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It's almost here! Your fourth year of medical school -
supposedly the easiest and most fun year of your medical training -
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
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 -which will certainly
help your residency application there. A potential disadvantage of
doing an away rotation is that you could actually lower the
program's 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 school's 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
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
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. Don't 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
Remember your personal statement you used for medical school
applications four years ago? Well, it is time to write another one
- or perhaps several. This is perhaps the most dreaded aspect of
the application, because students don't like having such an
open-ended assignment without any real guidelines. The length of
the personal statement is virtually unlimited, but don't 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 won't 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
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, "I 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?" It is important that you state that it needs
to be a strong letter, because an average letter won't 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 - which you are empowering your
letter writers to write - are very powerful. Be proactive and
organized, and you won't 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
don't 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 won't
change much about it. Perfect!
The ERAS cover sheet, which can be obtained from your Dean's
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 writer's 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 Dean's 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
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.
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
The Home Stretch - Rank Lists, Match Day, and
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.
Don't 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
Check out more volunteer
January 2010 Issue of IMpact
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