USCE: all you need to know about US Clinical Experience as an IMG

US Clinical Experiences (USCE) refers to the clinical experiences American Medical Graduates (AMGs) and International Medical Graduates (IMGs) have acquired in the US healthcare system. 

Whereas AMGs gain USCEs throughout their medical school curriculum, for IMGs to acquire medical experiences in the US, it can be trickier. 

Most US residency programs demand their applicants to have USCEs in order to be considered, as it reassures the programs that you’ve been exposed to and can navigate the US healthcare system.

However, before looking for a USCE opportunity, it’s crucial to first understand the difference between the types of USCEs that exist, their pros and cons, and, ultimately, choose the one that best suits you. 

In fact, there are differences between USCEs; the type of exposure and experience you’ll get from them and, therefore, their impact on your resume. 


Let’s dive in! 

What are the different types of USCEs?

Again, not all USCEs are equal regarding experience and value on your resume. 

For the sake of simplicity, I’ll classify the types of USCEs based on the following: 

  • The interaction you’ll have with patients. 
  • The location of the USCE. 

Classification based on interaction with patients


First, hands-on experiences are considered the strongest type of USCE, as you can directly interact with patients. 

In other words, you’ll have the opportunity – under the supervision of a senior doctor – to do the following: 

  • Collect medical history. 
  • Do a review of the system.
  • Examine the patient.
  • Enter the medical information on the EMS ( Electronic Medical System). 

And so on. 

Many types of USCEs fall into this category, including: 


A clinical elective is an “extra” away rotation that a finished medical student may take to get clinical skills outside the hospital of their parent institute.  

Because it’s optional, doing an elective in a given specialty demonstrates a particular interest. It could boost your chances to match into that specialty, especially if you get an LoR (letter of recommendation) from that experience.

To find an elective, you can visit the website of the institutions you’re interested in and look for their requirements (CV, LoRs, proof of English Proficiency, etc.)

The requirements vary. However, to do an elective, you’ll usually have to: 

  1. Be a medical student enrolled in the final year. 
  2. Apply through the VSLO portal.  

Only some institutions accept candidates outside the VSLO portal.

For more information about the VSLO portal, you can visit their website.

If you are a medical student whose medical school is part of the VSLO portal, I recommend you apply for this type of opportunity. 

However, if you’re still a medical student but your medical school isn’t part of the VSLO portal, don’t panic. Ask your medical school about an exchange program they might have with a medical school located in the US.

Unfortunately, if you’ve already graduated or your medical school isn’t part of the VSLO portal nor do they have an exchange program with a US medical school, there may be better options for you.  


A clerkship is a required clinical rotation for medical students done in their home institution to graduate. 

Many IMGs from Caribbean medical schools do part of their clerkship in US hospitals which later count as USCEs. 

Except for IMGs from Caribbean medical schools, this option isn’t common among other IMGs unless their medical schools allow students to do one or more clerkships abroad in the context of an exchange program or partnership. 


Unlike electives and clerkships, externships are an option for medical students and graduates. 

Although they’re hands-on, externships are considered weaker experiences than electives and clerkships for two reasons: 

  • Most institutes and hospitals don’t offer externships, so you’ll most likely rotate at a clinic. 
  • There is no guarantee that the externship will be supervised. 

Nonetheless, externships are still considered suitable options for IMGs seeking USCEs. 

Many agencies offer externships under the label of “hands-on experience,” but again, most of the time, this will be in a clinic, not a hospital.   

Some hospitals offer externships, but: 

  1. They’re rare.
  2. They tend to exploit IMGs to fill their gaps. 

Let’s get straight to the point. 

Sub-internships are the ultimate USCE for IMGs. Period.  

Because sub-internships are the same as electives, plus offering a higher level of responsibilities, the letters of recommendation you acquire from this type of experience are considered more robust. 

Moreover, as you’ll work closely with residents and attendings, you’ll have the opportunity to establish strong connections with people who can advocate for you during the residency match application. 

You can apply for a sub-internship as a final-year medical student or a graduate. 

Unfortunately, only a few hospitals offer sub-internships, and the pool of applicants exceeds the number of slots. 

Not hands-on


Observerships are usually considered last-resort options or a “better-than-no-USCE-option.” 

This is because, as the name implies, you’ll only be allowed to “observe” or “shadow” a doctor; thus, you won’t interact with or examine patients. 

However, I like to see observerships as opportunities that can open new doors. 

In fact, although they’re considered weak USCEs, observerships are a great chance to establish connections if you know how to take advantage of the experience. 

Connections play a significant role in the residency match journey and can ultimately make a difference in the process of matching with your dream specialty.

Medical students and graduates can apply for an observership, and, depending on the institution you apply to, the requirements are generally less tough than other USCEs. 

Virtual USCE

Virtual USCEs or Telerotations are online US clinical experiences. 

