Mastering Clerkships: Essential Tips for International Medical Graduates

Introduction: Why Clerkships Matter So Much for IMGs

For International Medical Graduates (IMGs), few steps in the journey toward U.S. residency are as pivotal as clerkships. These U.S. clinical experiences are often your first sustained exposure to the culture, pace, and expectations of American medical training. They shape how programs perceive you, influence the strength of your letters of recommendation, and directly impact your competitiveness in residency applications.

Clerkships allow you to:

• Translate textbook knowledge into real patient care
• Demonstrate that you can thrive in the U.S. healthcare system
• Build a professional network that can advocate for you in the Match

This guide goes beyond the basics to share practical, insider strategies to help IMGs not only survive but excel in their clerkships—and use them strategically to strengthen residency applications.

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Understanding Clerkships in the U.S. System

What Are Clerkships and Where Do They Fit in Medical Training?

Clerkships (often called clinical rotations or core rotations) are structured, supervised learning experiences in clinical settings. In U.S. medical schools, they typically start in the third year and run through fourth year, but IMGs may undertake equivalent experiences at different stages depending on their home curriculum.

Common core clerkships include:

• Internal Medicine
• Surgery (often general surgery)
• Pediatrics
• Psychiatry
• Obstetrics and Gynecology
• Family Medicine
• Emergency Medicine (often as a sub-internship or elective)

Each rotation usually lasts 4–12 weeks and takes place in:

• Teaching hospitals (university or community-based)
• Outpatient clinics
• Ambulatory care centers
• Occasionally subspecialty clinics within larger departments

For IMGs, clerkships can be:

• Core rotations completed as part of your original medical school training, sometimes done in the U.S.
• Elective rotations in specific specialties of interest
• Sub-internships (“sub-Is”) or audition rotations, which are especially important in competitive specialties or at target residency programs

Why Clerkships Are Especially Critical for IMGs

While clerkships are important for all medical students, they carry extra weight for IMGs because they:

1. Demonstrate your ability to function in U.S. clinical settings

   • Show familiarity with U.S. documentation, EMRs, and clinical guidelines
   • Prove that you can work effectively within U.S.-style multidisciplinary teams

2. Act as a live audition for residency programs

   • Attending physicians and residents often influence interview offers
   • Strong performance can lead to high-impact U.S. letters of recommendation

3. Provide crucial Networking opportunities

   • Exposure to faculty who sit on residency selection committees
   • Connection to residents who can share insider advice and advocate for you

4. Enhance your overall residency application profile

   • Documented U.S. clinical experience is valued by program directors
   • Clerkship evaluations and narrative comments can support your ERAS application and MSPE (if applicable)

5. Help you understand the unspoken rules of U.S. medical culture

   • How teams communicate and defer to hierarchy
   • Expectations for professionalism, presentation style, and patient interaction

When viewed this way, clerkships become more than “required training”—they are one of the most powerful levers IMGs have to influence residency outcomes.

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Preparing Strategically Before Your Clerkship Starts

Clarify Expectations Early and Specifically

IMGs sometimes underestimate how variable expectations can be between hospitals and even between services in the same hospital. Before Day 1, actively seek clarity on:

• Schedule and workflow

  • Typical start and end times
  • Pre-rounding expectations (which patients? how many?)
  • Call or weekend responsibilities

• Clinical responsibilities

  • How many patients are you expected to follow?
  • Are you writing notes independently, co-signing, or just drafting?
  • What is your role on rounds (presentations, orders, follow-up)?

• Educational expectations

  • Required readings or cases
  • Mandatory lectures, conferences, or online modules
  • Procedures you can or cannot participate in

• Evaluation system

  • Who is your primary evaluator—attending, resident, or both?
  • What domains will they score (knowledge, initiative, communication, professionalism, etc.)?
  • Are there mid-rotation feedback sessions?

A simple email or brief conversation with the clerkship coordinator, chief resident, or a previous student can dramatically reduce confusion and help you show up prepared.

Do Targeted Academic and Practical Preparation

Beyond reviewing core content, tailor your preparation to the rotation and U.S. context:

• Review U.S.-based guidelines and references

  • For Internal Medicine: ACC/AHA, IDSA guidelines, UpToDate summaries
  • For OB/GYN: ACOG practice bulletins
  • For Pediatrics: AAP recommendations
  • For Psychiatry: APA guidelines

• Practice oral case presentations

  • Aim for structured, concise, and problem-focused presentations
  • Use frameworks like SOAP (Subjective, Objective, Assessment, Plan) or one-liner + systematic problem list

• Familiarize yourself with common phrases

  • “Overnight events,” “interval history,” “dispo planning”
  • “Sign-out,” “check-out,” “touch base,” “circle back,” etc.

