The Journal of Emergency Medicine, Vol. 58, No. 3, pp.

e173–e176, 2020
Ó 2019 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

https://doi.org/10.1016/j.jemermed.2019.11.026

Medical
School Forum

DESIGNING THE THIRD- AND FOURTH-YEARS CLERKSHIP SCHEDULE

Ketan Patel, MD,* Louis Binder, MD,†‡1 Bobby K. Desai, MD,§ Fred Goodwin Jr., MD,k Amal Mattu, MD,{
Mohamad Ali Cheaito, MD,# Michael C. Bond, MD,{ and Amin Kazzi, MD#**
*University of Nevada School of Medicine, Las Vegas, Nevada, †Case Western Reserve University School of Medicine, Cleveland, Ohio,
‡University Hospitals Cleveland Medical Center, Cleveland, Ohio, §University of Florida, Gainesville, Florida, kMary Washington Health
Alliance, Fredericksburg, Virginia, {Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland,
#Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon, and **Department of Emergency Medicine, University of
California, Irvine, California
Reprint Address: Amin Kazzi, MD, MAAEM, FAAEM, Department of Emergency Medicine, American University of Beirut Medical Center, P.O. Box
11-0236, Riad El Solh 1107 2020, Beirut, Lebanon

, Abstract—Deciding on a specialty may be one of the
most daunting parts of medical school. Accordingly, it is
important for medical students to make informed decisions
regarding their choice of specialty. To do so, they should
start planning early by contemplating possible career
choices during the first 2 years of medical school, followed
by properly designing their third- and fourth-year sched-
ules. This article provides guidance and advice to medical
students on how to schedule their clinical clerkships in order
to optimize their ability to decide on a field of medicine to
study and, ideally, to prepare them for a career in emer-
gency medicine. Ó 2019 Elsevier Inc. All rights reserved.
, Keywords—medical student; emergency medicine;
match; schedule; clerkships; medical education
INTRODUCTION
Some people know early on that they want to become an
emergency physician, and others struggle with their
choice and hope their experiences during the third and
fourth years of medical school will help guide them to
the perfect profession. Planning these 2 years can be a
daunting task fraught with many questions, especially
regarding the optimal sequence of clerkships. For this
reason, it is crucial for medical students to begin evalu-
ating their interests early in their medical training in order
to understand their strengths, weaknesses, and needs in
subsequent years. During the first 2 years of medical
school, students should begin to critically approach the
decision of choosing a specialty. It is an ideal time to uti-
lize interest groups, senior medical students, and resi-
dents, and to do everything they can to learn about
every specialty that interests them. This will help them
formulate an idea of potential specialty choices going
into their clinical years, even if they have not pinned
down the exact one just yet.
PLANNING THE THIRD YEAR

1
In memory of Dr. Louis A. Binder 1954–2014. Deciding one’s
specialty is a challenge for many medical students. Dr. Binder
guided and mentored medical students through the labyrinth of
their medical education to be prepared for their chosen
specialty. He hoped that this would his legacy. This article that
he co-authored is one of many contributions that highlight the
excellence and mentorship he stood for throughout his life.
The key to a well-designed third year is a carefully
thought-out short list of specialties of interest to the med-
ical student. This is by no means a commitment to a spe-
cialty, but merely a guide tailored to interests that the
medical student has gravitated toward during his or her
first 2 years. Armed with this, the student will be able

RECEIVED: 30 October 2019;

