U.S. medical students traditionally spend the first 3 years of training in a pre-determined curriculum. In their 4th year, however, students have significant flexibility in how they tailor their time. For this last year before residency, they shift from a learner-centered curriculum to a patient-centered curriculum. There is a shift in mentality from “I am here to learn as much as I can about medicine” to more of a “How do I best prepare myself for working in a hospital in my chosen specialty?”

A 2007 prospective, qualitative study focused on residency program directors’ (PD) perspectives about this 4th and final year of medical school. Semistructured interivews of 30 PDs were conducted, spanning the top 10 most popular specialties for UCSF medical students during 2001-2006. At least 2 investigators independently coded the transcripts from the interviews.

PDs were asked the following questions:

  1. Name rotations you think students going into your specialty should take in their 4th year. How do you feel about away rotations?
  2. How much time should a student spend in his/her chosen specialty versus in other fields?
  3. We want to assess the level of responsibility that a 4th year student should have in order to be adequately prepared for internship. What are the differences you’d like to see between a 3rd year and 4th year student?
  4. What additional competencies do you expect a student to gain in the 4th year that he/she did not get in the 3rd year?
  5. Think of the last 5 interns that really struggled. Were there any themes?
  6. Invent for me two to three 4th year medical school rotations that would strengthen a student’s arrival for your internship.


PDs felt that competencies interns should gain as 4th year students included:

  • 60% – Advanced clinical reasoning
  • 53% – Near intern-level independence
  • 33% – Self-reflection and improvement (be teachable and willing to learn)
  • 30% – Effective use of evidence based medicine
  • 27% – Capacity to care for more patients
  • 27% – Responsibility and reliability
  • 27% – Ownership of patient care
  • 27% – Communication with patients

PDs recommended the following rotations during 4th year:

  • 93% – subinternship in field in which they are applying
  • 63% – internal medicine subinternship
  • 50% – internal medicine subspecialty
  • 43% – critical care
  • 27% – ambulatory care
  • 27% – emergency medicine (I can’t fathom why this number is so low. Most residencies require their interns to complete an EM rotation.)

Conclusion of article
Students in their final year of medical school should focus on preparing them for their future career. This patient-centered training, framed within the ACGME competencies, should focus more on (1) progressive responsibilities in patient-care skills, (2) practice based learning and improvement, and (3) professionalism.

My 2 cents

I have to echo the overall sentiments of this article for all students. I have a few thoughts specific to students, applying to Emergency Medicine residencies:

  • If possible, do an away rotation in EM. This allows for you to see what EM is like at another location and for you to get another EM letter of recommendation. Having 2 independent EM letters vouch for you helps to build a stronger application.
  • Do a critical care rotation.
  • High-yield elective rotations that might help prepare you for EM residency include: radiology, cardiology, orthopedics, and anesthesia. If you have more free time, consider ophthalmology or ENT.
  • During your EM rotation(s), focus specifically on your organizational skills, ability to manage multiple patients simultaneously, and comfort level with more autonomy. Identify 1 or 2 high-functioning residents and determine what skills you need to work on. You will be a senior resident before you know it.

Lyss-Lerman P, Teherani A, Aagaard E, et al. What training is needed in the fourth year of medical school? View of residency program directors. Acad Med. 2009; 84:823-9.


Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD