Senior medical students are tasked with negotiating the complex task of optimizing their learning opportunities while successfully navigating the residency application process. Of all the activities in the final year of medical school, students have ranked away rotations as one of the most important.1 Students enroll in these extramural clinical electives, completed at medical centers other than their home institutions, often for a combination of educational and residency planning purposes. The majority of medical students enroll in at least one away rotation. For highly competitive specialties—orthopedic surgery, neurosurgery, plastic surgery, and dermatology—nearly all students complete away rotations, at an average of nearly 2.5 aways per student.2 These numbers suggest that students view the away rotation as a “de facto requirement” for many specialties.2 To meet this requirement, medical students face pressure to invest a substantial amount of time, money, and effort.
Although away rotations can provide enriching educational experiences and may be instrumental in finding a “best fit” residency program, the process of applying to and completing aways is fraught with misinformation, inflated competition, and financial demands that lead to stress and anxiety. In this article, we use our perspectives as recent medical students to frame a discussion of students’ motivations for completing away rotations; weigh the benefits, risks, and costs; and explore ideas for improving the away rotation experience.
Pressure to Apply for Away Rotations
Student motivation for completing away rotations is undoubtedly multifactorial, yet there are a number of external factors that generally pressure students to complete away rotations. Away rotations in a desired field are a gateway to letters of recommendation. Despite evidence from medical school admissions data that letters of recommendation are poor predictors of students’ future performance,3 letters are an essential component of residency applications,4 thought to provide residency programs with information about an applicant’s character and abilities.5 Although students certainly rely on letters from faculty at their home institutions, they may regard away rotations as necessary to bolster their residency applications with extramural letters.
Recent changes to the format of letters for some specialties have increased their impact on residency applications, thereby increasing pressure for students to complete away rotations. Emergency medicine (EM), for example, has introduced the standardized letter of evaluation (SLOE), formerly the standardized letter of recommendation, to provide evaluation data that are standardized, specialty relevant, and comparable between applicants.6,7 Since its inception, the SLOE has become one of the most important components of the EM residency application.8 Almost all programs require at least one SLOE from applicants, and 20% of programs require a second SLOE before they will grant an interview,9 demonstrating a trend in which a single letter may be insufficient. Although a student may request two SLOEs from her or his home institution, this is regarded as less valuable than SLOEs from two different departments.10 In part because of the limited usefulness of the medical school performance evaluation (dean’s letter) and traditional letters of recommendation in residency selection,11 the concept of specialty-specific standardized evaluations is gaining traction. Otolaryngology has recently adopted its own standardized letter of recommendation,11 and there are calls to expand standardized evaluations to other specialties,12–14 which may further increase demand for away rotations.
Students’ perceptions about the competitiveness of residency may also contribute to the prevalence of away rotations. Virtually all students applying to the most competitive specialties enroll in away rotations, but many less competitive specialties see 50% or more of their applicants completing aways.2 The most recent data from the National Resident Matching Program (NRMP) show that the residency match rate for U.S. graduating medical students has remained steady, yet students continue to include more residency programs on their rank order lists each year.15 Perhaps years of discourse about increased competitiveness for residency positions16 have led students to safeguard against what they believe to be a more competitive process, even if numbers from the Match suggest otherwise. We know from experience that students hear cautionary tales from peers, medical school lore, or online message boards describing the stellar applicant who somehow failed to match. Perceptions about competition for residencies may drive even exceptional students to bolster their applications by enrolling in away rotations.
There is a lack of data regarding the ideal number of away rotations, in part because the number likely depends on the strength of each individual applicant.10 From the student perspective, it can be tempting to assume that more is better, and it is difficult to self-assess competitiveness as applicants as early as winter of the third year of medical school (the start of application season for away rotations). Furthermore, students may receive mixed messages from advisors. A top priority for medical school advisors is a successful Match for their students. Therefore, they may be incentivized to over-recommend away rotations compared with specialty-specific advisors who have a more nuanced understanding of what is required to match within the specialty.
When considering away rotations, we have many factors to consider: What is the optimal number of aways (if any), where should that rotation occur, and how might a rotation affect education and residency application? Students and their advisors must weigh the pros and cons of away rotations before making the commitment.
