Understand how pieces fit together

For students wishing to practice in the United States, OUM and most American medical schools require their students to pass USMLE Step 1 before they begin clinical clerkships, especially if they want to do those rotations at US teaching hospitals.

“It’s absolutely essential for medical students to understand the process and the ramifications of their decisions regarding where they do their clinical rotations,” says Sarmad Ghazi, MBChB, OUM Dean for North America. “One wrong move, and they may derail their dream of becoming a practicing physician in the US.”

In order to compete for post-graduate residency programs and ultimately be licensed to practice medicine in the United States, completing clinical rotations at teaching hospitals is always preferable. Rotations arranged in a community hospital or private practice are not looked upon favorably by residency directors.

Strong USMLE performance opens doors

 Passing USMLE Step 1 opens doors not only for rotations at teaching hospitals, but ultimately to better residency programs. Students who do NOT pass USMLE Step 1 will find themselves scrambling to find both viable rotations and a residency match.

“I can’t say it enough: not only is passing USMLE on the first attempt essential, but getting as good a score as possible (>220) will help students compete for the rotation and residency of their choice,” says Dr. Ghazi. “Second-attempt USMLE passers and those just getting by with scores around 200 are going to have a hard time matching anywhere.”

Most teaching hospitals even require certain Step 1 scores before considering students for rotations.  And regardless of where those students complete clerkships, they must also pass USMLE Step 2 CK & CS before they may apply for post-graduate residency match in the United States.

Because so much is riding upon USMLE performance, OUM offers several USMLE prep programs, interval performance exams, and an in-house exam (IHE) to help focus students on USMLE Step 1 early in the program. The IHE has proven to bolster student readiness for the all-important USMLE Step 1. OUM’s USMLE Step 1 pass rate for students passing the In-House Exam is 100%.

Choose rotation sites well

Long before taking Step 1, medical students should strategically plan their rotation sites.

“Green Book rotations at ACGME-approved teaching hospitals are the best,” says Dr. Ghazi.  “Blue Book works, too, but they may not meet the licensure requirements in some states.  A student should try to complete as many rotations as possible, especially core rotations, in teaching hospitals with residency programs in those disciplines.”

“Green Book” rotations are those offered at teaching hospitals which have a residency program approved by the Accreditation Council for Graduate Medical Education (ACGME) in the same discipline as the corresponding clerkship. In other words, a hospital with an Internal Medicine residency program is considered an Internal Medicine Green Book rotation site.  “Green Book” comes from the American Medical Association’s former Green Books, which listed accredited residency programs until they ceased publication in 2000.  Since then, Green Book and Blue Book designations have continued, especially among international medical students and faculty with accredited sites, noted online at

“Blue Book” rotations are those at teaching hospitals that do not have a residency program in that specialty.  For example, OUM students may rotate at Chicago’s Jackson Park Hospital, which has a residency program in Family Medicine.  A clinical rotation in Family Medicine at Jackson Park would be a Green Book rotation, but an Internal Medicine or Surgery rotation there would be considered Blue Book.

Since most teaching hospitals have post-graduate residency programs in several disciplines, they will have Green Book clinical rotations in the corresponding disciplines. But for students of an international medical school, those rotations may be difficult to arrange — because contracts with US medical schools may require a hospital to offer rotations exclusively to students at those schools. OUM students able to access core rotations at Green Book and Blue Book locations and students with contacts at teaching hospitals are encouraged to work with OUM to contract for rotations at those hospitals.

Checking ACGME’s website or the AMA Residency and Fellowship Database will give a good picture of where teaching hospitals are located and which rotations are Green Book or Blue Book.  Note: you will not see the terms “Green Book” or “Blue Book” on the website.

Green Book vs Blue Book: Why it Matters

 “The decisions that medical students make about where to do their clinical rotations will impact their competitiveness for residency,” says Dr. Ghazi, adding his preference for this order of rotation locations:

Tier 1: Rotations at US teaching hospitals with a residency program in that discipline (aka Green Book)

Tier 2: Rotations at US teaching hospitals with residency programs in areas other than the discipline in which the student is rotating (aka Blue Book)

Tier 3: Rotations at OUM’s teaching hospital in Samoa

Tier 4: Rotations at a non-teaching community hospital

Tier 5: Office-based rotations.

Most US residency program directors would prefer all core rotations to be at Tier 1 locations, perhaps a couple (at most) at Tier 2 hospitals if not in the discipline the student intends to apply for residency (and that residency is not terribly competitive). The other three locations generally are not preferred by many residency programs, but they may be accepted for electives.  For more information on how the post-graduate residency match works, visit the National Resident Matching Program website at

Most state medical licensing boards tend to look at the top three locations as being roughly equivalent, though in some states Tiers 4 and 5 may work, too.  However, without completing a residency program, licensure is not possible.  Students should research the licensure requirements of where they wish to practice when mapping out their clinical rotation plan.

Rotation sites may impact licensure

Where students complete their rotations may not be as critical to some state medical licensing boards as it is to residency programs. However, without having completed a residency, medical graduates will not be licensed. State boards generally accept rotations completed at the medical school’s teaching hospital, in OUM’s case, Tupua Tamasese Meaole (TTM) Hospital in Samoa. Residency directors generally prefer that core rotations be completed in US teaching hospitals.

“We always advise our students to research the licensure requirements in their state to be sure they understand what they need to do to be licensed to practice,” says Dr. Ghazi.

OUM admissions counselors have basic information on licensure in different states, and additional information is available at the Federation of State Medical Boards at

Residency and career options for students not passing USMLE

OUM students who do not pass USMLE before beginning rotations may complete rotations at OUM’s teaching hospital in Samoa, at non-teaching community hospitals, or in physician’s offices. However, these are not looked upon by residency directors as favorably as rotations in teaching hospitals, which in most cases requires passing Step 1.

Students should not be concerned about the graduation requirement to complete at least one four-week rotation in Samoa. It is unlikely to have any negative impact on residency or licensure. Residency program directors frequently view international hospital experience as a positive.

It may be possible for non-USMLE students to do an elective at teaching hospitals, but electives are not as valuable as core rotations when residency program directors review a student’s record.  It is improbable, though not impossible, that a student who passed Step 1 after commencing or completing rotations and did not do those rotations at teaching hospitals would be competitive for a residency.

Some US medical students begin their rotations before taking USMLE Step 1.  While that pathway is generally not recommended, there are a variety of reasons for doing so. Some students intend to take USMLE later before applying for residency match, and others plan alternative non-clinical career options with their MD degree.

“Without passing USMLE, you cannot get a residency or practice in the United States,” says Dr. Ghazi.  “However, a non-USMLE MD graduate may choose to do an internship and practice in another country, do missionary work, teach or work in research at the university level, or work in any one of a number of excellent jobs in insurance, employee benefits, healthcare administration, or other fields that may require an MD degree, but not a license to practice medicine.”