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Medical Student Perspectives: Planning for the fourth year of medical school

Itís almost here! Your fourth year of medical school Ė supposedly the easiest and most fun year of your medical training Ė is just around the corner. Currently halfway through my fourth year, I can attest that fourth year is a great time! However, do not be misled by those who paint fourth year as a walk in the park. You will be very busy at times, for example, working on your residency applications, functioning as a first-year resident on your sub-internship, and traveling to and from residency interviews. You will be busy, but it is a different kind of busy than you have experienced thus far in medical school.

Most medical schools will have an information session for students sometime in the spring to discuss fourth year planning. However, some schools hold these sessions too late in the spring and put their students at a disadvantage compared to other medical students. After reading this article, you will be way ahead of the game.

Away Rotations
The spring of your third year is the time to begin planning for any away rotations you will do during your fourth year. Consider doing an away rotation at a program where you are highly interested in matching for residency. An away rotation has advantages and disadvantages. The advantages are that you have a chance to see a potential residency program firsthand, up close and personal. You get to know the people well, and have an opportunity to really impress those influential faculty members Ėwhich will certainly help your residency application there. A potential disadvantage of doing an away rotation is that you could actually lower the programís opinion of you if you do not perform well. What if you have a conflict with an attending or resident there? What if you oversleep a few times and show up late to morning report? These pros and cons should be weighed carefully.

Fourth year rotations are almost always a month in duration, so consider the cost of living somewhere else for a month. If you decide that you can afford the added expense of a month of rent, travel costs, possibly renting a car, etc., then you are ready to apply for away rotations. The competitiveness of away rotations depends on the rotation as well as the hospital. Applications for away rotations vary in complexity. Some only require a transcript and verification from your medical school. Others include recommendation letters and personal statements. A great place to begin learning about away rotation opportunities is the Visiting Student Application Service (VSAS), a centralized application service used by many schools (63 schools used it in 2009). Information about VSAS can be found at www.aamc.org/programs/vsas/students/start.htm. Be aware that several schools do not use VSAS, so becoming familiar with a schoolís website is key.

Application deadlines for each away rotation vary, so stay organized if you are applying for multiple away rotations. Many of these rotations process applications on a first come first served basis, so applying as early as possible is vital. In 2009, February 1 was the first day you could begin applying through VSAS. The fall months are the most popular times to do away rotations, simply because that gives applicants time to impress faculty and possibly obtain a good letter of recommendation for their residency application.

Curriculum Vitae
One of the best things you can do now to plan ahead for fourth year is update your CV. Be sure that your CV is in a usable and easy-to-understand format. There are many formats you can use, but it is best to use one that highlights your accomplishments in the best way possible. Many medical schools have a writing center or designated person who can help students with their CVs. I highly recommend using such a service if you have access to one.

Allow several hours of concentrated time to brainstorm your activities and accomplishments thus far in life. Focus on what you have done since starting medical school, with brief mention of only the most outstanding accomplishments from college and high school. You will use your updated CV frequently in the coming months, so working on it now before your schedule gets much busier is highly advised.

Residency Applications
You will apply to residency programs through the Electronic Residency Application Service (ERAS). This is a centralized online program that allows you to enter your application information, upload personal statements, and apply to programs. Entering the necessary information takes a considerable amount of time, so you should definitely get started on this as soon as you can. In 2009, ERAS opened on July 1 for applicants to begin entering information in their applications, and programs were able to begin downloading applications on September 2. These dates should be similar if not identical for 2010.

It is vital that your goal be to apply as early as possible. Interview invitations from residency programs begin rolling in the first week of September, and are filled on a first come first served basis. Donít be fooled by application deadlines being several months later, because interview spots are likely to be accounted for well before then. Shoot for being ready to submit your application on the first day possible, and definitely by mid-September. There is no advantage to delaying. If you start planning now, you will have no problem being ready when the time comes.

Personal Statement
Remember your personal statement you used for medical school applications four years ago? Well, it is time to write another one Ė or perhaps several. This is perhaps the most dreaded aspect of the application, because students donít like having such an open-ended assignment without any real guidelines. The length of the personal statement is virtually unlimited, but donít make the mistake of writing a lengthy personal statement! You want people to read it with interest, and making it too long is likely to bore your reader. Many applicants try to keep it to a page, with two pages being the maximum.

You have the option of uploading multiple personal statements to ERAS, so you will need to decide whether to write one personal statement to use for all of your applications or write an individual personal statement for some or all programs. Most applicants seem to write one personal statement and use it for every program. One thing you can consider doing is drafting one personal statement to use for most programs, and customizing it slightly for some of your top choice programs. You can do this by adding a short paragraph near the end of the personal statement which includes some specific reasons for choosing that program as well as any ties to the program or its location. Including this extra paragraph is probably not going to make a big difference, but it certainly wonít hurt either.

Your personal statement will possibly provide your interviewer with conversation topics, so be prepared to discuss it. I have heard stories about people writing poems or doing something unique for their personal statement, but given the conservative nature of medicine it is probably best to play it safe and write a standard one. Overall, it should be interesting and personal. Use a meaningful experience or two as the foundation for your statement, and communicate your talents through examples. Doing so will assure that your personal statement is an asset rather than a liability.