• Anticipate documentation norms

  • Understand that note templates and EMR use differ widely
  • Ask for sample notes from residents or prior students

Arriving with a basic understanding of U.S. practice patterns makes you more efficient from the first week and signals that you are serious about integrating into the system.

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Daily Success Strategies During Clerkships

Be Proactive and Visible (In a Professional Way)

The most successful IMGs in clerkships consistently demonstrate initiative without overstepping. Some practical examples:

• Volunteer thoughtfully

  • Offer to admit the next patient, start the note, or pre-round on an additional case
  • Ask, “Would it be helpful if I [call the lab / talk to the nurse / follow up the imaging]?”

• Seek out learning opportunities

  • Ask to join procedures: central lines, LPs, deliveries, OR cases
  • Request to attend family meetings or care conferences when appropriate

• Follow through on every task

  • If you say you’ll check a lab or imaging, document it and report back
  • Use a small notebook or digital task list to avoid dropping anything

Your goal is to become someone the team can rely on—this is one of the biggest drivers of strong evaluations.

Communicate Clearly, Confidently, and Respectfully

For IMGs, communication can be one of the most challenging—and most crucial—skills in clerkships.

Practical strategies:

• Standardize your presentations

  • Open with a sharp one-liner: “Mr. X is a 68-year-old man with a history of CAD and diabetes, here with acute shortness of breath, being treated for decompensated heart failure.”
  • Use problem-based assessments: “Problem 1: Acute CHF exacerbation—today he is…”

• Adapt to team culture

  • Observe how seniors present, ask questions, and disagree respectfully
  • Mirror professional phrases: “I’m wondering if we should consider…”, “What do you think about…?”

• Address language and accent concerns proactively

  • Ask for honest feedback: “If my accent or phrasing ever makes something unclear, please let me know—I really want to communicate effectively.”
  • Slow down slightly during presentations and summarize key points

• Communicate with patients at their level

  • Avoid jargon: say “high blood pressure” before “hypertension”
  • Use teach-back: “Just to make sure I explained that clearly, can you tell me in your own words what the plan is?”

Strong communication is not just about English fluency—it is about structure, clarity, and professionalism.

Build High-Impact Relationships and Networking

Networking during clerkships is not about handing out business cards; it is about building genuine, professional relationships that can support your future.

With attendings:

• Introduce yourself early: where you are from, career interests, and that you are an IMG seeking U.S. residency
• Show longitudinal interest: follow their patients, ask follow-up questions, read about topics they mention
• Toward the end of the rotation, if appropriate, say:
  • “I’ve really valued working with you. I’m planning to apply for residency in [specialty]; would you feel comfortable writing a strong letter of recommendation for me?”

With residents and fellows:

• Ask for practical residency advice:
  • “How did you decide where to apply?”
  • “What do program directors here value in applications?”
• Seek feedback near mid-rotation:
  • “Are there 1–2 things I can focus on to be more helpful to the team and strengthen my evaluation?”
• Maintain contact:
  • Connect via professional email or LinkedIn
  • Let them know when you apply to their program

These relationships can translate into mentorship, advocacy, and even interview invitations.

Master Time Management and Prioritization

Clerkships often mean early mornings, long days, and limited study time. Effective time management keeps you from burning out and maintains performance.

On the wards:

• Create a patient list with action items
  • For each patient: brief one-liner + today’s tasks (labs to follow, imaging pending, consults, discharge planning)
• Triage tasks
  • Urgent patient care > documentation > reading
  • Do “quick wins” (calls, lab checks) between bigger tasks

Outside the hospital:

• Use short, focused study blocks (20–40 minutes) rather than long marathons
• Align your reading with your patients’ problems
  • If you have a patient with DKA, read one high-yield summary that night
• Protect basic self-care
  • Aim for consistent sleep window as much as your schedule allows
  • Keep quick, healthy snacks available to avoid relying purely on vending machines or fast food

Residency applications often ask for comments on your reliability, work ethic, and resilience—strong time management during clerkships directly supports this.

