We are constantly working to improve this data based on updates that may occur and the responses received from each state. Do make sure to verify any relevant information with your school’s clinical coordinator before making any decisions!
When considering United States clinical experience (USCE), students may need to think about their long-term goals and plan to prevent foreseeable obstacles. In particular, there are a handful of states that medical students (especially international medical graduates) need to be aware of when completing clerkships or considering residency. We will discuss these, as well as the other states, below. Unlike most other healthcare students, medical learners often have the opportunity to leave their home institution for away rotations (elective rotations) in other states. This can pose some unique problems as each state has its own regulations and rules about non-resident student authorizations required to treat patients in their state. Whether for reasons of responsibility or a standardized level of patient care and education, rotation regulations are an obstacle that every traveling medical student must take into account. Although most states allow medical students to complete clinical rotations without any special requirements, there are some notable exceptions.
Should I Complete Clinical Rotations in the US?
United States Clinical Experience (USCE) is a mandatory aspect of any IMG’s (and FMG’s) medical education. Without experience within the medical and hospital system in which they wish to practice, it is extremely difficult to prove environmental and educational competence. Lack of sufficient clinical clerkships in the U.S. alerts Residency Directors to potential weaknesses to a medical learner’s education and abilities. Although the negative stigma associated with IMGs has significantly decreased over the years, some states still restrict, or ban, international medical students and graduates from completing clerkships in their state. This list is frequently changing depending on the local politics at the time. An IMS/IMG from a Caribbean medical school is likely aware of these concerns and their school has formed temporary hospital affiliations within the US to assure all USCE requirements are met. However, students from schools outside of the Caribbean may face more challenges and more limitations. Most University hospitals require VSAS to apply directly to them. However, if you find a physician to sponsor you they may apply to the Dean of the school or head of the hospital. We are constantly building our network of physicians willing to sponsor international medical students and graduates. VA will also not accept IMGs.
What States Can I Complete Clinical Rotations?
State authorization is the fancy lingo used to say, “Does the state allow out-of-state and international medical students to complete clinical clerkships locally?” And, unfortunately, it’s not a simple and clear-cut answer. Every state has its regulatory board and the laws are constantly changing. As of the time of writing this, here is what you need to know. Is your state a SARA member? The National Council for State Authorization Reciprocity Agreements (NC-SARA) organizes the SARA agreement between states. This allows educational institutions to accept students from a member state with the understanding that the level of education will be the same. You can view if your institution is a SARA member via their Directory. HOWEVER! This does not ensure you will be able to complete your clinical rotations without extra work. The State Higher Education Executive Officers Association (SHEEO) is another post-secondary education regulatory body that may play a part in out-of-state clinical clerkships. They aim to “promote equitable education for all Americans” within higher education. They also have two state authorization programs that can impact which states accept students and when. In addition, some states have a separate registration and authorization process through their state medical boards. A list of directors may be found at the Federation of State Medical Boards. As a general rule, if the degree being sought after is for professional licensure or certification (i.e.: MD/DO) then the agency that regulates the licensure has the final say in what is required. The most updated publicly available information regarding each state (that we could find) was from this AAMC document in 2016. It has a comprehensive, as of its date of publication, list of the requirements of each state for medical students during their U. S. clinical clerkships. Of course, most of these rules become even more complicated if you are a foreign or international medical graduate (FMG/IMG), so refer to the section below for more details.
How Many Clinical Rotations Are There?