The Benefits of Away Rotations
Although it is challenging to assess how many away rotations are necessary, we recognize that aways have significant benefits. A survey of students applying to all specialties showed that students see value in away rotations for a combination of audition and educational purposes.2 There appears to be some correlation between rotating and matching at a site, with 36% of applicants to all specialties reporting that they eventually matched at an institution where they had rotated, whether home or away.2 However, this does not necessarily imply causation, and in fact audition rotations do not appear to improve chances of matching at an institution for the most competitive specialties.17 Applicants have also identified previous rotations with a department as an important factor in determining rank list order.18 After rotating with a program, students can make a more informed assessment of fit. Students may also view away rotations as necessary to demonstrate interest in residency in a particular geographic region where they otherwise lack connections.10
Regarding the educational benefits of away rotations, they afford students opportunities to learn medicine in new settings, navigating different health systems. An away rotation can provide appreciation for how different programs within a specialty of interest vary in personnel, approach to education, and values. Students can expand on clinical skills and gain experience working with different patient populations, with the accompanying differences in pathology and socioeconomic determinants of health. By offering a sample of differing practice environments, rotations at multiple institutions provide students with insight into future training and career preferences.
The Risks and Costs of Away Rotations
The investment of time and money in away rotations is significant and begins months prior to stepping foot in the host institution. The Association of American Medical Colleges’ Visiting Student Learning Opportunities (VSLO, previously Visiting Student Application Services) opens during the winter, allowing third-year students to start perusing options for away rotations. VSLO nonrefundable fees cost $40 for three applications, then $15 for each additional.19 Host institutions reserve the right to charge registration and processing fees, costing students up to several hundred dollars before the rotation starts. In total, the mean estimated cost for travel, housing, and transportation is $956 for a single rotation.2 Some host institutions, particularly those in large metropolitan areas, offer low-cost housing options. However, students are still responsible for the rent and utilities costs of maintaining their permanent residences while they are away. Away rotations also coincide with other fourth-year expenses—namely, residency applications, residency interviews, Step 2 Clinical Knowledge, and Step 2 Clinical Skills examinations—thus adding to the financial burden of the residency application process. A post-Match survey in 2013 found that students who chose not to complete away rotations cited cost most frequently as the reason why.17
Students face many challenges when applying to away rotations. Significant time is dedicated to filtering through the many programs listed on VSLO, in addition to programs that do not participate in VSLO and use their own application processes. Although the VSLO system streamlines the search, each participating program has different requirements, deadlines, and fees. Enrollment in away rotations during the most coveted months—dates that will yield letters of recommendation in time for residency applications—is highly competitive. International and osteopathic students face even slimmer chances of securing their away rotations of choice. Students often apply to a large number of rotations as compensation, with no assurance that they will receive even one of them. Applications open at different times, and students are notified of acceptances and rejections on a rolling basis, without transparency and often with short notice, which makes planning difficult. Rotation dates are not coordinated across institutions; when medical school calendars vary, students are forced to start rotations at different times and often end up with one to three weeks of vacation time between each rotation. If pursuing additional rotations at off-cycle schools, several weeks may be spent on vacation, precluding enrollment in other explorative electives.
The opacity of the application and acceptance process for away rotations is likely driving overapplying among students, who may apply to a smattering of “backup” programs rather than focusing on potential best fits. If accepted early on to a backup rotation, students are then faced with the decision of accepting, potentially missing out on a better fit if they waited, or declining, which risks alienating the program and could result in no acceptances at all. Highly competitive applicants may tie up more spots than they need in order to maximize their choices, limiting availability to others who might actually have greater interest in particular programs. Host programs may resort to arbitrary cutoffs such as standardized test scores to filter through a large number of applications. In its current form, the away rotation application process feels like a free-for-all and is a considerable source of stress for many of those who use it.
Excessive participation in away rotations also limits educational growth. The fourth year of medical school is already a target for reform because of its questionable value.20 Students view obtaining additional letters of recommendation as a priority during the fourth year21 and often pursue multiple away rotations at the expense of other important subject areas. Although away rotations may help students beef up their resumes and develop clinical skills relevant to their chosen specialties, completing an abundance of rotations within a single specialty sacrifices opportunities to explore broader learning, such as international rotations, classes for personal interest, or rotations that provide exposure to specialties complementary to a field of interest.
Though strong evaluations and positive letters of recommendation may bolster students’ applications, each additional rotation comes with the risk of a negative assessment. Although negative evaluations may benefit students by indicating a mismatch between program and student, they can also hurt their prospects for residency. If a student perceives that he or she did not perform up to standards for an away rotation, there is the option not to include a letter as part of the residency application. However, away rotations without accompanying letters are likely to raise questions about the applicant’s performance, and may be viewed negatively.
The repercussions of a negative evaluation can make an away rotation a highly stressful experience, with the advice that away rotations be treated as “a month-long interview during which you are always on.”10 Just as interviews favor extroverted personality types,22 these “month-long interviews” may reward extroverted students, who are able to make an impression on unfamiliar attendings and residents during a brief rotation. From personal experience, even when a clerkship director is responsible for authoring visiting students’ letters, face time with this faculty member may be quite limited or dependent on efforts to network within the department, which may be challenging for less outgoing students. Although one could argue that extroversion is an advantageous trait for physicians in some specialties, away rotations might place quiet students at a disadvantage despite strong clinical skills.
