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Medical Student Perspectives: Fourth Year Survival Guide

The fourth year of medical school is a unique time in a young physician's life. Instead of learning what you are told to learn, you can finally choose what you are interested in and focus your studies. You will be going on job interviews and working toward becoming a full-time employee instead of a full-time student. This is an important period in your life, and while the amount of free time and lack of responsibility you have during this period certainly make for a fun time, there are also important decisions to be made and vital resume-enhancing opportunities to take advantage of.

For this article, I have decided to forego the timeline format that many resources use and instead have created an ordered list of a fourth-year medical student's top 10 priorities.

#1: Figure Out What You Want to Be When You Grow Up
It is okay to not know what type of doctor you want to be by the end of third year. You have only had one year of clinical medicine and there are several areas of medicine that you have not even seen. Even in the fields to which you have had exposure (such as surgery, internal medicine, and obstetrics/gynecology), you have probably only seen the hospital version of those fields and not how those fields translate to the outpatient setting. The fourth year of medical school is the perfect time to take electives and figure out what type of residency you are going to apply for. Try to take electives in all the fields you may be interested in as soon as possible. Ideally, by August you should be fairly certain as to what type of residency programs you will apply.

I think too often students develop tunnel vision early in their medical school education and do not give all areas of medicine a fair shake. The importance of this decision should not be overlooked. This is your chance to see if radiation, oncology, ophthalmology, or hepatology might be for you. Even if you need to spend some of your free time rotating on services you are interested in, do it! Twenty years from now you will appreciate it.

#2: Get Your Letters of Recommendation Lined Up
If you are lucky and had a great experience with an attending on one of your clerkship rotations, and you are interested in that field, that is great! Most residency programs only require two letters of recommendation other than the departmental letter and the dean’s letter, so you are halfway there! If not, do not fret! Letters do not need to be in until the end of September and even after that is fine, as long as the rest of your application is done. If you took my advice and took the time to figure out what residency to apply for, then starting in August you should be actively seeking the two letters you need for your application. It is best if one of these letters comes from your acting internship rotation, so try to schedule that during July or August, although September would probably be fine too. Does it matter how well-known your letter writer is? I imagine for highly competitive programs with limited spots this could make a difference. I think as long as you have a strong letter from a faculty member at your institution, however, it does not matter so much who that faculty member is.

#3: Honor Your Acting Internship
This is your chance to show your stuff. The ideal month to schedule your acting internship (AI), in my humble opinion, is August. This gives you time to achieve priority #1 (see above) and brush up your medical knowledge, while giving your to-be letter writer enough time to get the letter in by September. Plus, with newbie interns on the floor, you may even end up looking sharper than them! Getting honors in your AI will be mentioned in your dean's letter and will look good on your application.

#4: Have Fun
This concept is usually ranked last on these types of lists, after stressing you out with all the stuff you need to do. This is expressed as kind of an afterthought, “Oh yeah, don’t forget to have fun!” Well, having fun during fourth year should be near the top of your list. While fourth year brings with it a lot of firsts, it also provides many lasts: the last time you will be around all of your medical school buddies and the last time you will have gobs of free time with little responsibility. So make sure you have fun. Do not schedule hard rotations throughout your fourth year. You will be on exhaustive rotations for the next three or more years, so give yourself a break. Take a trip, go out with friends, go see a movie, and watch the Rocky Marathon on AMC. If you ever feel guilty about not “getting things done,” think back to that scene in Billy Madison when he comes back from high school and tells one of his elementary school buddies, “You have to cherish it … you do …”.

#5: Try to Do Some Research
Research can be fun and fourth year is a great time to do some. Talk to physicians in some of the fields in which you may be interested and see what they have available. Even if you start after applications are due, you can talk about your research experience during interviews and it may help boost your fellowship application.

#6: Teach
Teaching is a large part of being a physician, and with your free time as a fourth year student, why not get some valuable practice at teaching? Most schools have an elective where you can be a teaching assistant for a basic science course. During my fourth year, I have been able to tutor first-, second-, and third-year students. It has been fun and it is also a great way to touch up on some pharmacology or pathology.

#7: Decide When to Take Step 2 Clinical Knowledge and Clinical Skills
This item should be placed higher on your list if you did not do well on Step 1. Step 2 Clinical Knowledge is considered to be easier than Step 1 and offers a good opportunity to make up for a poor showing on Step 1. However, if you are comfortable with your Step 1 score, there really is no need to take Step 2 until after your ERAS application has been submitted. Residency programs do not require Step 2 with your residency application and if you take it after you submit your ERAS application, you do not need to release your scores until after the match. I feel that the early months of fourth year are better spent on priorities #1 through 3 above. That being said, most people seem to do better on Step 2 than on Step 1, and you are probably best prepared to take it right after your third year is complete. So, it really is a personal decision as to when to take the test. Schedule two weeks off to study and you should be fine. As far as Clinical Skills goes, this test is really not that bad. If you have not slept through all of your third year of medical school you really only need a couple days with a review book and you should pass easily.

#8: Figure Out Where You Want to Live
This is a key part in the residency application process and will help you significantly narrow down your schools. A few key questions to ask yourself are:
• How close to family do you want to be?
• Big city? Medium-sized city? Rural?
• Cold or warm climate?
• Can you afford to live here?

#9: Discuss Features of Residency Programs with Your Mentor, Residents, Program Director, and Anyone Else Whose Opinion You Value
I have found that both residents and attendings are eager to talk about what they looked for in programs and what they think is important when applying for residency. Talk to them about different call schedules, patient populations, fellowship opportunities, program reputations, community hospitals vs. university hospitals, and whatever else you want to know. A good idea is to go to the AMA FREIDA Web site and print out a list of all the programs in the areas in which you are interested in living and review this list with someone whom you feel comfortable speaking with at your university.

#10: Enjoy the Interview Season
Traveling and answering the same questions over and over again is tiring for anybody. The key to being successful at each of your interviews is to have fun. Explore the area around the hospital, go to the pre-interview dinners, and talk to the other applicants as well as the residents. Do not worry about whether you are going to get in, or all of the money you are spending, or any of the many other aspects that could be stressing you out during this time. This is a fun time in your life and you should try to make the most of it.

Good luck! Feel free to e-mail me with any questions.

Joseph Sivak
Central Atlantic Region Representative, Council of Student Members
University of Virginia School of Medicine, 2009
Email: jasivak@virginia.edu

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Back to December 2008 Issue of IMpact

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