The First Line episode on this topic is the most listened-to episode for a reason. This blog post (and the episode) are required reading (and listening) for anyone entering their fourth year of medical school. It is essential for third-year medical students—and even first- and second-year students looking ahead—to prepare for selecting a specialty, scheduling rotations, and excelling in the U.S. Residency Match.
This post is focused on the U.S. Residency Match and includes insights for international medical graduates (IMGs).
Key Definitions
What Are Away, Rotations, Audition Rotations, and Sub-Internships?
Away Rotation: A clinical rotation not at your core site (where you did your 3rd-year rotations). Typically involves travel.
Audition Rotation: A clinical rotation at a site with a residency program you’re interested in. You’ll work closely with residents and attendings, providing a chance to make an impression. If you do well, you are more likely to be offered an interview there or get a “call-back”. If you don’t do as well, they may not invite you. That’s why it’s called an “audition”.
Sub-Internships (Sub-Is): A rotation in 4th year where you’re treated like an intern, often with responsibilities similar to those of a first-year resident. They can be home or away rotations. If an away or audition rotation is distinguished as a sub-I, it may be more intense than if it was not designated with this term. What a sub-I means at different institutions varies widely.
Auditions and sub-Is can be home rotations or away rotations. Away rotations are pretty much always audition rotations because, for the most part, you wouldn’t take the time to travel to a different site if they didn’t have a program you are interested in. Away rotations and audition rotations are sometimes sub-Is.
Observerships and Externships
Observership: A shadowing opportunity, primarily for IMGs, with limited hands-on experience.
Externship: A more active learning role for IMGs, offering experiences closer to a rotation.
Which Opportunities Should You Pursue?
Focus on rotations labeled “sub-internship” or “audition” to maximize your chances of impressing programs and securing interviews. However, any away rotation at a program with residents and attendings is still considered an audition, even if it is not labeled as such.
For IMGs, externships are typically more valuable than observerships.
Timeline for 3rd-Year Students for Applying to Audition Rotations
November: Start Planning
Specialty Selection: Aim to decide on your specialty by mid-3rd year. You will want most (if not all) of your away rotations in your specialty of choice.
Rotation Planning: Start a tentative list of programs for away rotations. Competitive specialties at top institutions require prompt applications. It doesn’t have to be the whole list but at least your top choices you would be interested in auditioning for.
For students at a medical school with home residency programs at a home hospital affiliated with your medical school, you can fill most of your rotations for your schedule at your home institution. You may want to travel for a few away rotations, but this depends on your specialty and your top choice institutions. For students at a medical school without home residency programs (like my school that only had family medicine residents in town), you’ll likely be required to travel. Even if you aren’t required, it’s smart to travel to get a new experience distinct from your core rotations. This means traveling to institutions with residency programs so you can see what it is like to be a resident there. No matter what medical school you attend, you’ll likely be traveling for at least one rotation, and these away rotations are competitive to get scheduled. Students from all over the country are applying to the same institutions for rotations. The more competitive the specialty and the specific residency program, the more competitive it will be when applying. Sometimes the application process is almost like a mini-residency application with a CV, personal statement, and sometimes even letters of recommendation. Others are on a first-come, first-serve basis. All that is to say that it pays off to be prompt with your applications to rotation experiences.
December-January: Begin Applying
Look at program websites to figure out how you will be applying to rotations. Some programs have an application on their website. Others tell you to email coordinators, while many programs will say they use an online application portal like VSLO or Clinician Nexus. If you don’t see specific info, you can always find the “contact us” area and reach out to their program coordinator to ask. All but one of my rotations were scheduled independently with the site directly through an online application or via email. I would start here first and fill as much as you can (in addition to Clinician Nexus if it applies to you) before February so you can apply on VSLO for any gaps in your schedule.
Begin asking for letters of recommendation from rotations you’ve completed. (More on this below)
Any earlier than December, programs are way more focused on recruiting for their intern class, so you likely won’t hear back by December at the earliest, which makes December and January the ideal time to start making your list and applying. I started over the holiday break when I had more time.
Start thinking about where you'd like to complete away rotations and begin applying if they do not participate in VSLO.
February: VSLO Opens (for most programs)
Apply early to rotations listed on VSLO. Each application is $15, which covers however many months you apply to, so it’s worth including all the times you have open and are willing to go.