Steps for a Better Away Experience
Competition within the residency application process has produced uncertainty about the ideal number of away rotations to improve probability of matching. We worry how residency programs will compare a student with letters of recommendation from three programs versus another student who has letters from only one. Individualized advising can guide students toward the appropriate number of aways, but without evidence that more away rotations are objectively beneficial, it is a challenge to honestly advise students. A prospective comparison of outcomes between multiple away rotation applicants versus home-only applicants would provide some clarity, controlling for variables such as applicant characteristics (demographics, standardized testing scores, overall clerkship performance, sources of income, individual cost of living, and individual debt burden) and location characteristics (average local cost of living, institutional applicant fees, travel expenses, and financial incentives or stipends). If the cost–benefit analysis of taking on multiple away rotations is favorable, then advisors may advocate for students to take on additional rotations to strengthen their candidacy.
Currently, students receive conflicting and mostly subjective information about the optimal number of away rotations. Students may have difficulty self-assessing their strength as residency candidates, leading to unnecessary away rotations even for strong applicants, who may go to extremes to maximize their perceived likelihood of success. At the same time, it is difficult to hear that we may not be as good as we think. One consideration would be to increase the transparency of letters of recommendation. Especially for the SLOE or future standardized evaluations, granting students more access to evaluation data (similar to the dean’s letter) could help assess strengths and shortcomings in applications. Only selective information would be revealed to the student to prevent devaluation of the letter. Future research could focus on what information from letters is most valuable to students, how increased letter transparency skews letter content, and to what extent the resultant letters are devalued in the eyes of residency programs.
Studies have assessed the predictive value of traditional letters of recommendation,23 yet the predictive value of the SLOE has not been determined despite many years of data. Research concerning SLOE or other standardized letter content and resident future performance would help students and residency selection committees evaluate how much to value these items. Until these data exist, educational leaders can speak up regarding the ideal number of letters of recommendation, to dispel misconceptions occurring at the institutional or peer-to-peer level.
There is great potential to reduce the burden of away rotations for students by improving the away rotation application process. Medical schools could improve the student experience by moving toward uniform rotation schedules and application opening dates for away rotations, as well as timely acceptances and rejections so that students may apply more efficiently. A number of schools offer visiting clerkships for underrepresented minorities, including stipends to offset the price of away rotations. We would encourage more programs to adopt this practice to promote equal access to away rotations and socioeconomic diversity among visiting students. VSLO could streamline the application process by promoting uniform requirements for participating programs, providing transparent application data and timelines, and capping the number of applications per student. It could also borrow from the NRMP, implementing a matching process that allows students and programs to prioritize their preferences, and offering open spots as soon as they become available. More research is needed to quantify the number of programs students are applying to and their motivations for doing so. Input from students will be essential in guiding improvements to the away application process.
Even within the current system, we can maximize the benefit-to-cost of away rotations by being strategic. We can prioritize rotations in diverse practice environments with varied educational experiences, and those that result in letters of recommendation written by departments (rather than individuals) or by faculty who are well known within their specialty. List 1 enumerates key attributes that students can look for when applying to away rotations. Although the stress and anxiety that result from the inevitable uncertainty of the away application process cannot be eliminated completely, we can mitigate them by addressing the most problematic aspects. A positive away rotation experience can be a source of immense learning but will always be accompanied by a variety of costs. If we critically examine students’ motivation for enrolling in aways and strategies for making the away application process more student friendly, we can expect a better return on investment.
Key Attributes for a Valuable Away Rotation
- Different practice environment: Clinical sites with different patient populations, pathology, and institutional values can provide insight for future career decisions.
- Letter writers: Ideally, letters of recommendation will come from faculty who are respected in their fields. For some specialties, a departmental letter of recommendation is preferable to a letter from an individual faculty member.
- Opportunity to audition: If a student is considering a particular residency program, an away rotation can provide an in-depth look ahead of residency application season (for applicant and program alike).
- Timing: If anticipating a letter of recommendation, away rotations should ideally be early enough to have a letter filed before residency application season in September. Students might also consider completing relevant electives at their home institution prior to traveling for an away rotation, in order to be prepared with foundational knowledge.
- Other benefits: Some programs provide financial assistance or subsidized housing. Certain programs may also emphasize mentorship and networking for underrepresented minorities in medicine.
Acknowledgments: The authors acknowledge Laura Hopson and Paula Ross for their critical review of this manuscript.
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