ACCEPTED: 11 November 2019

e173
e174
to toil through all other considerations and formulate a
well-prepared schedule that is optimal for him or her.
It is important to keep in mind that the academic per-
formance during the third year is arguably the single most
important component of the residency application. Ac-
cording to some, it is more important than the first 2 years
combined. While a comprehensive aptitude is necessary
throughout medical school training, the third year is the
students’ time to shine and showcase what they learned
during their preclinical course work (1–4).
Each medical school has a slightly different setup, but
the core third-year rotations are virtually the same every-
where. Because emergency medicine (EM) is not part of
the standard third-year curriculum at most institutions,
students will not be able to truly evaluate this field until
their fourth year. Students whose medical schools neither
include an EM clerkship nor allow for elective time to fit
in an EM clerkship during the third year should use this to
their advantage and dedicate this time to evaluating other
specialties on their short list. The key is to keep an open
mind about all specialties, as this will help applicants suc-
ceed on every rotation.
Applicants interested in pursuing a residency in EM
should focus on their EM, internal medicine (IM), and
surgery clerkships. The IM and surgery clerkships form
a comprehensive basis for almost all specialties; accord-
ingly, regardless of the choice of specialty, these 2 clerk-
ships are weighed heavily on the residency application.
While it is obviously most desirable to have a solid per-
formance across the board, this fact should be kept in
mind when planning the third year. It may be wise to
avoid taking these 2 rotations back to back and instead
have both interspaced by an ‘‘easier’’ rotation to give
the student a chance to breathe a bit and hit the ground
running for the second of these key rotations.
So where should all of these rotations be placed?
Because IM and surgery are important clerkships that
expose medical students to a large variety of medical spe-
cialties, students should consider scheduling them in the
middle of the year. This allows for an ideal balance be-
tween ‘‘getting your feet wet’’ and knowing the floors
and how they function before getting into the critical ro-
tations. This will also expose medical students to any
non-EM specialty of interest before having to finalize
their fourth-year schedule in the spring; however, taking
these rotations during this time might jeopardize getting
an honors grade or its equivalent on these rotations. In
fact, attendings and residents will look at students with
a more critical eye, as they understand that they have
had some clinical experience ‘‘under their belt’’ and
will therefore expect more from them compared to their
colleagues who take these rotations at the beginning of
third year. Additionally, because most people place rota-
tions that they are most interested in during this part of the
K. Patel et al.
year, competition will be higher during this period of
time, when everyone will be fighting for that highest
grade. This will make it even harder for the student to
get an honors grade for the rotation. These are important
factors that should be taken into consideration before
scheduling, and subsequently before starting, these clerk-
ships. Whichever of the 2 rotations mentioned that the
medical student decides to place in the middle of the
year (second or third quarter or the equivalent), he or
she should consider taking the other (or another similar
broad-based specialty like family medicine) earlier in
the year. This will allow him or her to see a wide range
of illnesses and get a solid assessment of his or her pre-
clinical knowledge base. It will also give the medical stu-
dent the chance to judge whether practicing medicine that
encompasses a broad base is ideal for him or her, as EM is
also a broad-based specialty. As mentioned earlier, it is
important to break up the surgery and IM clerkships.
When it comes to the end of the third year, the medical
student has to choose between a broad-based specialty
and a less challenging rotation. Saving a broad-based spe-
cialty for the end of year may benefit the medical stu-
dents’ performance on their audition EM rotation at the
beginning of the fourth year by allowing them to review
a large amount of pertinent material right before the rota-
tion starts. Proper preparation and consistent perfor-
mances throughout the year should be preparation
enough for their important fourth-year clerkships of
choice. However, planning a less challenging rotation at
the end of the third year gives students the chance to
mentally and physically prepare for the strenuous first
couple months of their fourth year, which are crucial,
and is the students’ time to shine in whatever specialty
they choose for their audition rotations.
Emergency medicine interest groups (EMIGs) are
ideally joined during the third year. Most schools today
facilitate EMIG organization by upperclassmen under
the supervision of an EM faculty member. Nonetheless,
participation in such groups is essential to bolstering
EM applications but not sufficient. Striving for leadership
within the EMIG is vital to architecting model applica-
tions (5,6).
It is important for students to take all of this advice
