Rules of the Road: Ch 16 Summary: “Planning Ahead for Success in Your Third and Fourth Years”

Originally Published: AAEM’s Rules of the Road for Medical Students, First Ed. Chief Editors: A. Antoine Kazzi, MD FAAEM MAAEM; Joel M. Schofer, MD RDMS FAAEM
Chapter Summary by: Adrian Tripp, MSIII

Thinking about which specialty to select can bring about feelings of uncertainty and uneasiness in every medical student. It is an important decision that should be made with an open mind, honest self-evaluation, and after thorough investigation. Fortunately, if you have already decided on emergency medicine (EM), or have at least narrowed down your list of possibilities to include EM, AAEM’s Rules of the Road for Medical Students can help you prepare for a successful match.

Planning for Third Year

Regardless of whether you have always known you wanted to be an EM physician, or if you are still trying to make that decision, use your third year to check out some other specialties that interest you. Since you will have to wait until fourth year to do an EM rotation at most schools, consider scheduling rotations in other specialties of interest about halfway through the year. This allows you to “get your feet wet” on other services and get accustomed to working in the hospital system. Every rotation will necessitate getting used to a slightly different way of doing things, but at least this way it won’t be completely new to you on a service you really want to impress on. Attendings and residents will expect more from you as the year goes on, but this will allow you to shine when you are compared to the group of your peers that went before you and after you, as students tend to take clerkships they aren’t interested in either at the beginning or at the end of the year.
It is important to consider that your performance in your third and fourth year clerkships, especially those in EM, surgery, and internal medicine, is arguably one of the most important components of your residency application. Third year is difficult, and you want to give each clerkship your very best effort. Consider not scheduling particularly heavy rotations such as surgery and internal medicine back to back so you can stave off physical and mental exhaustion. Also, try to schedule a “light” rotation as your last clerkship of the year. This will allow you to be well rested for when you do your EM rotations early in fourth year.
Planning for Fourth Year
The first few months of fourth year will be some of the most important months of medical school, as you will be doing your EM rotations and trying to impress, and form relationships with, key EM faculty. Other factors to consider in scheduling your fourth year are: studying for and taking Step II of the USMLE, getting letters of recommendation, preparing your residency application, and having time off for interviews.
The ERAS can be submitted in September, so plan ahead when asking for letters of rec; ask for them early and make sure you inform the writers of the timeframe for the letter. If you did exceptionally well on USMLE Step I, you may consider setting some time off during interview season so that you have flexibility for travel, but also to study for and take the Step II. If you think your USMLE I wasn’t stellar, doing better on Step II can strengthen your application and you may want to consider taking it earlier so your results are back to include with your application.
When planning your 4th year rotations, allow yourself two (no more than three) EM rotations. One of these should be at your home institution, if your program offers an EM rotation, and another “away” rotation at an institution you are interested in matching at. Think of these as month long interviews, but also make sure you compare and contrast the strengths of the programs you rotate through while there. Doing very well in your rotations should almost guarantee an interview at that program, so make sure you take advantage of your time there!
Excelling in your EM Rotations
So, given the breadth and variety of what an EM physician sees and does, and considering how important your performance on these rotations is, how do you prepare for your EM rotations? The answer essentially begins as early as your first and second years: make sure you get a solid foundation of medical knowledge that you can carry with you into your clinical years. Also, study diligently and develop your clinical skills during third year so you can apply these skills in the ED.
Beyond that, doing well involves building on the basics: Always show up on time or, better yet, 10-15 minutes early to your shifts, dressed professionally. Plan to work hard and stay late every shift. Take ownership of your patients and follow up on all their studies. Be proactive and show your interest in the ED. This can be as simple as asking a busy nurse if you can help them by drawing a blood sample for your patient, taking your stable patients to radiology and back to avoid delays in their treatment, or calling the lab when necessary.
Part of the appeal of ED is how busy and hectic it can get. As such, you want to carry a few items on you at all times so you can “jump in” whenever possible. Having trauma shears, a pen light, reflex hammer, and other physical exam equipment in your white coat can help you perform a variety of complete physical exams. Things like suture removal kits, extra 4×4’s, and tape can allow you to expedite simple procedures with your team. Therefore, you should take time during your first shifts to orient yourself to where the supply closets are, where the portable ultrasound machines are kept, and the general layout of the department.
Of course, you are primarily on your rotation to learn! Remember to read book chapters or journal articles on at least one interesting patient you had each shift, and if you have questions, ask your resident or attending the next day. There are a variety of pocket references that you can stuff in your white coat that will also help you throughout your rotation. Taking a couple of minutes prior to presenting your patient to thumb through one of these guides can give you an extra edge in formulating comprehensive differentials and thorough plans- this will really help you shine!
Last, but certainly not least, never forget that the ED is ultimately a team-centered environment. Make sure you introduce yourself to all members of the team, help them when you can, and develop good relationships with nurses, techs, etc. Your ability to do so may be one of the components of your final assessment.
Although there is pressure to excel and do well in your EM rotations, remember: you should also be enjoying yourself! EM has become a competitive specialty and will continue to become more competitive, but by preparing adequately in advance you should be able to hit the department ready to contribute to quality patient care, develop your clinical skills, and build relationships that will help your career.

For more helpful tips, be sure to get your copy of AAEM’s Rules of the Road for Medical Students today.