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Goals for the 4th Year of Medical School

by Mohammad Hajighasemi-Ossareh, MD, MBA
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    00:00 Welcome to the 4th Year of Medical School lecture series. In this video, we're going to discuss the goals of being a 4th year medical student, we'll discuss what is a sub-internship, we'll discuss the differences between the expectations of 3rd year of medical school and now being a 4th year medical student, and we'll also discuss away rotations. Now, the goal of the 4th year of medical school. What's the difference? How is it any different than 3rd year? Well, the 4th year of medical school is the home stretch. This is where all your hard work culminates into taking USMLE Step 2, you perform sub-internships, and during your 4th year you apply the residency and you hopefully match. These are the goals of the 4th year of medical school. Do well in Step 2, rock your sub-internships, match into the program of your choice, go on and have a great life. But the expectations for a 4th year medical student are greater substantially than that of a 3rd year medical student. In life as you progress every year through your academic training, a little bit more was probably expected of you each year. You can think of that in college in the beginning of medical school; however, the transition from the 3rd year of school to the 4th is actually quite a significant jump. You are expected to make the largest leap as a student from the 3rd year of medical school to a somewhat fairly functioning sub-intern as a 4th year of medical school.

    01:30 So on that topic, what is a sub-internship? The 4th year of medical school contains co-rotations that are similar to the 3rd year of medical school; however, certain rotations during the 4th year of medical school are called sub-internships. This means the 4th year of medical student will be on a rotation and they will be auditioning essentially or attempting to perform or work at the level of an intern and this will be called as a sub-internship or a sub-intern and the purpose of the sub-internship is multi-fold. The first is applying to residency. That's the first reason we do sub-internships. You want to go to residency. Now, part of the residency application process requires letters of recommendation. Students will traditionally perform sub-internships during their 4th year in the specialty interest of their choice. For example, if you wish to apply to neurology residency, then you will perform a neurology sub-internship at an institution. During this rotation, you will work really hard, you'll try to work at the level of an intern, try to impress the residents and your attending and in that process earn a very strong letter of recommendation from an attending in the specialty of your interest and then you will use that letter to apply to residency programs of your choice. This is the key reason of why we do sub-internships. The second reason is for graduation requirements. Most medical schools require the students complete sub-internships in various co-rotations for graduation. For example, if you are applying to neurology residency, you will perform a neurology sub-internship like we previously stated. However, your school may also require you to perform an internal medicine sub-internship just as a graduation requirement. An important note: If you are performing a sub-internship in a specialty outside of the specialty you are applying for, don't slack off. For example, if you are applying to neurology and your program says "You know what, you got to do a medicine or a surgery sub-internship as a graduation requirement." Don't say to yourself "Oh, well I'm not going into that, I will just slack off." No. Alright that's a big mistake, don't do that. It is absolutely imperative that you work as hard as you can on any sub-internship that you're on. Slacking off during the sub-internship will be noticed and your program director or some other program director, they all talk to each other and they may speak of you and this could inadvertently hurt your chances of getting into a residency of your choice. Never ever, ever slack off during a sub-intern. You're always expected to perform your best irrespective of sub-specialty interest choice, and let me tell you why. When I was on my internal medicine rotation and I was on the sub-internship at that point, I had to do the sub-internship even though I was going into neurology for a simple graduation requirement. Now, that sub-intern, you're on the service, the attending who comes in and says "Okay who's on the team today?" This is what they always ask on the first day. Here is our 3rd year, here is our 4th year sub-i and then here's the residents, and here's our whole team. The moment you're categorized at the sub-internship, the attending has eyes on you. They want to see how you perform. They're interested in evaluating you. So just being the sub-intern on a service you immediately get the spotlight whether you like it or not and if you don't perform well that attending will notice because the spotlight is on you with the big label of sub-intern and they could go talk to their program director and do you say the internal medicine program director could go speak to the neurology program director and say "Hey that kid I think wants to do neuro but he was on my service and it didn't go too well." So it could all come around, so never slack off on a sub-internship, you're on the spotlight.

    05:27 Now, what are the expectations for a sub-intern or a 4th year medical student? Given that the 4th year medical students are expected to function at the level of a sub-intern, it raises the question of "What does it really mean and how is it different than being a 3rd year medical student?" During the 3rd year of medical school you will pretty much, let's be polite about it, a large liability to the team. Okay. You weren't an asset and then you try to be the best asset that you could but you weren't the resident. The 3rd year medical students are new to the hospital environment, they're still learning the ropes, they’re still trying to know how the hospital works so they're continuously taught by residents on how to do things. Now, as a 4th year student, the expectation is that you've learned the basics. You know how to interview patients, you know how to perform exams, you know the basics of medical management and how to get that started.

