In contrast to the junior year, the senior year is predominantly an elective year (students can select the majority of their rotations, usually the only year in their pipeline of medical education when they will have this opportunity) and is less rigorous than the junior year. The other major difference which makes the senior year more difficult is that the focus on medical education and professional development must be balanced with a priority of "seeking a job" for the next year. The distraction of this priority varies with each student's situation - some will be minimally impacted, while others will find the residency application process a major distraction in the senior year.

In addressing the organization of the senior year, attention needs to be given to both content (questions 2 - 5) and sequencing (questions 6 - 10) issues.

CONTENT ISSUES

Organization of the senior year by content areas can be considered. The advantage of this approach is that it suggests a reasonable template for both an appropriate content and sequence for the senior year. For most medical students, a reasonable senior year sequence by content areas would be planned as follows:

1. Career choice rotations in early senior year (July/August) - experiences taken to finalize career choice.
   
2. Preparatory rotations (August - October) - once career choice is resolved, key rotations may be taken to obtain essential skills in preparation for key upcoming rotations (in specialty area, or away at outside institutions).
   
3. Rotations away, if desired (September - December) - taking a clinical experience at an institution of interest for residency training.
   
4. Interviews for residency (December/January)
   
5. "Finish up" rotations (January - May) - finishing up remaining curriculum requirements at home institution.
   
6. "Exotic" rotation, if desired (March - May) - taking a unique or "world class" rotation (exotic rotation choice of interest, international rotation) to finish the senior year.

In general, a broad based senior year, in preparation for the broad based specialty of Emergency Medicine, is a good idea. Virtually anything taken will have applicabity to Emergency Medicine.

In general, the four best experiences as preparatory rotations for an Emergency Medicine rotation or career include Cardiology (particularly CCU critical care experience), Radiology (reading plain films, CT, ultrasound), Orthopedics (fracture management and musculoskeletal exam), and Intensive Care experiences.

Other useful rotations include Internal Medicine, Pediatric Emergency Medicine, Neurology/Neurosurgery, Anesthesiology, Surgery and/or Trauma Service experiences, Toxicology, and Ophthalmology/Otolaryngology.

The worst reason to do a rotation away is "Because I was told by the residency director/faculty at another program that I would not have a realistic chance to be selected unless I spent a month on site at their institution". Selection to a specific residency rarely correlates to completion of a "command performance" requirement, and if duplicative, affords no educational value to the student.

What are good rationales to do a rotation away? Two suggestions:

1. If one particular residency stands out as an especially exciting possibility as a residency choice (due to geographic location, special expertise or emphasis, or reputation within the field), doing a rotation on site makes sense, due to mutual benefit. Not only does the program evaluate you - you also evaluate the program, there is something in it for you.

2. To experience a unique or "world class" rotation in an area of interest. For example, if your interest is prehospital care or toxicology, an EMS or toxicology rotation at an institution with a fellowship program or with an excellent or unique set up in these fields might be desirable for future career development whether or not you ultimately match to that particular program. If your interest is trauma, taking a trauma rotation at an institution with an acclaimed or unique trauma experience is something you will always remember and benefit from regardless of your future directions.

Research, community service, international experiences, organizational involvements, or pursuit of additional degree training (public health, business, administration, education, etc.) could all be considered, depending on specific interests. None of the above are required as an applicant to Emergency Medicine programs, so do not feel obligated to undertake such activities if you are not truly interested in them for their own sake. Additionally, heavy emphasis in one or more of these areas will generally not compensate for academic deficiencies in the medical curriculum. However, if you are so inclined, such experiences can be invaluable developmentally. As with rotation choices, selection of such extracurricular experiences should be carefully considered and sequenced appropriately in the senior year amidst other priorities.

SEQUENCING ISSUES

Some students will be fortunate enough to identify their career choice over the course of the junior year (whether in Emergency Medicine or another field). If so, congratulations!! This affords ample time over the spring and summer to contemplate subsequent questions regarding senior year organization, whether to take a rotation away, and which residencies to apply to.

Probably the majority of students are not able to make a final choice of specialty by the end of their junior year. In most cases, this may be due to needing to take a senior year experience to confirm an intended choice, or to take two or three early experiences in the senior year to finalize a choice among several possibilities. In general, a good objective for students to strive for is to narrow down your possibilities for career choice to two or three related possibilities by the end of the junior year. The early part of the senior year can then be used to take confirming clinical experiences to finalize specialty choice.