The number of clinical clerkships required for graduation can vary depending on the accreditation board your school is associated with and the school itself. In the U.S., the Liaison Committee on Medical Education (LCME) accreditation standards give guidance to US MD schools while the Commission on Osteopathic College Accreditation (COCA) accreditation standards cover the DO curriculum. There are different accreditation agencies for the Caribbean and foreign medical schools. Unfortunately, there is no simple answer for students exploring clinical externships. Each school is given a certain amount of leeway in choosing which clinical clerkships they offer and the length required for each. The accreditation boards suggest a minimum number of clinical hours, but the schools and state medical boards have a final say in their specific requirements. When it comes to potential clinical sites, this is much more interesting. Medical students in their early academic journey may not realize how diverse the clinical settings may be. Your clinical rotations may be in many different demographics, locations, and facilities. It may be a heavily populated city or a rural area. Tapping into these resources allows students to study in a wider variety of clinical settings. There are approximately 5,100 community hospitals in the US, including academic and teaching hospitals accessible to the public. Private sector hospitals add nearly 1000 more to this count. Each hospital, depending on its size, could house dozens to hundreds of medical learners. Of course, only a relatively small percentage of hospitals host students to any significant number. There were also somewhere between 35,000 and 40,000 outpatient clinics as of 2016. Yet, each year there are hundreds to thousands of US-residency seeking medical students and graduates struggling to find clinical clerkships in their desired specialty or location. This is due to the current system’s inefficiencies and limitations placed on clinical experience options by scholastic and federal organizations. Even VSLO, one of the largest single repositories of clinical sites, only lists approximately 210 Host Institutions (those that accept students for rotations). It is impossible to know exactly how many of the 5,100 community hospitals and ~40,000 clinics accept students. There is no central database to collect this information and sites change from year to year. However, the current system could be vastly improved upon by crowdsourcing more clinical experience locations.
State with Clinical Rotation Restrictions and Limitations
We surveyed both the SARA and SHEEO directors and contacted most of the state medical boards to bring you the most updated information. We also noted that many independent institutions have separate requirements and prerequisites to complete a clerkship at that site. Based on those that responded, and a LOT of independent research, here’s the TL/DR. Most University hospitals require VSAS/VSLO to apply directly to them if you are an American medical student or graduate. Your school must be on the list of Home Institutions to apply for a ~210 Home Institution mentioned above. If your school is not listed here and you cannot use VSLO, refer to the next section for more options. However, many institutions allow physicians to sponsor students outside of the hospital or university purview. There are also a few locations that have statewide restrictions. These mostly apply to IMGs, but sometimes limit the number of out-of-state AMGs that may participate in clerkships at a given time. Though many state universities have a blanket policy disallowing IMGs to complete externships (officially) through them, this does not mean that the state regulations ban students from international medical schools. These regulations are also constantly changing so see the appropriate state website or ask your clinical department for more information. If you are an international medical student, make sure that your visa is current and an English competency test may be mandatory (even for US-IMGs). It is important to note that being able to complete rotations or observerships in a certain specialty may be satisfactory for your medical school curriculum, but not meet the requirements for residency in that state. For example, you may be able to complete non-ACGME clinical rotations in many states, but those state residency programs may require all credits to come from ACGME-accredited programs. Make sure you verify the residency and licensure requirements in those states you are considering applying for.
Arizona has year-round sunshine and breath-taking sites, such as the Grand Canyon, along with historic and fun places throughout the state. Information for international medical students that are looking for clinical rotations is not quite as easy to locate when searching for these opportunities. The Arizona statutes Article 9 15-1755 indicate that, “A public or private medical school in this state shall not prohibit a hospital from entering into an agreement to provide student clinical rotations to qualified osteopathic or allopathic medical students.” That likely sounds like good news for international medical students, but there are potential issues. The University of Arizona website indicates, “The University of Arizona College of Medicine – Tucson does not allow international students to enroll in our courses. However, if a student has an established relationship with one of our faculty members and that faculty wishes to directly supervise the student in an educational activity here, then the faculty member may apply to the Dean of the College of Medicine – Tucson for permission to sponsor the student.” The Observership and Shadowing Program has a similar statement. It indicates that an international student or physician is not eligible to participate in the program unless they are specifically invited by a faculty member. There are options for international medical graduates at the University of Arizona – Tuscon Department of Medicine. An international medical graduate applying for an internal medicine program residency position must meet the following requirements, in addition to requirements for all applicants:
- Applicant must have passed USMLE Step 1 and USMLE Step 2 (CK)
- Must have either taken and passed, or applied to take USMLE Step 2 (CS) by the time of application to the residency program
- USMLE Step 3 is not required for residency training
- USMLE Step 2 (CS) must be verified by the time of Match (mid-March of every year)
- If you have graduated by the time of the Match, ECFMG certification is required
Another option for international medical students is at the Mayo Clinic. Students that are interested in the Visiting Medical Student Clerkship Program can apply at the Phoenix/Scottsdale, Arizona location. International students must comply with all requirements, along with additional requirements for international students, which include:
- Showing demonstrated fluency in English if instruction at their home school is not in English
- Has completed approximately 48 weeks of actual patient care clinical experience before starting the clerkship, including a minimum of six weeks each of medicine, pediatrics, obstetrics and gynecology, and surgery, and approximately 20 weeks of electives
- Be enrolled in the final year of medical school at the time of clerkship
The school will likely help with visas for eligible international medical students and graduates.