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Navigating System, Culture, and Practice Differences as an IMG

Understanding U.S. Clinical Practice Patterns

Even if you have extensive clinical experience abroad, the U.S. environment may feel very different.

Key differences to pay attention to:

• Guideline-driven care
  • More emphasis on following standardized pathways and evidence-based guidelines
• Documentation and medicolegal culture
  • More detailed documentation, clear rationales for decisions, explicit risk–benefit discussions
• Team-based care
  • Involvement of nurses, pharmacists, case managers, physical therapists, and social workers in daily planning

Actively ask questions like:

• “Is there a protocol we follow for [chest pain, stroke, sepsis] here?”
• “How does discharge planning usually work for patients like this?”

Demonstrating curiosity and adaptability reassures teams that you can integrate into residency-level expectations.

Cultural Competence and Bedside Manner

Being culturally sensitive is not just about understanding American culture; it is about recognizing the diversity of U.S. patients.

Practical steps:

• Learn common cultural considerations in your region (e.g., religious needs, language barriers, family dynamics)
• Use interpreter services correctly and early if language is a barrier
• Be nonjudgmental about lifestyle differences; avoid assumptions or moralizing

You can also highlight your own cultural competence as a strength:

• If you share a language or background with a patient, offer to help communicate—with permission and within policy
• When appropriate, say, “In my home country, we sometimes see this handled differently; may I share that perspective?”—then relate it back to U.S. practice

Leveraging Your International Background as an Asset

Your background is not a liability—it is a differentiator.

You may bring:

• Experience with different disease patterns (e.g., TB, rheumatic heart disease)
• Multilingual skills that improve patient rapport
• Resilience from navigating new systems and limited resources

Make this explicit in residency applications and, when relevant, during clerkships:

• “Where I trained, we used [X approach]—seeing how it’s done here helps me appreciate both systems and refine my practice.”

Programs often value this perspective, especially in diverse or underserved communities.

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Professionalism, Feedback, and Evaluations

Non-Negotiable Professionalism Standards

In residency applications, “professionalism concerns” are very difficult to overcome. Clerkships are where your professional reputation begins.

Essential professional behaviors:

• Punctuality and reliability

  • Arrive early, not just “on time”
  • If an emergency delays you, notify your team as soon as possible

• Appearance and demeanor

  • Follow dress code (white coat, ID badge, clean and appropriate attire)
  • Maintain calm, respectful behavior—even when stressed

• Ethics and confidentiality

  • Always de-identify cases when discussing outside patient care or teaching
  • Never share patient information on social media—even if “anonymous”

• Boundaries

  • Maintain clear professional boundaries with patients and staff
  • Avoid gossip and negative talk about other team members

Your conduct during clerkships can directly influence whether attendings feel comfortable writing a “strong” letter for you.

Seeking, Receiving, and Using Feedback Effectively

Many IMGs come from systems where feedback is rare or mostly negative. In U.S. training, active feedback-seeking is viewed very positively.

How to ask for feedback:

• Mid-rotation:
  • “We’re about halfway through—could you share one thing I’m doing well and one thing I should focus on improving?”
• End of rotation (to align with written evaluations):
  • “Is there anything specific you’d like me to emphasize or work on going forward?”

How to respond to feedback:

• Listen fully without interrupting
• Avoid defensiveness—even if you disagree
• Summarize: “So if I understand correctly, I should work on making my presentations more concise and prioritizing the major problems?”
• Show change: apply the feedback, and if appropriate, mention:
  • “I’ve been trying to focus on [X] as you suggested—does this seem better?”

Programs love to see evidence that you are “coachable” and committed to continual improvement.

Understanding and Optimizing Clerkship Evaluations

Clerkship evaluations vary by institution, but most assess:

• Clinical knowledge and reasoning
• History-taking and examination skills
• Communication with patients and team
• Initiative and dependability
• Professionalism

To optimize your evaluations:

• Identify who will actually complete them (often attending + resident input)
• Ensure they see your work:
  • Present on rounds when they are present
  • Volunteer to admit or follow new patients
• Ask near the end:
  • “Is there any additional responsibility I could take on in this last week to demonstrate my growth?”

Remember: strong, detailed clerkship evaluations often translate into powerful narrative comments and letters for residency applications.

