Planning Your 4th Year
The fourth year of medical school has definitely been my favorite; it did live up to the expectations shared with me in the past by other medical students. As I’ve mentioned in previous posts, one of the reasons it’s so fun is that you have almost complete control over what rotations you will do, and you can make them all related in some way to the specialty you’re applying for.
Some Terminology
During my third and fourth years of medical school, I would often get confused on some of the terminology used to describe clinical rotations. The terminology may vary based on your school’s curriculum, but I’ll share my understanding.
In your third year, your rotations are almost completely determined for you by your school, and those are referred to as “clerkships”. You may have 1-2 short “elective” rotations in your third year where you get to select from a list, but your clerkship schedule will largely be the same as your peers, just in various orders. The clerkships of third year are standard to ensure that you get a well-rounded clinical education, and that exposure to your “core” or required specialties will be reflected in the knowledge that is on USMLE Step 2 CK. Our clerkships were 2 weeks long, but many other schools will have 4-week rotations starting in third year.
In your fourth year, there are a few variations on types of rotations and terminology. I think technically you can call all of the rotations “electives” because you choose them for yourself. Most rotations will be 4-week rotations, but there may also be some that are two weeks.
“Away rotations” (often referred to as “aways” for short) are rotations at other hospitals outside your home hospital, and you apply for through a separate online application system. Whether or not you do aways will vary based on the specialty you’re applying for. The number of away rotations you do will depend on your school, whether or not you have a “home hospital” where you rotate a majority of the time, and on what rotations your hospital offers.
A “Sub-Internship” (often referred to as “sub-I”) is a special type of elective in your fourth year, and not all electives will qualify as a sub-I. As I mentioned in my previous post on my sub-internship experience in the ED, this type of rotation implies that you will have the most responsibility you can have as a medical student. Regardless of the specialty you’re applying for, most fourth year students tend to ask for letters of recommendation from their sub-I’s so there is usually that added pressure. Your school will require you to complete a certain number of rotations that qualify as sub-internships. Your sub-I’s may all be completed at your home hospital, or they may be away rotations.
Get advice from a handful of people or sources
You should definitely ask your advisor, upperclassmen and residents that are in your specialty of choice. Ask them some questions such as:
- What rotations did they do in their 4th year?
- What types of rotations will residency programs want to see on my transcript?
- What were some of their favorite rotations/experiences in 4th year?
- Were there any rotations that they regret not doing?
I would also consider asking some upperclassmen that are not in your same specialty what some of their favorite rotations were. Part of the purpose of the fourth year is to have fun, and to explore specialties you may never have the chance to rotate in again during residency. If you are possibly interested in a fellowship or niche within a field, try to experience that as well.
Limit yourself to asking just a handful of people and look for a specialty-specific resource, but don’t go overboard. Everyone may have a slightly different opinion on what your fourth year should entail, but ultimately do what you want, do what will be good for your application, and trust the process.
Interview Season & The End of Fourth Year
It was surprising to me how much time off we have during fourth year, and I had to be reassured a few times that this is normal. One purpose of this is to have time off as you are completing your residency interviews (and in non-COVID times you’ll be traveling to all of those places). Another purpose is for you to use the time to relax, enjoy your hobbies, etc. while you can before the residency adventure starts. Take advantage of this time, nurture your mental and physical health, spend time with your loved ones.
Because of the way many of us medical students are wired, it can be an odd feeling not to be studying all the time, and we tend to get anxious about the medical knowledge that is collecting dust in our minds as it’s not being used. I am definitely guilty of this myself. But, I’ve asked other students and residents for reassurance that studying for intern year is not the way that this time is meant to be spent. I’ve been told by every EM resident I ask that the only expectation of us when we show up on our first day is that we’re ready to learn, work the hardest we’ve ever worked, and to give it our best. Most residencies will likely have an orientation month where you can dust the cobwebs off and exercise that medical knowledge part of your brain again.
A note specifically for students applying for Emergency Medicine
EMRA has amazing resources, and I’ve used their student advising guide throughout my 3rd and 4th years, I highly recommend using them.
In non-COVID times, EM applicants are expected to complete at least 2 (but often times 3-4) Sub-Internships in Emergency Medicine. This usually looks like one “home” sub-I at your school’s hospital, plus 2-3 away rotations. From each of your EM Sub-Internships, you’ll obtain a SLOE (Standardized Letter of Evaluation), and those SLOE’s will act as your letters of recommendation when you apply for residency programs. Obtaining a SLOE does imply that you are completing your sub-internship at a location where there is an EM Residency.
In my year we were not allowed to to away rotations due to the pandemic, so they wanted at least one SLOE if possible and then we asked attendings who knew our clinical skills well enough to fill out a SLOE-like form.
Some recurrent advice I received was to consider rotations in the ICU, anesthesia, trauma, orthopedic surgery, and ophthalmology, but EMRA’s resources have even more detail about this. As I’m reflecting now, the experiences that really defined my fourth year so far were primarily from my sub-internship, doing ICU nights with the EM residents, and from my Pediatric EM rotation, and I look forward to finishing those posts soon to share with you.