Letters of Recommendation
Third year is the best time to begin asking for letters of recommendation. As you know, it is essential that you obtain letters from those attendings with whom you have worked closely. There is definitely an art to asking for a recommendation letter. I advise asking faculty members in person, within a week or two of working with them. Say something like, ďI really enjoyed working with you on my __________ rotation, and would be honored if you would write a letter of recommendation to be included as part of my residency application. Do you feel that you can write a strong letter on my behalf?Ē It is important that you state that it needs to be a strong letter, because an average letter wonít help you. Many students have good letters, but far fewer students obtain outstanding letters. And trust me, a really strong letter carries a lot of weight.

If he or she agrees to write a strong letter for you, prepare a packet to assist them in writing your letter. Include your residency personal statement (if you have completed it), your updated CV, an ERAS cover sheet (more on this later), and a brief list of bullet points of things that might help them get to know you better. Use this list of bullet points to remind your letter writer of specific instances from your rotation. For example, you could mention a time you worked with him or her to solve a complex problem, an instance where you showed particularly strong leadership skills, or even your general habit of arriving early/staying late to assure that the work was accomplished. Letters with specific examples Ė which you are empowering your letter writers to write Ė are very powerful. Be proactive and organized, and you wonít be sorry.

Occasionally, particularly busy physicians will ask you to draft a recommendation letter for them to edit before submitting. You have hit the jackpot! This is an amazing opportunity for you to communicate exactly what you want him or her to say. While you donít want to sound cocky, do not make the mistake of being too humble either. Chances are, if it is a well-written letter with specific examples to back up your statements, he or she wonít change much about it. Perfect!

The ERAS cover sheet, which can be obtained from your Deanís Office, is to be included when your letter writer submits a letter to be included in your file. Be sure to fill out the form with your name, the letter writerís name, the date, and your AAMC ID. You must also check whether or not you waive your right to see the letter. It is generally advised to waive your right to see the letter before it is submitted, as this implies a more genuine letter. Many times, your recommenders will send you a copy of their letter after it has been submitted. Always keep these letters in your personal file at home, as they serve as a great template should you need another letter from them in the future.

Your application will include several letters. One letter will be your Medical Student Performance Evaluation (MSPE) Letter (formerly known as the Deanís Letter). This letter is basically a summary of your medical school coursework, and is written in a standard format by all deans. Try to meet with your dean in March or April if possible to allow him or her plenty of time to write your letter. Remember, deans are writing many of these letters each year!

You will also need a letter from the chairman of your internal medicine department. This letter is required by almost all internal medicine residency programs, and will focus on your performance and evaluations from your internal medicine rotations. Many students will meet with the chairman (or someone else in the department, such as the clerkship director) to discuss the letter. As with your other recommendation letters, come prepared with an information packet and leave it with them.

Step 2 CK and CS
At some point during your fourth year, you will need to take both Step 2 exams. Step 2 Clinical Knowledge (CK) is the computer-based exam similar to Step 1. It covers clinical science material from third year, with only a very small amount of information from the basic sciences. If you did not do well on Step 1, you should consider taking Step 2 CK early in your fourth year to compensate for the Step 1 score. Many students in this situation take it during July or August so that it can be included in their residency applications. In contrast, students who did well on Step 1 tend to take Step 2 later during fourth year. Either way, this exam requires intense study and should not be underestimated. The conventional wisdom has been to study two weeks for Step 2 CK, but these days most students spend about a month. Consider taking vacation time to study, as it will be difficult to properly prepare while also being on a rotation. Most students use the USMLE World question bank as their main resource, although there are many books and question banks out there from which to choose.

Step 2 Clinical Skills (CS) is the all-day exam with standardized patients. It is considered to be far less important than Step 2 CK in the eyes of residency programs. In fact, you basically just need to pass it before you start residency. Most students use First Aid for USMLE Step 2 CS to prepare, but as with Step 2 CK there are many review sources available.

Interviewing
Interview invitations will be sent starting in early September, and will continue into November. Interviews occur during November, December, and January, with a few in early February. You will probably choose to take a vacation month and schedule most of your interviews during that time. There is no advantage to interviewing early, as programs will meet sometime in February after all interviews have occurred to rank applicants. You can best prepare for these interviews by looking over your application to refresh your memory, as well as reading program websites to familiarize yourself with the details of each program. Be sure to dress professionally and look your best. Smile, be positive, and arrive prepared to show your enthusiasm for internal medicine. I have found it beneficial to think about answers to potential interview questions you might be asked. Also have several questions you want to ask residents and attendings, because you will be asked over and over if you have any questions. Having some questions ready to ask shows that you are prepared as well as interested in their program.

The Home Stretch Ė Rank Lists, Match Day, and Graduation
After interviews, you will be in the home stretch. You will finalize your preferences for your rank list near the end of February, and Match Day will follow the third Thursday in March. Before you know it, you will be graduating from medical school!

As you can see, there are many things to consider when planning your fourth year. Stay organized, keep track of important deadlines, and continue to work hard. Not only will you begin reaping the rewards of your hard work during the last few years, but you will also enjoy some wonderful experiences along the way. Donít forget to have fun and enjoy your last year as a medical student! Best of luck!

Jonathan D. Stegall
Chair, ACP Council of Student Members
Medical University of South Carolina, 2010
E-mail: stegallj@musc.edu

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