How to Start Your Fourth Year of Medical School (M4)

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A Comprehensive Guide on Getting Started, Letters of Recommendation, Sub-Internships, and Away Rotations

The fourth year of medical school is full of changing expectations, moving pieces, and a lot of uncertainty. To make it more digestible, I broke my fourth year into six distinctive parts: 1) the STEP 2 study period, 2) sub-internships and the letter-writing period, 3) away rotations, 4) application curation and submissions, 5) interviews, and 6) and post-match bliss. In this piece, I will discuss parts 2 and 3; see our other article (“Ultimate Study Guide for USMLE Step 2 CK”) for details regarding part 1, the STEP 2 study period.

First and foremost, what are the steps that you can take to start early? How can you be prepared for fourth year before it begins? I’ll start with a quick list here and dive into more detailed sections below.

Letters

Letters of recommendation are arguably one of the most important parts of your application. Programs want to hear from your mentors that you would be an asset to their department. Acquiring letters is one of the more difficult parts of fourth year because there is so much uncertainty to it. First and foremost, do your research. How are letters often done in your specialty? Do students receive 2 letters from specialists within your field and 1 letter from a physician outside of your field? Plan your rotations around this. (For example: I applied into ophthalmology and was told that most students receive 1-2 letters from ophthalmologists and 1 letter from an IM/general surgery attending. I signed up for two IM-related rotations and two ophthalmology rotations to ensure that I could pull together three letters.)

Next, think back to your third year. Do you have any attendings who you connected with? Any who have served as mentors? Email them early to ask for a letter; in your email, say: “What can I do to receive a positive letter of recommendation from you?” This will give the attending room to make suggestions; perhaps they will be ready to write a letter from you. Perhaps they will recommend working on a research project with them or more clinic time. Whatever it is, try your best to do it and to do it well. Your work will be reflected in the quality of your letter.

When you start a rotation that you are hoping to gain a letter from, set expectations. Tell your attendings that you would like a letter; as with the email, ask for pointers, feedback, and details on what this specific attending needs from you for a positive, glowing letter. Keep in mind that you do not have to use every letter you receive. Attendings can write and submit a letter for you, and you can choose whether or not you want to send that letter to programs; it is also helpful to know about your letter writers (i.e., Where did they train? Where are their connections? Where would their names hold weight?) to better aid in your decision of where to send which letters. At the end, in my opinion, the more letters the better; keep in mind that some programs allow for supplemental (read: additional) letters, which is another reason to collect as many letters as you can.

Lastly, I would recommend talking to residents and fellows about their recommendations as to who should write your letters. Often, residents and fellows have themselves asked for letters from their departments and may have an “inside scoop” as to who writes letters that are well received.

Once an attending has agreed to write you a letter, make it easy for them. Send them your essays and your CV; send them the ERAS request and be clear about deadlines. Send reminders as you feel are appropriate as well! It’s your letter, so don’t be afraid to chase it down. Of note, I told all of my letter writers to submit my letters to my application platform ~2 weeks before the actual deadline; this allowed for some wiggle room when there were tech issues or inevitable delays in letter submissions.

(P.S: How do you ask for a letter? How do you help your attending to write you a good letter? See my templates below.)

January - May

3rd Year

Start thinking of your “story” and the different parts of your application that come together. Ask for letters from attendings you connected with in your third-year clerkships. Start talking to upper years at your medical school about how to set up your fourth-year schedule. Work on updating your CV. Start checking VSAS for availability of away rotations and start applying. Take the USMLE STEP 2 CK as early and as close to third year possible if you can.

January - May

Sub-Internships, Away Rotations, and Preparing for Them

Sub-internships go by different names depending on the medical school you are attending. In general, these rotations are in the field you are applying into and are an attempt at “practicing being an intern.” The purpose of these rotations is multifold: to solidify your interest in the field, to build practical skills for intern year, to receive letters of recommendations, to prepare for away rotations, and to build relationships with the attendings and residents at your home program.

By the time you get to your sub-internships, you should already be a seasoned medical student—you know what it takes to do well on your rotations. Sub-internships are your chance to step it up. Ask for more responsibilities and challenge yourself. Take on as many patients as the intern and see them as your patients. Work on your efficiency. Write notes on each patient as if you were the only team member writing the note. Make a list of all the tasks that need to be done and volunteer to complete them, even if they aren’t related to patients you are following. Ask questions and contribute to teaching when you have space to; take on helping the new third year medical students with getting accustomed to the hospital— this will help you acknowledge your own growth and may be observed as “stepping up” by your attendings and residents. Be a team player and embrace your place as a member of the medical team. And this goes without saying but… be prepared. Know your patients like the back of your hand. Know their pathologies and spend time with them. Ask for feedback often and incorporate that feedback into your care of our patients.

