Preparing for a Successful Fourth Year of Med School

Your fourth year is the most enjoyable time of medical school, but also one of the most important periods of your professional career. You now have more freedom to choose which your rotations you do, but along with it the responsibility to prepare yourself for residency. This tutorial will detail the fourth year, and offer advice on how to position you for a residency in Emergency Medicine (EM).

Select an Advisor

By late in your third year, you should begin identifying potential advisors. This individual should be an emergency physician familiar with the residency application process. Ideally, they know your strengths and weaknesses and are willing to provide you with personal and candid advice. Beware of physicians overloaded with other students, out of touch with the current residency environment, or with strong preferences for a small group of programs. Frequently the Dean's office of your school can offer guidance on good candidates, as can current fourth-year students.

With this advisor, you should begin brainstorming a list of residency programs to which to apply to in the fall. While geography may be the most common factor, other characteristics such as institutional quality, elective training, and residency length may be more important to you. Many students apply to over 20 programs, so keep the list long in the initial stages.

Scheduling Key Rotations

Obviously you should have at least one solid month of EM under your belt before applying for a residency position in the specialty. However, most programs like to see two months of EM clerkship time. Start by finding out the last rotation month that will be included in your Dean's letter (usually September). Work with your registrar or contacts at away institutions to schedule rotations before this deadline. Think twice about scheduling it first, though, as you may benefit from some warm-up rotations in cardiology, gynecology clinic, or infectious disease. Near the end of the rotation, or immediately following, make sure to ask for a letter of recommendation as most residency programs want at least one letter from an emergency medicine physician.

Other recommended electives include trauma surgery, ICU, anesthesia and radiology. Other related electives include cardiology, dermatology, neurology, psychiatric emergency, gynecology, and EMS or toxicology. Additionally, most schools require a sub-internship in internal medicine or surgery. Depending on your ability to excel in these intensive rotations, there are advantages and disadvantages to completing them before your MSPE (i.e. Dean's Letter) goes out.

Recommendation Letters

Every Emergency Medicine applicant should have at least one letter from an Emergency Physician though it is highly advised to have all three letters from EM faculty. Remember, most programs want to see the Standard Letter of Recommendation (SLOR).

Although it is nice to have a chairman's letter, it is more important to choose a physician who knows you well. They should be able to comment on your clinical performance and fund of medical knowledge, but also your character and teamwork skills. An enthusiastic and descriptive essay letter from a rising professor is always better than a form letter from a department chief.

Away Rotations

Each year many students do away rotations at other schools in their target specialty to find out more about the institution or try to get their foot in the door. This can be very important in some of the more competitive programs or for students trying to change location (e.g. moving from one coast to the other). Most programs will extend a courtesy interview to all visiting students, so this can help you get noticed at a "reach" program. However, audition rotations can just as easily sink your chances for matching as improve them. You must go into the experience committed to make the best possible impression and demonstrate both your hard work and friendly personality.

Away rotations usually must be scheduled well in advance. Home students frequently get selected first, but most programs reserve at least a few spots for visiting students. Check with programs as early as possible to learn about their particular sign-up process. A listing of many EM electives is available on EMRA Match.

Scheduling Interviews

Emergency medicine interviews don't really get going until Thanksgiving, although there are programs that get an early start. You will likely need to take a month vacation in either December or January in which to schedule your interviews. Taking a "light" rotation in the other month is advised.

There are numerous arguments about what time is best. Some students feel interviewers are in a better mood before the holiday season. Others say later is better because the interviewers will remember more about them while making their rank lists. With that said, studies show that the date that you interview has no influence on what rank you match to. Another important factor is weather, as the northern climes are at the mercy of snowstorms and other inclement weather.

Have Fun!

Most importantly, make sure to make your fourth year fun. Whether taking some well-deserved time off or expanding your horizons with international travel, try to make it memorable. Internship will be exhausting, so take time to rejuvenate yourself both mentally and physically. Work hard to stay on top of the application process, gently reminding your recommendation letter writers and being prompt and courteous with interview invitations. Approach each program you visit with an open mind and remember that everyone likes students who smile. Best wishes for a happy and successful fourth year!

Original Contribution:
Matthew D. Bayley, MS III
University of Pennsylvania

Edited/Updated 11/2005 by:
Jonethan P. DeLaughter, MSIV
University of North Texas Health Science Center – Texas College of Osteopathic Medicine
EMRA Medical Student Council

Edited/Updated 1/2009 by:
Camaran Roberts, MS IV
University of Texas Health Science Center at Houston
EMRA Medical Student Council

For additional information:
Le T, Bhushan V, Amin C. First Aid for the Match. New York: McGraw Hill, 2001.
Iserson K. Iserson's Getting Into a Residency: A Guide for Medical Students. Galen Press. 2003