    06:20 You don't have to come up with a complete and a full assessment and plan but you should know what's going on, which questions to ask during the history, what to do on a physical, and how to focus thought process. You should always have basic plan recommendations at this point.

    06:36 Now, there is the increased expectation for 4th year medical students and this may seem daunting.

    06:42 You may say to yourself after I just said all that "Hey, I don't know if I know all the right questions to ask during a history, I don't know if I know all the maneuvers, what if I'm not very good at performing a plan. Oh mo you're stressing me out. Why am I watching this video?" It's okay, it can seem daunting and it’s supposed to. Remember we said, the 3rd year or the 4th year is the biggest leap you have to make. It's when you become the biggest kid of all. You know, you suddenly going to grow up. So, how do you go from being a kid 3rd year student to a big kid 4th year medical student and really you have to become more in control and you have to ask more thoughtful questions and in fact there is a secret to this and you will need the strategic help of your interns and your residents. They will help you grow and they will make you into a star sub-intern and we'll talk about this shortly. A topic we need to discuss are away rotations.

    07:35 Now, performing sub-internships is a vital component to the 4th year of medical school as we discussed earlier. A question that's often raised is "Is there a benefit of doing your sub-internships at your local home institution versus doing them at away outside rotations?" Away rotations, as the phrase goes, are simply sub-internships that you perform at a medical school other than your own. For example, let's say you're a medical student at Stanford Medical School and you want to do an away rotation at Harvard Medical School. In order to do this, you need to apply for an away rotation at the end of your 3rd year or maybe even in the middle of your 3rd year or possibly at the beginning of your 4th year, a.k.a. you'll start looking early so you know when the application deadlines open. You are responsible and you are absolutely solely responsible for setting up all the details of the rotation knowing when to apply, knowing where you want to apply to and managing the travel and the housing for these away rotations. Thus, setting up an away rotation is not easy, it takes effort. So you may be asking yourself "Well why do I want to do it? Who wants to do all this extra work? Is there a purpose?". And really the purposes of doing an away rotation are multi-fold. If you were very interested in matching into a specific residency program, then it's extremely valuable to do an away rotation there. The program director, the faculty, the residents will get to meet you. They'll work with you in person in the hospital and if you work hard and shine as a great 4th year sub-intern, performing an away rotation there really highlights your dedication to the program and allows you to personally meet and influence people from the program and really increase your chances of matching. Their core concept here for this is essentially networking. Get yourself exposed to the people who can get you in and make them like you through your hard work. Also, another reason for seeing how or doing an away rotation is you want to see how other hospitals in other parts of the nation or world practice medicine. You can expand your understanding of how medicine is practiced even within your own specific specialty and broaden your world view. For example, there were some students in my class who are going into neurology with me but some people did rotations on the other side of the coast or some did them internationally just because they wanted to see how is neurology practiced somewhere else and how does it differ from how we do it. Neurology is not the same anywhere and medicine is not the same anywhere. So you really have the opportunity to expose yourself to more ways in which we practice medicine. Another reason why some students do away rotations is simply for fun. You can do an away rotation at a great vacation spot. I have had friends do away rotations in Hawaii. Sounds pretty nice, they were surfing. Or you can do an away rotation near family so you can visit them. Right, this third reason of doing away rotations is more personal enjoyment and organized but just so you know this is a thing that people do as well. Now let's go over what we’ve talked about. The goal of the 4th year of medical school is to match into a residency program. The sub-internships are co-rotations that utilize and you can shine as a student, build the networking bases for matching into your residency program of choice. As a 4th year medical student and as a sub-intern, you're high expectations and you are expected to function at the level of an intern. Away rotations are great ways for you to express your interest in a specific program or see how medicine is practiced at other institutions.

    11:17 Thank you.


    About the Lecture

    The lecture Goals for the 4th Year of Medical School by Mohammad Hajighasemi-Ossareh, MD, MBA is from the course Med School Year 4. It contains the following chapters:

    • Goals for Medical School
    • Goals for the Fourth Year of Medical School
    • What Is a Sub-Internship?
    • Expectation for MS4/Sub-I
    • Away Rotations
    • Lecture Summary

    Author of lecture Goals for the 4th Year of Medical School

     Mohammad Hajighasemi-Ossareh, MD, MBA

    Mohammad Hajighasemi-Ossareh, MD, MBA


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