Green-book vs blue-book hospitals
The terms green-book and blue-book come from the ACGME's directories. Green-book hospitals have their own ACGME-accredited residency programs in the specialty you are rotating through, which means you learn alongside residents, present cases at their conferences, and receive evaluations from attending physicians who train residents. Blue-book hospitals are teaching sites that host medical students but do not run their own ACGME residency in that specialty. Both are legitimate clinical sites; green-book rotations tend to produce more useful letters and more competitive clinical grades for the residency match.
Core clerkships you will complete
The six core third-year clerkships mirror US MD programs and are required for eligibility to sit USMLE Step 2 CK.
- Internal Medicine — typically 12 weeks
- Surgery — typically 12 weeks
- Pediatrics — 6 weeks
- Obstetrics & Gynecology — 6 weeks
- Psychiatry — 6 weeks
- Family Medicine — 6 weeks (some schools substitute Ambulatory Medicine)
Fourth-year electives and audition rotations
The fourth year is largely elective and is where you build a specialty-specific case for residency. Audition rotations (also called sub-internships or aways) are 4-week electives at programs where you would like to match, and they double as extended interviews. Most competitive Caribbean applicants complete two to four audition rotations in their target specialty at green-book sites, ideally at hospitals with a history of ranking Caribbean graduates.
What to ask about rotation quality
Before choosing a school, ask specifically how many of the six core clerkships are guaranteed at green-book hospitals, how many total ACGME-affiliated sites the school works with, whether you are scheduled together with US MD students at the same site, and whether the school arranges housing near rotation sites or leaves it to you. Answers vary widely between schools and matter more than the marketing brochure suggests.
How rotation quality affects the match
Program directors read letters from attending physicians they know or recognize by institution. A strong letter from a well-known green-book site is often the single most impactful non-USMLE factor in a Caribbean graduate's ERAS application. Conversely, rotations at unknown sites with no ACGME footprint can be neutral at best and, in competitive specialties, a real disadvantage.