CLERKSHIPS IN CALIFORNIA
For the third largest state in the U.S., it is no wonder that California offers a diverse population with diverse county laws. Luckily, the field of medicine is regulated by federal and state laws and not by county! However, that doesn’t make understanding the rules governing medical clerkships any easier in the Golden State. According to the Medical Board of California (MBC), schools recognized by the LCME, the World Federation for Medical Education (WFME), or the World Directory of Medical Schools (WDMS) are recognized in the state. This seems to suggest that the majority of medical schools that US-bound students attend should qualify for clinical experience. Here are some of the laws that may interest students and graduates from foreign medical schools. For international medical students, Title 16 of the California Code Regulations (16 CCR) § 1327 gives JCAHO accredited medical programs the ability to take IMSs with limitations. For example, the ratio of physician to student must be one-to-one and rotations are not to exceed 12 weeks. This greatly limits the number of students that will be able to rotate in the state as the funnel (1 physician per student, only JCAHO accredited programs) is relatively narrow. Externships completed outside of these requirements will seemingly not count for credit towards a degree. However, they can still satisfy many learner’s needs for extra clinical experience, increased Letters of Recommendation opportunities, or simply to rotate in a specialty that they were previously unable to attain. As of 2019, the Business And Professions Code (BPC) 2066.5 gives UCLA the ability to take IMGs who have passed USMLE Step 1, Step 2 CK, and CS. These rotations are not to exceed 24 weeks, but no more than 16 weeks is generally recommended. It is unclear what the changes in Step 2 CS will mean for this law. For international medical graduates, 16 CCR §1325 also gives guidance for “medical trainees” and requires school records, proof of board exams, and ACGME credentialing.
FLORIDA CLINICAL ROTATIONS
The Sunshine State not only has more golf courses than any other state in America, it is also the only state that touches both the Atlantic Ocean and the Gulf of Mexico! If you like sunny beaches and warm weather, and don’t mind mosquitoes, this state can provide you with a great environment in which to learn medicine. Florida used to limit out-of-state rotations to 2 externships per student. However, this has been revoked! The most recent statutes, according to our email correspondence with the FSMB, fall under 458 statutes & 64b8 4.004 for residency and fellowship requirements. You will need Florida ACGME accredited rotations if you plan to explore licensure in this state down the road. For clinical clerkships, core rotations are not permitted unless the medical school has been licensed through the Florida Commission for Independent Education. If your school is not licensed in the state, your Dean of Clinical Studies (or clinical department head) will need to contact the Accreditation Council of Florida Medical Schools by email, fax 850-245-3233, or letter, to request the proper forms at Accreditation Council of FL Medical Schools Office of Educational Affairs 1866 Southern Lane Decatur, Georgia 30033-4097 Your school can call 404-679-4500 for more information. Do be aware that students from foreign medical schools will be restricted by the “Rule of 3’s” for elective rotations. This means “no more than 3 students from any one unlicensed foreign medical school in any calendar year, with each of the 3 students doing no more than 3 elective clerkships in Florida in any calendar year” and it will take at least 3 weeks for their approval or rejection of your school’s application. The Commission will notify the clinical site of their decision and the site will then notify your school. If you are coming from a small international medical school or Caribbean medical school, make sure your school has followed these requirements. Otherwise, you may be placed in a rotation that will not count as accredited and could pose a problem during the residency match.
ILLINOIS MEDICAL CLERKSHIPS
The “Land of Lincoln” is home to historical landmarks, museums, and parks. It also provides international medical students with information and opportunities related to clinical rotations. The Cook County Health & Hospitals Systems (CCHHS), for example, provides a comprehensive “International Medical Student Application for Rotations in Trauma, Burn, or Anesthesia” packet. The packet walks students through the complete application process. The introduction provides details such as the fact that senior elective clerkships are available “to qualified students for an aggregate period not to exceed three months.” Students are potentially eligible if they are current students in good standing and will be in the last year of the formal medical school program by the beginning of the clerkship. Applicants must also have completed their required core clerkships. The University of Illinois School of Medicine recently altered their clinical rotation and clerkship program availability to all international and most domestic students. This is only a temporary change. Individuals should visit the site for updates. Similar situations occurred at some other schools, including the Loyola University Chicago Stritch School of Medicine. The school invites students to continue to apply. Many Illinois University hospitals require the application submission through VSAS including Northwestern University Feinberg, Rush University, and Southern Illinois University. However, there may still be international opportunities at select locations for qualifying applicants. The rotation process for international medical students starts with making the appropriate departmental contact. There, students learn about availability and other information. Students that have completed a clerkship in five core categories may advance in the process. The Illinois State Medical Society provides a starting point for international medical graduate physicians who hope to complete their residency training within the U.S. The site also provides an International Medical Graduate Mentor Center.