with a grain of salt. There are countless ways to set up
and justify the third-year schedule. Students will not be
disadvantaged if they decide later to go into a specialty
that they scheduled as their first rotation, as long as
they keep an open mind and a positive attitude during
all rotations. It would be unfortunate to discount a spe-
cialty before even being exposed to it. EM by nature is
a broad field, therefore, all clerkships should be ap-
proached with strong consideration. This will not only
afford students the opportunity to critically evaluate their
specialty choice in the most informed light, but will also
Third- and Fourth-Year Clerkship Schedule
show through their composite evaluations how prepared
they are in all facets of emergency medicine.
Ultimately, the order of the rotations does not really
matter. Having an open mind, being optimistic, helpful,
energetic, and eager to learn are more important. Most
EM residency program directors want to know that an
applicant chose EM after loving all of his or her rotations,
as opposed to choosing EM because he or she hated all of
the other rotations.
PLANNING THE FOURTH YEAR
Once in their fourth year, medical students will need to
make a decision regarding their choice of specialty by
September at the latest, and that only gives them 3
more months to evaluate this critical decision. In addi-
tion, students have to take other considerations into ac-
count, including taking the 2-part Step 2 U. S. Medical
Licensing Examination (USMLE), completing the
required subinternships/clerkships, and securing and
excelling on electives, in addition to other special consid-
erations for interviews (7).
Planning the first 2 or 3 months of the fourth year is
straightforward if the student is interested in EM. Most
applicants should plan on doing 1 to 2 months of EM in
the first few months of the year. Many schools have a
required EM rotation in the fourth year.
If the student attends a school with a strong EM resi-
dency program, he or she may be able to do a single
month of EM and dedicate the other months to electives
that will strengthen his or her clinical skills. However,
if the school is not affiliated with a residency program,
the student may not get the experience or a letter of
recommendation that he or she needs from a recognized
EM faculty member. In this case, the student should
sign up for an away elective at an EM program that is
highly regarded and busy. Either way, applicants may
want to strongly consider an ‘‘audition’’ elective for
some time in the fall if there is a program in which they
are strongly interested. It will serve as a great opportunity
to be exposed to the program of interest and may be of
great help for the applicants, especially if they perform
well on their externship. Many program directors regard
competent performance in EM clerkships to be a defining
and vital factor in safeguarding EM residency admis-
sions. Although there is no set number of clerkships to
be pursued, 2 EM rotations are conventionally recom-
mended. A third rotation is unnecessary unless it is funda-
mental to your application or fulfills personal learning
needs (5,8–10).
Moreover, it is important to begin gathering docu-
ments, such as letters of good standing and proof of
malpractice coverage for away rotations in March or
April of the third year. This will help applicants avoid
e175
missing any deadlines and, more importantly, get their
application in early for those precious away audition
rotations.
By September of fourth year, medical students should
have their decision made regarding the specialty they
want to pursue. This is the time to start filling out their
residency application with the Electronic Residency
Application Service (ERAS). While most of the applica-
tion process is dependent on the applicant, parts left out of
his of her control, such as letters of recommendation, can
be a source of frustration. This is why it is important to
complete EM rotations early in the fourth year and to
request the letters early. Many physicians will be writing
letters for numerous people, therefore, the earlier the
applicant approaches a physician for a letter, the better
the chance he or she will get a good, well-thought-out let-
ter in a timely manner. Setting appropriate and consid-
erate deadlines for letter writers, as well as sending
them friendly reminders as dates near for submission,
can be helpful. The ERAS application should be
completed as soon as possible, ideally by mid-
September. Programs usually begin to review applicants
and send out offers for interviews in October, and it
gets progressively more difficult to secure and schedule
interviews as the season progresses.
The period after the EM rotations and before the
Match is the time to take electives that will best prepare
the applicants for the career they selected. For EM, these
include a broad selection of choices—from critical care,
to cardiology, ophthalmology, orthopedics, radiology,
anesthesia, and research, if they have an interest. It is
best to plan electives during the interview season of
mid-November through early February; this will allow
some scheduling flexibility. In addition, applicants should
consider scheduling vacation or board study time during
this period to not only facilitate preparing for Step 2
USMLEs, but to aid in scheduling the interviews. The
key during this period is to ensure flexibility, as this
