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Medical Student Perspectives: How to Prepare for Your Fourth Year

Unlike the first three years of medical education, most schools have no standardized structure for fourth year. As such, fourth year can be a difficult time to plan. Many students may find themselves with questions about sub-internships, away rotations, electives, residency applications, and the USMLE Step 2 exam. With the help of several resources, including advice from the ACP Council of Associates (COA), I will attempt to answer some of these questions.

Sub-Internship
Doing a sub-I in medicine is generally encouraged for a number of reasons. "First, to ensure you actually like medicine, secondly for letters of recommendation, and lastly for the experience" explains Chris Allen, MD, a COA representative from Case Western University. When to do one? Generally, the most important factor is to complete the sub-I before you finalize your residency applications in order to utilize letters of recommendation—usually by the end of September. Most people will do theirs in the beginning of fourth year or the end of third. There are advantages and disadvantages of both, but one advantage of doing it at the beginning of fourth year is that you will stand out more compared to other students, many of whom will be at the beginning of their third years. Dr. Allen adds that a good way to stand out on your sub-I is to "pick something interesting about a patient you are caring for and do a 5 minute or so presentation."

Away Rotations
Away rotations are more controversial than sub-internships. The issue is that the benefit of doing an away rotation and making a good impression does not necessarily outweigh the risk that you might not make a great impression. Therefore, conventional wisdom dictates that you should only do an away rotation if you are very interested in the program and if you work very hard to make a good impression. "The best time to do an away rotation might be after a sub-I at your own school, so you’re really on top of your game," notes Sara Selig, MD, an intern at Brigham and Women’s. It is also important to complete it before you might interview at the place of the rotation—usually before February. To find an away rotation that interests you, visit the American Association of Medical Colleges Extramural Electives Compendium.

Electives
"There are no electives that will prepare you for your internship," Dr. Selig warns. "You can have all the book-knowledge in the world and still not be completely prepared. That being said, we all know our weak spots, so if you feel you are weak in something, doing an elective in that might help build your knowledge base." Dr. Allen adds, "Two weeks of radiology would be helpful, some time in the ICU would be helpful as well … To be a good general internist, you need to know a lot, so consider electives you think you might be weak in or not have much exposure to."

Residency Applications
Ask for letters of recommendation soon after your interaction with whoever will be writing them. Remember that it may be better to have a junior faculty who knows you very well write you a letter than a full professor who does not. You can network with people in residencies you are considering through the ACP, or through your school’s alumni. Another option is to talk to your medicine program director, since most program directors have connections in multiple schools that might be of interest to you. When interviewing, remember to be yourself. "Interviews should be an opportunity for both you and the school to see how well you fit," Dr. Selig explains. To find more information about internal medicine residency programs, visit ACP’s Residency Programs and Selection Web page.

Step 2 Exam
Although Step 2 is widely considered to be easier than Step 1, it may be more important for your residency applications, so it’s best to start preparing early. As for timing, "the general rule of thumb is that a student with a high Step 1 score might not need to take the test early in the year, fearing that a lower score might only hurt his or her application," Erin Dunnigan, MD, a COA representative from Duke University explains. "For those students who have an average to borderline low performance on Step 1, Step 2 is actually very important--taking this exam early and doing better may convey to program directors a special aptitude in clinical medicine and positive trajectory in future performance." Dr. Dunnigan also notes that the exam "is actually very helpful in forming the knowledge base that a new doctor needs for the first day on internship, or more specifically, the first night on call!" Most people prepare for the exam in very similar ways as they did for Step 1, with emphasis on questions such as those in Kaplan’s QBank. ACP’s MKSAP for Students 4 can also supplement your question bank.

General Advice
Dr. Allen suggests taking fourth year easy, but not too easy. There are a number of things you can do with your time that will help strengthen your residency applications. Research, away or international rotations, volunteer work in clinics, and summer scholarships are all helpful, both for your applications and for preparing for internship. "If you want to specialize or go to a top program, you need to show interest in research and plan to remain in academics," Dr. Allen adds.

Aliza Monroe-Wise, MSc
Council of Student Members Representative, Pacific Region
Stanford University School of Medicine, 2009
E-mail: aliza1@stanford.edu

Back to January 2008 Issue of IMpact

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