CLINICAL ROTATIONS IN NEVADA
Sin City (Las Vegas) and The Biggest Little City in the World (Reno) are the only two cities large enough in Nevada to host most clinical experiences. However, rural NV also serves over 3M residents! Helping those that are underserved can be a great learning experience while also giving a learner insight into the National Health Service Corps (NHSC) Rural Community Loan Repayment Program (LRP) is right for you. There has been coverage in local news in the past stating that foreign medical students cannot rotate in the state of NV. So much so that even local providers may quote this “fact.” This is partially true, but incomplete. According to the Nevada Revised Statutes (NRS) 449.1815 students may not participate in clerkships or observerships for credit towards a medical degree unless from an LCME or Bureau of Professional Education of the American Osteopathic Association accredited school (NRS 663.121). This does not appear to prevent IMGs from completing non-credit clinical experiences in the state. As always, we are not legal experts so make sure to verify this with your Dean of Students or equivalent. If this changes, we will be sure to update this section!
NEW JERSEY EXTERNSHIPS
Many states have a “state animal” or a state nickname, but the Garden State one of only six with a state microbe! Streptomyces griseus was discovered in New Jersey in 1916, and in 2017 a bill was introduced to honor Streptomyces for its anti-tuberculosis properties. Unfortunately, state regulations for medical students are less entertaining. Codes 13:35-1.1 (Observership Program) and 13:35-1.2 (Fifth Pathway) of the New Jersey Administrative Code Title 13 appear to allow non-hands-on (observership) experiences for any student from a school listed in the World Health Organization Medical Schol Directory or the International Medical Education Directory. The one speculation is that the New Jersey Board of Medical Examiners must also state that graduates from this school are eligible to sit for the state licensure examination. At this point, the Board of Medical Examiners (BME) does not appear to have a list of accepted or rejected medical schools. Email and phone correspondence thus far have not shed any light on this subject. We will update this section as more information becomes available.
USCE – NEW YORK
There are more than 800 languages spoken in the Big Apple making it a great designation for those multilingual medical students out there. Unfortunately, for any learners outside of the state, domestic or international, there may be some important limitations to consider before completing medical rotations here. The state of New York has a lot of confusing legal speak regarding clinical clerkships for medical students and international medical graduates. The specifics can be found in the New York State Office of the Professions §60.2 Clinical clerkships. In short, if your medical school is in NY, you are a medical graduate, or you are participating in observerships (and possibly some electives) within the state these rules should not apply to you. We are not legal experts so do check with your clinical director prior to scheduling clerkships in this state. If you are a student with residence in another state or from a foreign medical school (that is not an approved international medical school below), you may:
- Only complete up to 12 weeks of rotations in an ACGME certified teaching hospital.
- Must secure a Letter of Eligibility (LE) for EACH rotation in many clinical sites.
- The teaching hospital must have a residency program SPECIFICALLY for the clerkship you are applying for. For example, if they have a residency program for pediatrics only and you wish to complete a neurology rotation, this would not count as a verified rotation.
