trust and they will let you do what you want !

Research Elective: It is a research experience at a reputed University that medical students can undertake for accademic credit. They have no comparison to a Clinical Elective because its not USCE. So I cannot comment if its better or worse, but your application will cary more weightage if you have done a research elective in addition to some USCE, compared to someone who has only a research elective experience.

In my opinion, a Research elective experience, adds a very unique flavor to your residency application. 1) It helps proving that your an indivisual with a multitute and diversity of experiences and that you 'bring more to the table'. 2) It helps proving your dedication towards your specialty, especially if you had the opportunity to work in a clinical research setting. 3) It proves that you also have a research experience in addition to just USCE. 4) You have a big institute name in your resume. 5) if you were fortunate, a publication. 6) It can be a doorway to help you get an observership in future via the contacts you develope with people whome you help in their research.

Remember that Research alone cannot compensate for USCE deficit, unless it is done for an extended period and is rewardingly fruitful with publications and you are able to build strong contacts during the process.

Johns Hopkins University is very famous for offering research elective positions, but over time the application load is increasing with an inverse relation to availability of spots at a given moment. You might wanna take a look at their website incase you are interested or try your luck e-mailing individual attendings and calling labs separately.

Internship: In USA Internship is the first year of postgraduate training (PGY1) in the specialty of your choice. In other simpler words the 1st year of your residency training is an internship year and the person undertaking internship is an Intern. This definition is not strictly true, and not universaly applicable as in some countries e-g in India internship is completed before graduation and essentially constitutes as final year of undergraduate training.

Some specialties like Neurosurgery, Urology, Vascular surgery, opthalmology have an internship year where where residents rotate through 1st year of general surgery to learn and develope some basic surgical skills. After completing that first year of general surgery training, they then carry on with their respective specialty training. This type of an internship is also called Transitional year or Designated PGY1. Prelimnary PGY1in any specialty is also an example of internship. Quiet a few surgical programs require you to have atleast 1 year of USCE in shape of an internship or collectively othervise, before they will consider your residency application. Internships in USA are always paid.

For additional terms like Residency, Fellowship and ECFMG Certification visit the web page : Getting started