This is an individualized consideration for each student, and there is no right or wrong answer. Students may wish to or need to utilize unscheduled time to complete make-up requirements for clerkships, research, organizational involvements, additional training, personal commitments, etc. that could occur at virtually any point in the senior year.

However, having stated the above, a few logical points for placement of unscheduled time for the majority of students exist:

1. July of senior year - to relax and undertake "a breather" after a rigorous junior year.

2. A month in late summer or early fall for "paperwork" related to residency applications - compiling a curriculum vitae, personal statement, recruiting letters of recommendation, completing residency applications, finishing ERAS diskette, setting up away rotations, etc. May be especially effective if coupled with USMLE II preparation, complete two priorities with one unscheduled month.

3. December or January to allow dedicated time for interviews.

4. And of course, at the end of the senior year as terminal leave.

Again, this is an individualized consideration for each student, and there are no right or wrong answers. Below are some of the salient considerations:

1. Will you have completed all of your core junior year clerkships (Medicine, Surgery, Pediatrics, Psychiatry, Ob/Gyn, Family Practice) by August? If not, plan on deferring Step II until prerequisite clinical experiences are completed.
2. Is passing USMLE II a requirement for graduation at your school? If so, this mitigates toward taking USMLE II earlier, in order to preserve time for a second attempt at the exam if unsuccessful.
3. What is your level of standardized test taking skill? If you are not a proficient standardized test taker, consider taking the exam in August to preserve time for an additional attempt prior to graduation.
4. Preparing for the Step II exam will cause a certain amount of extra distraction in conjunction with other priorities. What is you preference - to have this distraction occur in early fall amidst specialty choice decision making and residency applications, in late fall during important rotations, or in the winter with interviews and rank order lists? There is no "right" answer; each student is able to pick the point in the senior year when the least parallel distraction is anticipated, allowing the best focus on the examination. Whether you choose (or not) to plan unscheduled time for these periods, or for USMLE II preparation, may influence this consideration.
5. The final consideration on when to schedule USMLE Step II is whether you would desire for USMLE II to be a consideration in the residency application process (take early) or not (take late). To explain the thinking here, use the analogy of the "NFL Draft". At the scouting combines, top draft prospects will often skip these sessions, while weaker prospects want to attend to show scouts what they can do, and enhance their chances of getting drafted. Why? The top prospects have nothing to gain bya good workout, but have a lot to lose with a sub-par workout performance, including draft position and money. The weaker prospects have little to lose from a poor workout, but have much to gain from a strong one.

The analogy carries over with Step II timing from a residency application viewpoint. If you achieved a Step I score of 240, you have little competitiveness to gain in taking Step II early, but much to lose with a sub-par performance. From a competitiveness standpoint alone, you might consider deferring the exam (although if it is better to take it early for other timing reasons, then do so).

Conversely, if you achieved a Step I score that is marginally competitive in your intended specialty, then take Step II early.You have little to lose from a poor score (correlates with the lower score for Step I anyway, doesn't change programs thinking about your candidacy), but everything to gain in raising your competitiveness with a good score. This is a golden opportunity to improve your application if you can prepare well and perform superbly.

The heaviest interview months for residency interviews in Emergency Medicine are in December and January. Some residencies may extend interview invitations earlier (October or November) to especially well qualified applicants, to students already on site undertaking away electives at that institution, or to applicants well known to the institution (i.e. students from their home school, repeat applicants, or those with clinical or research experience at the site). If you are offered an early interview and it is convenient to accept, go ahead. However, for planning purposes, anticipate that the majority of your interviews will occur in December and January, and plan accordingly for time off, flexible rotations that will allow absences for interviews, and so forth.

If you are planning to undertake a lot of out of town interviews around the country, it is generally a good idea to plan for time off in December and/or January in order to block travel for interviews and to avoid compromise of clerkship experiences and responsibilities. If you are planning fewer interviews that are predominantly close to home, you may be able to work them around your clerkship obligations, particularly if your clerkship at that time can be a flexible one regarding necessary absences and makeups with you for missed experiences.

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