How Should I Spend My Fourth Year?

Megan L. Fix, MD


June 15, 2012


How should I schedule my fourth-year clerkships and still allow time for interviews and an international trip?

Response from Megan L. Fix, MD
Assistant Professor, Tufts University School of Medicine; Director, Medical Student Education, Maine Medical Center, Portland, Maine

First things first: Know your medical school's requirements. The third year is usually structured and has little room for electives. In contrast, fourth-year requirements vary widely; some medical schools have more structure whereas others have more flexibility.

If your school has many requirements, you will need to plan ahead, especially if your chosen field (such as anesthesia, emergency medicine, ophthalmology, dermatology) is not included in the third year. Most schools require a subinternship and allow for multiple blocks of elective and interview time.

Think of the fourth year in 3 phases: From July to October (phase 1), you prepare residency applications; November to January (phase 2), you interview and submit your rank list; and from February to June (phase 3) you finish up and make the transition to internship.

Phase 1:

From July to October of your fourth year is a critical period in medical school. For most students, this phase involves a subinternship, electives in their chosen fields, and residency applications. You will want to be on your game and secure strong letters of recommendation for residency.

Let's talk about the subinternship. You can take this either early in your fourth year or postpone it until after interviews.

If you are going into a general specialty such as surgery or medicine, then it is common to do your subinternship early in the fourth year. This will help you solidify your clinical skills and confidence and secure a strong letter of recommendation.

If you have chosen a field that is not part of third year, then consider scheduling your required subinternship later in the year. That allows time in the summer to schedule home and away rotations in your chosen field and obtain letters of recommendation from those rotations.

Next you need to schedule electives for phase 1. Once you have chosen your specialty, consider where you want to end up for residency. Many mentors will tell you to schedule 1 or 2 away electives in your chosen field to "audition" for residency at that institution.

Make sure you do a home rotation first so that you are ready to shine at the away elective. These electives take time to schedule, so don't wait until the last minute.

The dean's letter or MSPE (Medical Student Performance Evaluation) comes out in October rather than November, so it is paramount that you schedule rotations before then. Don't forget that you also will be working on your Electronic Residency Application Service (ERAS) application during this phase and some will take Step 2. Allow time to work these in.

Phase 2:

November through January involves interviews, travel, and formulating your rank list. If you are planning to have many interviews, then schedule electives of interest that are flexible.

Many schools offer 2-week electives such as radiology, ophthalmology, or sports medicine. These are good to do during phase 2 because they allow more time to travel.

In addition, consider a research or reading elective that will let you work on the road. Make sure, however, that you respect the rotation(s) you do during interview season. Do not skip out on key aspects of the rotation or make scheduling difficult for the staff. It's better to schedule time off rather than schedule a rotation that you are going to miss most of if you are away.

Phase 3:

From February to June, make it count. By this I mean finish up your requirements, explore electives of interest, and treat yourself with a trip or international experience.

During phase 3, many students take subspecialty electives within their chosen field. However, consider taking electives outside your field. Medical school will be the last opportunity to learn skills such as the slit lamp examination or to take time to understand common rashes. I encourage you to take electives for pure interest, such as radiology, dermatology, or ethics.

Consider an international elective -- and remember to plan ahead for these -- or a language elective. Don't forget to plan a break for yourself and your family before starting internship.

Some schools are now requiring "transition to internship" courses that occur before graduation but after match. Make sure you take any trips before this course so that you can recharge your batteries and relax before becoming an intern.

Most of all, the end of fourth year is also a time to reflect on your medical school years and remember the friendships that you have made. Try to connect with your colleagues and family and be proud of yourself for all the hard work that you have done.


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