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Turning Clerkships into Residency Application Strengths

Documenting Your Experiences Strategically

As you progress through clerkships, keep a running log of:

• Memorable patient cases (de-identified)
• Procedures you observed or assisted with
• Teaching sessions you led or topics you presented
• Instances where you showed leadership, problem-solving, or advocacy

These notes will be invaluable when:

• Writing your ERAS experiences section
• Preparing for residency interviews
• Drafting personal statements that include specific clinical examples

Securing Strong Letters of Recommendation (LoRs)

For IMGs, U.S.-based letters of recommendation can carry significant weight.

To maximize your chances:

1. Perform consistently well for at least 3–4 weeks with a potential letter writer
2. Ask clearly for a “strong” letter
   • “Would you feel comfortable writing a strong letter of recommendation in support of my application to internal medicine residency?”
3. Provide supporting materials
   • Updated CV
   • Brief summary of your career goals and why you’re interested in their specialty
   • Your ERAS personal statement draft, if available

Aim for letters from U.S. attendings in the specialty you’re applying to, ideally from academic centers or programs with residency training.

Aligning Clerkship Choices with Residency Goals

Whenever possible, choose clerkships strategically:

• If you’re applying to Internal Medicine:

  • Aim for an Internal Medicine sub-internship at a program you’d like to match into
  • Consider additional electives in subspecialties (cardiology, GI, ID)

• If you’re applying to Surgery:

  • Try to schedule a sub-I or audition rotation at your top program choices
  • Seek opportunities to scrub in regularly and be active in the OR

• If you’re undecided:

  • Use clerkships to explore different specialties consciously
  • Note what environments energize or drain you (wards vs. clinics vs. OR)

Clerkships can both clarify your career direction and signal focused interest to residency programs.

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FAQs: Clerkships for International Medical Graduates

1. Why are U.S. clerkships so important specifically for International Medical Graduates?

U.S. clerkships show residency programs that you can function effectively within the American healthcare system. They:

• Provide direct evidence of your clinical skills, communication, and professionalism
• Generate U.S.-based letters of recommendation, which are highly valued
• Help programs feel confident that you will adapt smoothly to residency training
• Allow you to build a local network of mentors and advocates

For many IMGs, strong performance in clerkships helps overcome concerns about unfamiliar medical schools or different training systems.

2. How can IMGs make the most of Networking opportunities during clerkships?

Focus on building professional, genuine relationships rather than “collecting contacts.” Some strategies:

• Introduce yourself to attendings and residents early and share your career interests
• Ask thoughtful questions during rounds and teaching sessions
• Request feedback and show that you apply it
• Stay in touch via professional email or LinkedIn after the rotation
• When the time is right, ask for mentorship or residency guidance

Networking during clerkships can lead to mentorship, research opportunities, and residency interview support.

3. What should IMGs focus on most before starting a U.S. clerkship?

Prior to starting:

• Clarify expectations (schedule, responsibilities, evaluation tools)
• Review high-yield, guideline-based content relevant to the specialty
• Practice concise oral case presentations in English
• Familiarize yourself with U.S. medical terminology and common abbreviations
• Learn about the hospital’s documentation system if possible (e.g., Epic, Cerner)

Even a few focused hours of preparation can dramatically improve your confidence on Day 1.

4. How should IMGs handle mid-rotation and final evaluations?

Treat evaluations as both a learning tool and an opportunity to advocate for yourself:

• Ask for mid-rotation feedback and adjust your approach accordingly
• Near the end, briefly remind your evaluator of specific contributions you made (e.g., presentations, extra responsibilities you took on)
• If written evaluations are accessible to you, review them to identify patterns for improvement
• Use feedback to target specific behaviors in subsequent rotations

Program directors often read your evaluations closely, so consistent improvement across clerkships is very powerful.

5. What if I struggle with communication or cultural differences during clerkships?

This is common for IMGs, and programs understand that adaptation takes time. To manage it:

• Be honest with yourself about areas of difficulty—speed, accent, idioms, or jargon
• Ask for specific feedback from trusted residents or attendings
• Observe how others communicate with patients and team members, and adopt effective phrases and approaches
• Use hospital interpreter services appropriately rather than relying solely on your own language skills
• Remember that willingness to improve and adapt is often valued more than perfection

Over time, most IMGs find that their communication and cultural comfort improve significantly through intentional practice.

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By approaching clerkships with clear goals, strong work habits, and openness to feedback, International Medical Graduates can transform these rotations into powerful assets for residency applications. Your U.S. clinical experience is not just a requirement—it is your stage to demonstrate that you are ready to join and contribute to the next generation of U.S. physicians.