MD Away Rotation Advice; No Home Program

[Welshman]

Hi everyone, I haven't been able to find much relevant advice for my specific situation, especially given COVID changes to the residency application process, so I thought I would ask here.

I'm planning on applying to a small surgical subspecialty this year but unfortunately, my med school is a newish (~15 years old) low tier MD school that doesn't have a home program or even a home department in the field really (we can rotate with a large private practice in the area or some fellowship-trained general surgeons who are a bit more academic but not really and lack connections to the rest of the field). Ergo, away rotations are really important for me to get letters from academic attendings and make connections in this field.

Our national society has endorsed up to two away rotations for students applying from schools without home programs to level the playing field a bit. So far I've been fortunate to get 3 rotation offers. However, some factors are troubling me. Here are the facts:

• Program A offered me a spot in August, Program B in September, and Program C in October (notably, too late to include a letter for ERAS).
• Program A and Program B are top of the line residencies, some of the most competitive in the field (looking at their residents though, they come from all over, not only top schools)
• Program C seems to be more of a "match" choice if that can be said at all
• I've lived in Program C's city before and would love to go back, also love Program B's city
• Program A's location isn't a great fit for me but I'd rather match somewhere and it would be very good training
• Program A offers the best chance to secure a LOR from a well-known faculty member with time to spare before ERAS, Program B is similar but the window is much tighter to get it in before the deadline. Program C cannot help me with any letters d/t timing.

If we consider program B to be locked in, my dilemma is whether to choose Program A to maximize my chances for a great letter which would be a great asset to my application overall or choose Program C to target more of a "match" school to theoretically maximize my chances of matching there but forgo an opportunity for a letter and more influential networking. This would put me in a stressful spot and double the pressure on Program B to provide at least one good letter but follows the more conventional wisdom to rotate where you want to match. I know that aways can always hurt and most students aren't very impressive but not having a home program to fall back on for letter writers I feel forced to make it or break it on aways.

What are everyone's thoughts? I would like to hear from @operaman if possible as I believe it is his field.

Sorry if this was long but I wanted to be as clear as possible about the situation and my thought process!

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[operaman]

Wait you can only do two aways now?? That’s news to me since I remember people who did 4+ before. Do you really have to chose between A and C? Obviously both would be ideal in your case.


The other missing piece of information for me is what the rotations themselves look like in terms of structure. If there’s any chance of moving dates around then this becomes relevant for assuming those dates are fixed then it’s moot.

If there’s no leeway, you need to pick A unless C can get you in sooner. You just don’t have a choice with getting letters. The other considerations are secondary.

If it were me, I would do A and B and reach out to C about possibly coming anyhow. Even if they are limiting people to 2 right now, that may change as people turn down offers. I’m guessing an away in October is not a hot commodity so they may have room for you anyhow. I would email them about your situation that without a home program you need letters before eras. If they could move you earlier then do C instead of A. If they can’t, ask if you could be on a wait list for October and if they have space could you still come and do it as a 3rd rotation? You have a clear interest in their program and location so it’s not unreasonable.

It goes without saying you have to kill it on service. You should also make sure that whoever is doing your schedule knows you need to get letters because no home program. We used to make sure to schedule those students extra face time with a specific attending so they could make an impression. Our chair would also write a letter that was essentially a summation of everyone’s impressions. So make sure you are proactive about that part ahead of time.

 

[NicMouse64]

Wait you can only do two aways now?? That’s news to me since I remember people who did 4+ before. Do you really have to chose between A and C? Obviously both would be ideal in your case.


The other missing piece of information for me is what the rotations themselves look like in terms of structure. If there’s any chance of moving dates around then this becomes relevant for assuming those dates are fixed then it’s moot.

If there’s no leeway, you need to pick A unless C can get you in sooner. You just don’t have a choice with getting letters. The other considerations are secondary.

If it were me, I would do A and B and reach out to C about possibly coming anyhow. Even if they are limiting people to 2 right now, that may change as people turn down offers. I’m guessing an away in October is not a hot commodity so they may have room for you anyhow. I would email them about your situation that without a home program you need letters before eras. If they could move you earlier then do C instead of A. If they can’t, ask if you could be on a wait list for October and if they have space could you still come and do it as a 3rd rotation? You have a clear interest in their program and location so it’s not unreasonable.