will afford applicants the opportunity to schedule as
many interviews as they see fit, while minimizing sched-
uling conflicts.
As stated earlier, one consideration for scheduling
Step 2 of the National Boards is to save some study
time and vacation time for preparation during the ‘‘inter-
view’’ months. However, one could also argue that med-
ical students will be most prepared for this examination at
the end of their third year, after completing the core clin-
ical rotations. While this will allow them to get the exam-
ination over with, some argue that if a student did
exceptionally well on Step 1, he or she may want to delay
Step 2 until after his or her interviews are completed to
avoid risking a less remarkable score. For students in
the opposite boat, however, the potential for strength-
ening their application by doing well on Step 2 is worth
e176
serious consideration. Either way, students should under-
stand that although Step 2 is not required on the applica-
tion for residencies, many schools require it be taken prior
to graduation. For this reason, students should seriously
consider planning and preparing for this examination to
avoid potential issues at the end of the year, which could
delay their graduation and jeopardize their position at a
residency (5,7).
Once the interviews are completed, students should
plan to take some vacation near the end of the year for
some well-deserved rest and relaxation. This is also a
great time to plan unusual rotations, such as international
electives or wilderness medicine electives, which will
provide a unique experience and opportunity that they
may never have again. Students should take advantage
of this time and enjoy the fruits of their hard work.
CONCLUSIONS
Medical students should start planning early. This in-
cludes considering career choices during their first 2 years
of medical school, designating a faculty member to be
their mentor, planning away rotations, and requesting let-
ters of recommendation. This will allow applicants to
make the most informed decisions in a timely manner
and will put them on par, if not ahead of the game, for get-
ting their work done by the various deadlines. With that
being said, it is not about how quickly applicants come
to a decision regarding their career choice, it is about
making the most informed decision. Third-year students
should try narrowing down the fields of interest that
they are truly considering. Additionally, they need to
plan their schedule around these, while keeping an open
mind about all specialty choices. This will allow them
to make an unbiased and informed decision. It will also
serve them well from a performance standpoint. Finally,
for the fourth year, students should be organized and start
early. Positions for away rotations, dates for National
Board examinations, and interview dates not only creep
up fast, but also fill up very quickly. Being organized
and having some foresight will allow them to tackle these
K. Patel et al.
conflicts head on as they arise, and they will only be mi-
nor bumps rather than hindrances in their path to gradua-
tion and matching.
Acknowledgments—This work was supported by the Depart-
ment of Emergency Medicine at the American University of
Beirut Medical Center. The funding source was not involved
in the preparation of the article, writing of the report, or decision
to submit the article for publication. This research received a
non-restricted educational grant from the not-for-profit Resident
Student Association (American Academy of Emergency Medi-
cine) and the Department of Emergency Medicine at the Amer-
ican University of Beirut.
REFERENCES
1. The Emergency Medicine Residents’ Association (EMRA). EMRA
and CORD student advising guide—3rd and 4th year planning.
Available at: https://www.emra.org/books/msadvisingguide/third-
year-and-planning-for-fourth/. Accessed February 13, 2019.
2. Crane JT, Ferraro CM. Selection criteria for emergency medicine
residency applicants. Acad Emerg Med 2000;7:54–60.
3. National Resident Matching Program (NRMP). Results of the 2018
NRMP Program Director Survey. Available at: https://www.nrmp.
org/wp-content/uploads/2018/07/NRMP-2018-Program-Director-
Survey-for-WWW.pdf. Accessed February 13, 2019.
4. Katzung KG, Ankel F, Clark M, et al. What do program directors
look for in an applicant? J Emerg Med 2019;56(5):e95–101.
5. Lotfipour S, Luu R, Hayden SR, Vaca F, Hoonpongsimanont W,
Langdorf M. Becoming an emergency medicine resident: a practical
guide for medical students. J Emerg Med 2008;35:339–44.
6. Pitre CJ. The unique educational value of emergency medicine stu-
dent interest groups. J Emerg Med 2002;22:427–8.
7. The Emergency Medicine Residents’ Association (EMRA). Fourth
year schedule. Available at: https://www.emra.org/students/
advising-resources/fourth-year-schedule/. Accessed February 13,
2019.
8. Counselman FL, Griffey RT. Fourth-year elective recommendations
for medical students interested in emergency medicine. Am J Emerg
Med 1999;17:745–6.
9. The Emergency Medicine Residents’ Association (EMRA). Pre-
paring for a successful fourth year of med school. Available at:
https://www.emra.org/students/advising-resources/preparing-for-
a-successful-fourth-year-of-med-school/. Accessed February 13,
2019.
10. Walling A, Merando A. The fourth year of medical education: a
literature review. Acad Med 2010;85:1698–704.