They became popular during the Covid-19 pandemic and were offered to IMGs through agencies and universities.

To be honest, there has yet to be a consensus about the value of a virtual USCE.  

Some consider them equivalent to observerships, while others consider them even less valuable than observerships. 

In my opinion, virtual USCEs are, give or take, the same as observerships, although you won’t have the opportunity to network and establish connections like with observerships. 

Virtual USCEs can be considered if there are Visa issues or one cannot afford to travel and stay in the US. 

Otherwise, other types of USCEs are preferred. 

Research Elective

Research electives aren’t considered USCEs. 

So why do I talk about them in this article?

Well, for some programs, observerships aren’t considered true USCEs, either. 

However, as with observerships, research electives are an excellent opportunity to fill out the blank in your resume, build connections, and create new opportunities that can ultimately get you a match. 

Classification based on the location

Another way to consider USCEs is based on their location. 

In fact, USCEs can take place in an outpatient or inpatient setting, and the distinction is important as the two won’t have the same value in your residency application. 


Inpatient rotations refer to clinical experiences that take place in a hospital setting. 

Inpatient rotations are generally considered stronger than outpatient rotations. 

However, depending on the type of exposure (hands-on VS not hands-on), it might be better to do an externship in an outpatient setting than an observership in an inpatient setting. 


Outpatient rotations refer to clinical experiences that take place in a clinic. 

Although outpatient rotations are considered weaker than inpatient rotations, they’re the most common type of USCEs for IMGs.

To identify the clinical rotation opportunity that would best fit with your profile, be sure to check out my comprehensive guide, which includes a list of available clinical rotations for international medical graduates in the US

What sort of USCE to do

Finding a USCE can be a real headache for IMGs, mainly because there are so many types and yet, only a few opportunities for IMGs.

This is why it’s important to consider specific parameters before looking for USCEs to narrow down the possibilities and focus your research. 

These parameters are the following: 

The type of USCE

Depending on the exposure and location, a particular “hierarchy” exists between the different types of USCEs that you should keep in mind. 

From the “strongest” to the “weakest” you have: 

Hands-on inpatient > Hands-on outpatient > Observership inpatient > Observership outpatient > Virtual USCE. 

Your status (Medical student VS graduate)

Unfortunately, there are fewer opportunities for graduates than for students. 

For example, you won’t be able to apply for electives or clerkships when you graduate.   

The best option will be for you to start looking for opportunities while still in medical school once you’ve decided to pursue a residency in the US.

The specialty you’re applying to

This might sound obvious, but you’d be surprised by how many candidates apply to psychiatry with zero USCE in psychiatry, for example. 

Don’t do a USCE just for the sake of doing a USCE if it’s not coherent with your overall application. 

Doing a USCE in the specialty, you’re applying to will not only strengthen your application but also allow you to get the appropriate LoRs, which is crucial. 

Depending on the specialty you’re applying to, take the time to select the appropriate location, as you might not fully benefit from an outpatient experience if you’re applying to a surgical specialty. 

Your finances

Fact: USCEs are very, very expensive. 

Institutions’ fees can reach thousands of dollars for a 4-week elective.

Agencies will also charge you a lot for hands-on, and if you don’t live in the US, you’ll have to factor in the price of travel and your daily expenses. 

Depending on your budget, the options might vary a lot. 

Luckily, we’ve got some tips on getting USCEs while on a tight budget:: 

  • Email doctors in the US for an observership, as you may find free opportunities.
  • Maximize your investment by doing multiple USCEs during one trip. 
  • Opt for a virtual USCE.

Why USCEs are essential

Regardless of the type, keep in mind that a USCE is a unique opportunity for doctors and medical students worldwide seeking residency in the US to experience what it’s like to evolve in a US healthcare environment and learn how to: 

  • Interact with patients. 
  • Integrate medical records on the Electronic Medical Record system. 
  • Collaborate with other staff members( nurses, colleagues, etc.) 

They also present opportunities to: 

  • Get strong letters of recommendation. 
  • Make connections and network.

More importantly… 

If a residency application were a house, USCEs would be its foundation because they’re an excellent chance to assess whether or not you want to pursue this direction and what your reasons are. 

Try to think about it this way: how can you justify during an interview or even in your Personal Statement, your choice to pursue a residency in the US if you have zero experience in the US healthcare system?  


USCEs are a unique opportunity for IMGs to familiarize themselves with the US healthcare system, strengthen their application and get letters of recommendation that will make them match with their dream specialty.

As there are different types of USCEs, it’s essential to understand what opportunities exist for IMGS and choose wisely the one that best suits your profile. 

Although hands-on experiences are considered the strongest type of USCE, observership and other kinds of USCEs should be considered. They can be unique opportunities to access the US healthcare system and make connections that might help you match your dream program. 

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