Most US medical students and residency programs have just completed a process known as the “interview season.” This is a long process for residency program faculty, coordinators, and medical students that typically encompasses much of the fourth year of medical school.


This year has received considerable evaluation as some feel that it lacks rigor, whereas others feel that it may not even be necessary. Recently, in the New England Journal of Medicine, Aagaard and Abaza described a need to reinvestigate and standardize the fourth year of medical school.1 Although there are no right answers to how to revamp the fourth year of medical school, it does represent a challenge.

What does the fourth year involve? Most of the time between July and January is spent preparing for, applying to, and interviewing for a residency position. This includes preparing Electronic Residency Application Service (ERAS) applications (curriculum vitae, list of activities and research, personal statement), taking US Medical Licensing Examination (USMLE) Step 2, and completing subinternship rotations, and most emergency medicine–bound students also complete at least one “audition rotation” outside of their home institution. This serves to help students obtain an interview at a desirable program and provides evidence that they can function in an unfamiliar environment. A recent study showed that emergency medicine– and surgery-bound students were the most likely to complete audition rotations, and approximately 89% of emergency medicine students completed at least one away rotation.2 In October to January, students spend considerable time and money interviewing. The number of interviews has been increasing, and based on 2014 National Resident Matching Program (NRMP) data, the mean number of contiguous ranks (approximately near the number of interviews completed) was 12. The interview season is expensive: in the Benson and colleagues study, the majority of students reported spending between $1,000 and $5,000 during interviews.2 Finally, in March, Match Day occurs, and students find out where they will start their internship.

If the fourth year mainly involves residency preparedness, then some argue that we should focus clinically on achieving “milestones” that students will need to excel in their chosen specialty. The Aagaard and Abaza article calls for medical schools, residency programs, and accrediting bodies to work together to define milestones that can be standardized to allow all students to meet core competencies but also be prepared for their chosen specialties.1 The authors noted that this will involve considerable collaboration between medical schools and residency programs and, specifically, will necessitate greater transparency in articulation of milestone data.

Stay tuned in the coming years for likely evolution of the fourth year of medical school to contain—it is hoped—more standardized, transparent milestones to make the process clearer for students and residency programs alike.



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  1. Aagaard EM, Abaza M. The residency application process—burden and consequences. N Engl J Med 2016;374:303–5.
  2. Benson NM, Stickle TR, Raszka WV Jr. Going “fourth” from medical school: fourth-year medical students’ perspectives on the fourth year of medical school. Acad Med 2015;90:1386–93.

Written by Megan Fix, MD

Associate Residency Program Director, Emergency Medicine, University of Utah Hospital, Salt Lake City, UT