Observerships, Externships and Clerkships: Sorting through the confusion

The terms observership, externship and clerkship are sometimes used interchangeably in medical education which can cause some confusion for residency applicants. Applicants are often unsure of which experience to pursue and how residency program directors view each experience when examining a candidate’s clinical background. We will attempt to clarify the differences and provide guidance on the merits of each.

What is the difference between an observership, externship and clerkship?

Understanding this question involves first understanding the structure of medical education in the U.S.

Medical Students in the United States typically complete two years of basic science education before proceeding to another two years of clinical education commonly referred to as clerkships or “rotations”. Hence the term clerkship is most often used to refer to clinical experiences provided by the school as part of the curriculum required to graduate medical school.

Externships therefore, can be understood in this context. These refer to clinical experiences not directly provided by the applicant’s medical school. For example candidates looking to apply in competitive specialties typically do rotations at other institutions to attempt to get letters of recommendation from influential people in the specialty or try to impress people in a department in which they will apply. These are commonly known as “audition rotations” or externships. Note that while this term is used for applicants who have not yet graduated from medical school it is also used to refer to clinical rotations done by applicants who have already graduated medical school but are using this experience to further strengthen their resume.

The above two terms both refer to experiences that refer to direct patient care including history taking, physical examination and sometimes entering orders or prescribing medications under the supervision of a resident or attending physician. This distinction matters when it comes to the final term

So what is an observership?

An observership refers to a clinical experience that does not involve direct patient care. While this experience can be pursued by students at varying levels of education it is typically done by medical students and post graduates looking to gain experience and familiarity with a particular specialty, obtain letters of recommendation for applications and improve their clinical skills and cultural competency. The restrictions on patient care are typically for malpractice insurance issues as the typical applicant has not yet been cleared to practice supervised medicine in the U.S. Despite these restrictions these experiences are valuable for the reasons listed above.

So how do you choose between an observership, externship or clerkship?

Well it depends on what stage of education you are in and what your goals are.

Clerkships by definition are provided by your medical school either directly or indirectly and must be approved by your medical school in order to obtain credit towards graduation. So if you are in medical school and looking to do a clerkship in an area not directly provided by your school some medical schools allow applicants to pursue other opportunities after certifying that the experience meets the degree and curriculum requirements .

Externships are very valuable and thus preferred to observerships as it allows for direct patient care and can allow preceptors to comment directly on a candidate’s clinical proficiency. Due to the legal restrictions, these opportunities can be very limited and hospitals offering them typically receive numerous applications so applying early and applying to multiple programs will increase your chances of success.

Observerships are useful for applicants who are looking to fill gaps in their clinical education for example applicants studying for qualifying examinations for an extended period of time. Residency programs typically frown on gaps in clinical education as it raises questions of how ready an applicant will be to begin direct patient care upon the start of residency. They are also useful for applicants unable to secure an externship in a desired time period, location or specialty. Applicants who are applying to competitive specialties will also benefit as these programs typically like to see multiple letters of recommendation from physicians within the field. Letters of recommendation from outside the field hold less weight for the more competitive specialties.

Candidates pursuing these experiences should carefully weigh their goals and options. An unbiased look at their application by a third party might be helpful to see what defects exist and which experience would do the most to strengthen their application.