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Chapter 7-Year 4 of Medical School 

Away Electives

These are often called “Audition” electives, and rightfully so.  You are basically auditioning for a job/residency, and based on your performance there, your chances of getting the position will either go up, or down.  It is really important to speak with an advisor before setting these up to try and figure if an away elective will most likely hurt you, or help you.  If you think it will help you, then do one at an institution you are highly interested in for residency.  If you think an away elective may hurt you, it might still not be a bad idea to take one so that you can get a different perspective of the specialty or field from outside your institution (a great perspective to have.)  It takes time to set these up, so hopefully you prepared for this by setting these up during the end of your third year.  When preparing for an audition elective, know this, you must work hard and do well.  You can usually gauge how well you will do, based on your performance on the clerkship most related to your upcoming elective.  If you did not get honors, these types of electives are even more important.  Read over your evaluations, analyze the experience of the clerkship, and figure out what went wrong, and compensate for it before your audition elective. If you did poorly on test, read more and do lots of practice questions.  Get my drift.  If it was a clash of personalities with an attending or chief resident, you must learn how to better work with people under these type of circumstances because they are out of your control, yet bound to occur again.  Of course you can never predict who will be your chief residents or attending on your upcoming audition elective, but overall things work out pretty fairly, and if you work hard, and know your stuff, it will not go unnoticed. 

Sub-Internships

The main two types of sub-internships required are Internal Medicine and/or Surgery (some medical schools may allow other types in replace of these two).  The sub-internship is an important time for most because it will demonstrate to program directors, how well you will do as an intern next year.  This is especially true for those who did not honor the clerkship most closely associated to their specialty of choice for residency, this will provide a second chance to prove your self.  In addition, most specialties usually also require an internship in either medicine (psychiatry, dermatology, etc) or surgery (orthopedics, Neuro-Surgery, ENT, etc) again outlining its importance.  It turns out based on my informal conversations with Program, and Assistant program directors (especially true at top programs), that most applicants will have honors (or the equivalent mark of excellence) in the respective sub-internship when applying.  Furthermore, one even stated it sometimes becomes more important when someone did NOT get honors, “You wonder why?”  Of course these comments and beliefs will vary from program to program, especially for those more competitive than others.  All that being said, work hard during your sub-internship, especially if you want to go to the residency program where you do that rotation.  It is a great time to integrate and grasp concepts encountered during the respective clerkship.  Furthermore, it will help you develop time management, and efficiency skills on the wards that will become invaluable during internship.  The best thing to do is to determine who will be grading you on the sub-internship, as there is often no exam, the subjective part of your grade is literally everything.  The next thing to do to help you during this experience if you haven’t been asked already is to somehow inform your team about you interest for residency (the common question for 4th years on the wards.)  Identifying to your team that you are interested in the sub-internship because of your career choice will place you and your teammates on a common ground, but also provide the opportunity to gain insight and additional guidance for the upcoming application process (if the sub-I is taken early enough, perhaps you will even be able to get a letter of recommendation to add to your ERAS application).  Furthermore, a common trait of physicians is to take junior physicians under their wings, and provide them with help and guidance, especially through the painful application process that we all had to suffer through.  This does not give right to pester, however, just be an opportunist when appropriate to ask questions.  The best way to assure honors in your sub-I is to work hard, read a lot, and be reliable!  If you have a choice, it might be a good choice to complete the sub-internship with an attending that you got along with during your clerkship, or on your advisor’s service.  Also, if you did not get good exposure to the heads of the departments during your clerkship (rotating at different hospitals), it might not be a bad idea to complete your Sub-I on the chief’s service (department chair, or program director) so they become familiar with you, and hopefully help out with either a letter come application time, or a phone call after interviews. 

Letters of recommendation from your chairman or program director.

Of all of your letters of recommendations that you will include in your ERAS application, the letter from the chairman or program director of the department related to the specialty will be the most important, especially if it is very positive.  The reason is that everyone who applies to residency usually gets great letters, because you get to choose who you will like to write them.  Chairs or program directors of a department usually know the chairs and program directors of other departments quite well.  They usually won’t lie to each other, and know how to evaluate applicants for residency.  Therefore, if they are approached by a student to write a letter, they will either decline to do so if they either don’t know you well, or don’t think they would write you a strong letter, or right you a letter in support.  The best way to get to know them is to meet them early, like in the spring of your third year.  Although usually very busy, they are also usually enthusiastic about meeting medical students interested in their field.  In preparation to meeting them, send their secretary a copy of your CV a week or two ahead of time, so she can give it to him or her either the day of, or day before to review.  Briefly talk to them about your goals, your highlights, and be prepared to answer the question why you want to go into their field.  Also ask questions about the field, and their future projections of the field.  Before leaving, ask if you could set up a later meeting sometime in the summer, to get help with choosing programs for the Match.  These meetings will go a lot better too if you got honors in the clerkship they control (they will usually have your grade and evaluations for the clerkship in front of them before the meeting.)  If you got honors in their respective clerkship, then I will think only a little additional exposure to them is needed before asking them to write you a letter, as you can probably at that point only mess things up.  If you did not get honors in the clerkship, then ask them if they have office hours when they see their own patients that you could perhaps join them in.  If you work hard, this will perhaps give you a second chance of proving yourself, and getting a great letter from them in support.  At your second meeting to review your list, go to the meeting with a list of programs they can select from, and make sure their program is included.  If you are a going to be a competitive applicant, be prepared to answer the question, “are you interested in coming here?”  If yes, by all means say so.  If not, be honest but don’t talk down about their program.  You should say something like you want to be closer to family, etc.  Obviously, not that you want to go to a better program.  Before the end of the meeting if you feel you have developed a good relationship through the experiences mentioned above, ask if they would write a letter of recommendation in your favor.  You never get to see the letter, but you will get a sense of how good it is during interviews for residency because interviewees will sometimes say, you have a nice letter here from your chairman. 

When to take Step 2

The first way to decide is to see if your school has any deadlines as many require you either pass, or take step 2 by a specific date.  If this is the case the next question is, do I need to do really well on this exam because of my step 1 scores, to get into a good residency.  The reason for this is that if you do need to do very well on it because you had fair to poor, but passing scores on your step 1, then you should take it sometime before September of your application year.  This will give you the chance to kick butt on them, and include your grade into your application for residency.  If you did very well on step 1, and there is no deadline by your school to take it, then consider taking it later in the application cycle where the grade won’t be back in time for residency programs to see it because unless you do very well again, the test can only hurt you.  If you are confident that you will do very well on this exam too, then take the time to prepare for it and take it to get it over with during your application cycle.  Use your best judgment.

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