A note about sub-internships in specialties that are more niche: It’s really hard to stand out as a medical student on an ophthalmology rotation; as a fourth year, I barely knew how to use a slit lamp/an indirect, and I only had a handful of diagnoses on all of my differentials. It’s kind of the natural way of things— the majority of us just don’t have much exposure to or experience with the field prior to fourth year clerkships. That being said, your best bet is to be present, be interested in learning, and be “teachable”—that is, show that you can learn how to use a slit lamp or that you can broaden your differentials throughout the rotation. Beyond that, try to find small ways to be helpful while not being in the way. And try to connect with the attendings (who may become future mentors!) or with the residents who you meet.

Away rotations are similar to a sub-internship but are done at another institution other than the one you attend for medical school. Most students apply for away rotations through VSAS (Visiting Student Learning Opportunities, a platform by the AAMC), but some institutions have an internal application that they post on their programs’ websites. Speak to fourth years who have already matched about how they approached away rotations. Are they necessary for your specialty? When should you apply for it? How do you decide which program to do an away rotation at? Once you have narrowed it down, applied, and been accepted, reach out to residents at the program you plan to rotate at. Ask how you can be prepared. Be professional and eager to learn. Make notes on what you like about the program and what you don’t like about the program. How is it different from your home program? Even if you do not end up applying to or matching at the program you rotated at, these residents/physicians will always be your colleagues.

Final Thoughts and Looking Forward

Fourth year and preparing for applications was, for me, a very stressful time. I think we all have some degree of imposter syndrome, and I also think that it’s hard to know how “competitive” you are as an applicant upfront. Most of all, I wasn’t sure what I was walking into or what to expect from the year. I believe I was ultimately successful during my fourth year in part to three big things. First, I spoke to a lot of people to get opinions on my own application, rotations, programs, and interviews. It helped to hear pros and cons from different people and to have different lenses from which to view fourth year and the application process. Second, I wove a thread throughout my application— my letters, essays, activities, and research were all centered around similar themes; I worked on weaving this thread early on. Lastly, I have been supported by the most wonderful network of friends, family, and mentors. I made it a point to surround myself with people who cheered me on to keep my tempo and positivity up!

The best advice I would give is to keep in mind that there isn’t one perfect applicant. Everyone who matched this year had different stories, different scores, different letters, different experiences, and different journeys into the field. There is no one way to do things. There is no right way to do things. All of this to say—believe in yourself and spend your time around people who believe in you. Most importantly, be confident… that goes a long, long way.

TEMPLATE 1: Asking for a Letter

Dr. [ X ],

I hope this email finds you well! My name is [ X ], and I am an M4 at [ X ]. I was one of the students who worked with you in [ X]. Since then, I have finished my third-year rotations and have taken my STEP 2 exam. I am now working on preparing my application into [ X ] residency programs.

As I move forward with planning the application process, I wanted to ask if you would be comfortable with writing a letter of recommendation on my behalf. I have attached my updated CV here for your reference.

I know you may get many requests of this nature and that it has been a few months since we have worked together, so please feel free to share any concerns with me if you have them. I am happy to spend more time with you in clinic as you see fit.

Thank you for your time and consideration. I am looking forward to hearing from you!

Best regards,
[ X ]

TEMPLATE 2: Confirming a Letter/Sending Details

Dr. [ X ],

Attached are documents that may help you in drafting my letter. The first is a full CV including activities, research, and honors I have received since starting medical school. I have also included drafts of my personal statement for your reference. Please let me know if you would like any additional information to aid in your writing of my letter.

The ERAS portal is open, so I can send you the official request when you are ready; just let me know what Title & Department you would like me to list under your name. The letter is due on [ X ].

Thank you again for everything; I look forward to hearing from you!

Best regards,
[ X]

Sunidhi Ramesh

Sunidhi Ramesh, MD is a resident at Thomas Jefferson University and Wills Eye Hospital. She graduated Alpha Omega Alpha and top ten in her class from Thomas Jefferson University. In 2018, she graduated Phi Beta Kappa from Emory University with degrees in both sociology and neuroscience.