Proactively monitor deadlines and submit applications promptly.
VSLO is run by the AAMC and usually in early February. It was formerly known as VSAS. This allows you to have a common application for rotation experiences, but these are the most competitive ones since VSLO makes it easy to apply. For each rotation, you can apply to multiple time frames, so many students apply to 3 or 4 months per experience, which counts as multiple applications. A few institutions will have several types of experiences for a given specialty. I applied to over 50 total slots (probably around 20 rotations experiences at about a dozen institutions) and was accepted to one. I have classmates who had even worse luck. It is a game of chance and getting in your apps early. On VSLO, institutions each have their timeline for submissions, acceptances, and confirmations.
The process ends once you fill out your schedule! The number of away rotations you apply to will depend on how many you want to do. This depends on your competitiveness for residency since doing more will increase your chances of matching in that specialty, while others will have marginal benefit from completing additional rotations. It also depends on your specialty of choice since some specialties expect you to complete a sub-I (e.g., most surgical subspecialties). Others don’t have this expectation (e.g., family medicine).
Clinician Nexus is another tool used for hospitals that are part of HCA. If you have an institution on your list that is part of HCA, you can easily apply for a rotation on this site. I did not personally use this site, but my classmates had great luck with it. Some classmates set up all their rotations with this service.
Deciding on Your Specialty
Starting this process in December and January of 3rd year is pretty early, earlier than you would think. At this point in the year, you may have only rotated through half (or less) of the core rotations, so there are some specialties you haven’t rotated through yet and many others you won’t see during the third year.
Research different specialties online. You can even ask questions on Reddit or Student Doctor Network to get a rough idea about specialties and hear from residents and attendings about why they chose their specialty. Take these anonymous sites with a grain of salt!
Questions to Consider
What Did You Enjoy Most During Preclinical and Clinical Years?
What material came naturally to you?
What topics intrigued you?
Were there any topics you found yourself looking for supplemental materials on just because you were curious?
Read through a research journal that includes categories by specialty (like the American Medical Association journal). What catches your eye and is something you would be interested in reading?
What Rotations Were Most Fulfilling?
Do you prefer inpatient or outpatient care?
Surgery or medicine?
What Patient Populations Do You Prefer?
Pediatrics, geriatrics, adults, pregnant individuals, or a mix?
What Types of Patient Interactions Do You Like Best?
Are you hands-on?
Do you enjoy building relationships over time?
What patient case has been most interesting to you over your clinical experience?
What was the high point of your rotations so far, when you felt most like a doctor?
Resources to Explore Specialties
AAMC Careers in Medicine. This was helpful to me in 2nd and 3rd year.
Scholarly journals categorized by specialty
Individual physician (reach out to physicians you know in different specialties you are curious about or alumni from your school about how they found their specialty)
Shadowing opportunities (ask a lot of questions while spending time with them)
Narrowing It Down
You don’t necessarily need to nail down quite everything. If you know you like internal medicine, you don’t have to decide on pulmonology or cardiology quite yet. You can do general internal medicine rotations and maybe explore one of your subspecialty interests in one month of your away rotations (or save it for later in the year).
If you answered one of my questions that yes, you love surgery, you also don’t have to decide on your specific surgery quite yet. Schedule some general surgery rotations and a rotation or two in a subspecialty if you are interested. Just make sure you do get exposure to the subspecialty before you apply in September!
Letters of Recommendation (LORs)
Timing
Ask preceptors for letters during or shortly after your rotations.
Request LORs tailored to your chosen specialty to make them impactful.
Secure letters early to avoid scrambling in September.
Best Months for Audition Rotations
Schedule key rotations in July or August so you can ask for a letter of recommendation.
Deciding on your specialty early also helps with getting strong LORs. When you ask one of your preceptors to write you a LOR, you want to tell them what specialty you are applying to so they can gear their letter towards that specialty. Ideally, you are asking for letters during your rotations or shortly after the rotation finishes. It helps to give them direction so that your letters can be all uploaded as soon as possible. Don’t be one of those students scrambling for their last letter or two in September.
Tips for Success
Plan Early and Strategically
Align your rotations with your specialty.
Start applications early to secure competitive spots.
Explore different specialties through research, shadowing, and conversations with mentors.
Good luck as you prepare for this pivotal year in your medical career!