Preparing for Residency

Mastering M4: Top questions for your fourth year of medical school


AMA News Wire

Mastering M4: Top questions for your fourth year of medical school

Sep 22, 2023

From USMLE Step 2 to residency interviews, the AMA offers answers to frequently asked questions to help medical students navigate the fourth year of training. 

This is likely going to be dictated by your institution. Traditionally, Step 2 of the United States Medical Licensing Examinations® (USMLE®) was taken between M3 and M4 year.

And, historically, Step 2 was broken into two parts. Step 2 Clinical Knowledge is a multiple-choice exam that covers the application of the basic sciences highlighted in Step 1. Unlike Step 1, Step 2 test-takers are given a numerical score. The other half of Step 2—Step 2 Clinical Skills (CS), a simulated patient exam—was permanently canceled in 2020.

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The question most students ask is a simple one: What should I study?

“For Step 2 CK the dominant area is going to be internal medicine. Even for things like the surgery questions, a fair number of them have internal medicine principles,” said Christopher Cimino, MD, chief medical officer, Kaplan Medical.

“For example, things like nutrition are in the surgical domain. They are surgical principles, but because they don’t involve cutting, students tend to think of them as internal medicine. So the internal medicine aspects of all the disciplines are probably a good place to focus on in Step 2 CK.”

Following a similar timeline two Step 1, Level 2 of Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) is typically taken by osteopathic medical students during the third or fourth year of medical school.

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While away rotations are often referred to as audition rotations, their value for the purpose of making an impression on residency program directors is somewhat specialty dependent. The decision to pursue away rotations is individualized, and it makes sense to speak to your advisers about the necessity of pursuing them from both a clinical growth and residency exposure perspective.

In a recent episode of the “AMA Making the Rounds” podcast, Kelli E. Krase, MD, director of the obstetrics and gynecology residency at the University of Kansas Medical Center, opined that away rotations “are not right for every student.”

“Some students need to do an away because the specialty that they're interested in or they're thinking about isn't available at their school,” Dr. Krase said. “Some students should do aways when they have a specific place that they're really interested in going to, and then other students who are interested in some of the more competitive subspecialties or specialties really are highly encouraged to do aways as well.

“Those are the kind of groups of people that really benefit from aways, but I think from an educational standpoint, it can be really valuable to see that medicine isn't practiced the same at every institution, and it can be a really wonderful experience to go and to go to a different institution and see that medicine is just a little bit different.”

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Where you will do your residency training becomes a focal point of your final year in medical school.

Residency applications typically open in late September. Before that point, you are going to want to make sure to conduct exhaustive research. That’s where FREIDA™, the AMA Residency and Fellowship Database®, and its profiles of more than 13,000 programs—all accredited by the Accreditation Council for Graduate Medical Education (ACGME)—can help.

Medical students using FREIDA can find information about training programs, key application deadlines, and specialty training statistics, which provide a helpful overview of residency programs based on trends across all programs in a specialty. Explore more than 180 specialties and subspecialties on FREIDA’s Specialty Guide, which has expanded to include important training information such as graduates’ career plans and specialty statistics.

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Residency applications typically open in early September and programs can begin accessing those applications a few weeks after that date.

When it comes time to submit your applications, some key tasks include: Finalizing letters of recommendation; crafting a personal statement and comprehensive CV; and obtaining your token for the Electronic Residency Application Service (ERAS), which transmits students’ residency program applications and key information from their designated dean's office to program directors. 

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The Match is a constant focus of one’s final year in medical school, but growth and development shouldn’t take a back seat. Emergency medicine resident Leanna Knight, MD, offered advice on other key areas for growth as an M4, including professional identify development and expanding your horizons.

“It is so important to see this M4 period as an opportunity to think about who you want to be as a physician,” Dr. Knight said. “Who do you want to be to your patients and colleagues? Most importantly: Who do you want to be for yourself? Fourth year, we spend so much time focused on the Match. But the truth is you've already done the hard part before applications even begin.”

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Since the onset of the COVID-19 pandemic, residency interviews have largely been held in a virtual format, and that looks like it will remain the case for the foreseeable future.

Interview invitations can go out at the end of September and the most active weeks of invitation sending tend to be in mid-October. To feel good about your Match prospects, the number of interview invitations you want to amass should be in double digits. For instance, according to data from the National Resident Matching Program (NRMP) the median number of interviews for Matched applicants in the 2020–2021 cycle was 14. If you aren’t getting enough interview invitations, it’s best to reach out to your school’s student-affairs office to consider your options.

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After interviews, applicants need to ask themselves the key question of the entire process: Where do they want to end up?

The National Resident Matching Program’s ranking process opens in January and the deadline to certify and submit final ranking lists is typically in mid-February. Remember, the match process is binding, so you shouldn’t rank any program you don’t intend to work in.

The path to putting together a successful rank-order list can be tricky. Still, Oluwabukola “Bukky” Akingbola, DO, MS, an ob-gyn resident at the University of Minnesota urged applicants not to overthink it.

“I personally recommend: Go with your first picks,” Dr. Akingbola said. “I put my rank-order list [in ERAS] and submitted it. Don’t change anything last minute. Whatever the thoughts you had when you made that original list probably ring truest.”

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The odds favor that you will Match. In 2023, seniors from US MD-granting medical schools matched at a 93.7% rate. DO seniors matched at a similar rate (91.6%). Still, each year qualified candidates don’t find a home.

The Supplemental Offer and Acceptance Program (SOAP) is a vehicle through which eligible unmatched applicants in the Main Residency Match apply for and are offered positions that were not filled when the matching algorithm was initially processed. On Monday morning of Match Week, all applicants will receive an email notification informing them whether they have matched, and if they have not matched, whether they are eligible for SOAP. SOAP is a service of the National Resident Matching Program (NRMP). 

After not matching during the initial process, Victoria Gordon, DO, an emergency medicine intern at HCA Houston Healthcare, in Kingwood, Texas, mobilized quickly and found a home.

“It’s OK to feel your feelings about not matching, but you also have to set yourself a time limit, which sounds cruel, but you can’t sit there and cry all day—you have to revamp your applications,” Dr. Gordon said. “So, get up and feel your feelings, but set yourself a timer. Then sit down and start working.”

If you don’t find a program through SOAP, there are options to move forward, including reapplying the following year.

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Across the country, residency training officially starts July 1, though orientation programs often begin in advance of that date. That leaves little time between the date when students get the news of their future home in Mid-March and when they begin the next phase of their career.

“For most applicants, the reality of the Match is the thing to come to grips with,” said John Andrews MD, the AMA’s vice president of graduate medical education innovations, during a recent episode of the “AMA Making the Rounds podcast.”

“Even if you matched your first choice, you suddenly realize that this is now a commitment and that this is the next phase of your professional development,” he said. “And that's both exciting and daunting.”

Some key tasks ahead include finding housing and taking time for self-care.

The AMA’s Facilitating Effective Transitions Along the Medical Education Continuum handbook takes a deep dive into the needs of learners along the continuum of medical education—from the beginning of medical school through the final stage of residency. Download now.