If you complete more than 12 weeks of clerkships (observerships and some electives may not count), then you will not be eligible for residency within the state. Some students are accepted into a residency program without knowing this quirky law. The program is then legally required to apply for an NRMP Waiver to withdraw the residency contract leaving the student stranded. Graduates may need to complete a Form 2CC “Certification of Approved Clinical Clerkships” as well before starting their rotations. Students from exempt schools do not need to fill out Form 2CC. These schools are (as of March, 2021):
- American University of Antigua, Antigua
- American University of the Caribbean, Cupecoy, St. Martin
- The Autonomous University of Guadalajara, Guadalajara, Mexico
- English Language Program, University of Debrecen, Medical and Health Science Center, Medical School, Debrecen, Hungary
- English Language Program, Medical University of Lublin, Lublin, Poland
- English Language Program, Medical University of Silesia, Katowice, Poland
- Fatima College of Medicine, Manila, Philippines
- International Health and Medicine Program, Ben Gurion University of the Negrev, Beer-Sheva, Israel
- Kasturba Medical College, Manipal, India
- Medical University of the Americas/Nevis, Nevis, West Indies
- Ross University School of Medicine, Bridgetown, Barbados
- Saba University School of Medicine, The Bottom, Saba
- St. George’s University School of Medicine, St. George’s, Grenada
- St. Matthew’s University School of Medicine, Grand Cayman, Cayman Islands
- Technion Israel Institute of Technology – Technion American Medical Students Program (TEAMS), Haifa, Israel
- The University of Queensland, Brisbane, Australia
- Xavier University School of Medicine, Oranjestad, Aruba
We will continue to receive clarification from the state board and if any new information is brought to light we will update this section!
ROTATIONS IN PENNSYLVANIA
The American Medical Association explains that all state licensing jurisdictions require a graduate of an international medical school to complete a minimum of one year of accredited U.S. or Canadian graduate medical education before receiving licensure. Some states require that international medical graduates complete three years of graduate medical education before licensure. Pennsylvania is one of those states. Chapter 17 of the Pennsylvania Code governs the licensure of medical doctors and graduate medical trainees. Section § 17.22. Graduate medical trainee registration, states, “Short-term trainees and physicians from out-of-state or out-of-country institutions doing rotations through training facilities in this Commonwealth shall submit an application for a graduate license.” The statute states that the training institution accepts full responsibility for the trainees. There do not appear to be state-wide restrictions on international medical students. The individual schools seem to have greater detail than some statues. The Perelman School of Medicine at the University of Pennsylvania provides services for students interested in the international medical student: clinical elective rotation application, or for international trainees and scholars placement. The Center for Global Health helps to facilitate research and clinical experiences at the University of Pennsylvania Perelman School of Medicine. Assistance is limited to students from international medical schools that have affiliation agreements with the school. The Einstein Healthcare Network features a Physician Observership Program. It is hosted by the Philadelphia location. International graduates are welcome to the program. However, UPCM and many other institutions require the student to attend an LCME or AOA-accredited program, preventing most international students. International medical students and international medical graduates need to check with each medical school in the state to learn the specific policies regarding application requirements and how international students and graduates may be affected by certain programs and opportunities. There do not appear to be any state restrictions disallowing faculty to directly supervise (sponser) a medical learner.
The Lone Star State has a saddled past when it comes to foreign medical students participating in local clerkships. In 2013, foreign medical learners were barred from participating in clinical rotations in TX due to concerns raised about local medical students lacking sufficient clinical sites. Although statutes covering medical education in Texas (Chapter 58A and Chapter 74 of the Education Code) do not expressly restrict foreign and international students from participating in clerkships, it can be difficult to secure a rotation in the state. UT Southwestern is one possibility that students may investigate, while the Long School of Medicine and McGovern Medical School are currently not accepting international students. Our research suggests that most of the large medical centers are limited to Texas affiliated medical schools. However, you may still be able to be sponsored by a physician to gain externship experience.
WYOMING CLINICAL SITES
Wyoming is known for its awe-inspiring scenery and landmarks. International medical students and international medical graduates that are interested in clinical rotations or other related opportunities need to know the definition given by Chapter 33 of the Wyoming Statutes. Section 33-26-702 (a)(xi) defines a physician as “a graduate of a medical school accredited by the liaison committee on medical education, the commission on osteopathic college accreditation or a medical school listed in the international medical education directory or its equivalent.” The University of Wyoming is a part of WWAMI, which is affiliated with the University of Washington (UW) School of Medicine in Seattle, Washington. WWAMI is an acronym for the five states affiliated with the program, which are Wyoming, Washington, Alaska, Montana, and Idaho. International medical students are required to use VSAS for their applications to UW and can find out more information at their International Visiting Medical Students for non-US and non-Canadian students programs page. It is unclear if there are boundaries for visiting students who set up clinical rotations outside of the WWAMI program. International medical graduates must hold a valid ECFMG Certification before the start of a residency program at the University of Wyoming, and when applying for a fellowship.