It goes without saying you have to kill it on service. You should also make sure that whoever is doing your schedule knows you need to get letters because no home program. We used to make sure to schedule those students extra face time with a specific attending so they could make an impression. Our chair would also write a letter that was essentially a summation of everyone’s impressions. So make sure you are proactive about that part ahead of time.

I think actually we are only allowed to do one.

 

[Welshman]

The vast majority of students are only allowed one away this cycle due to remaining COVID restrictions under pain of "Residency programs are encouraged to take into consideration if a learner exceeded the one away rotation limit during the residency selection process". Although, there are rumors that a few people ignored the rules and did aways last year... I think there were fears that if spots were limited the best students would snap up all 3 aways and leave the rest of the applicant pool with the leftovers. A few of the national societies have taken pity on those without home programs and are allowing them to do two. Medical Student Away Rotations for Remainder of 2020-21 and 2021-22 Academic Year

Regarding doing more than two, I definitely see where you are coming from, they probably will have the room, but in today's climate, people flouting COVID rules are pretty ostracised, so I'm a bit fearful of coming across as 'that guy' without meaning to. My home institution would also almost certainly not support doing more than two as well for the same reasons. And if the cat got out of the bag somewhere else, I'd likely not know or have the opportunity to explain the circumstance.

At Program C I was initially offered a rotation in November and was able to work with them to get October, they've said they're keeping a lookout for any openings in August or September but nothing has come up yet. Since receiving Program As offer for August yesterday I haven't brought it back up with Program C because if they did find the room I would be obliged to accept and the debate between Program As prestige/letter and Program Cs 'matchability' was still on my mind.

They are pretty firm with the dates, the registrars control most of the process and everything goes by the institutional calendar. I'm doing a home rotation in July to get more experience before going on aways so that also limits me to August and September.

The summative chairman's letter is a very interesting idea, I had no idea it was an option. I will definitely bring it up and it will probably be a very good excuse to increase my facetime with important players.

 

[calivianya]

The coalition guidelines say no more than one away in something you can study at your home program, and no more than one away in each area of interest. There is a caveat that if you don’t have a hospital, and you have to do aways to graduate, you are allowed to… so the one rotation limit really only applies to people who have somewhere to go.

For the rest of us, we can safely do one away in each area of interest, so long as the hospitals are not making us check that “this is the only rotation I have done this year” box. I am doing five aways so far, and all of my rotations are in different specialties/subspecialties because of the coalition recommendations. I would have obviously preferred to have all of them in what I plan to match in, but that doesn’t work this year.

Residency programs understand this situation. I am applying radiology, and I had already gotten a diagnostic radiology and an interventional radiology rotation through VSAS when one of my favorite hospitals finally opened up their apps much later than everyone else. I explained thoroughly in the essay they required that I already had those rotations, and so I was applying to a different radiology subspecialty because I could not follow the guidelines if I took a diagnostic or interventional rotation at their hospital. They offered me the subspecialty, and they have something on their app about following the coalition recommendations, so this was not a dealbreaker for them.

That being said, I would take program A for the letter, and then explain to program C that you are very sorry, that you already had a rotation in that specialty and did not withdraw your app to them in time after you had already accepted another (true or not lol), and ask if is there any other rotation in general surgery or a different surgical subspecialty that you don’t have at home still open that you could apply to because you are really interested in their program but don’t want to go against the guidelines.

On your days off or weekends, as long as you are at that facility, you could always ask the people in the specialty you’re interested in if you could come in and shadow on your time off from the other rotation. After all, you are already cleared to go in the hospital if you are doing another rotation there. I’m planning to do this on my non-radiology rotations if they let me.

 

[Matthew9Thirtyfive]

Residency programs are encouraged to take into consideration if a learner exceeded the one away rotation limit during the residency selection process

They said that last year and at least anecdotally it seems that the people who broke the rules had an advantage.

 

[operaman]

They said that last year and at least anecdotally it seems that the people who broke the rules had an advantage.

Yeah I’m positive any program I’ve ever been part of wouldn’t care less if a student did more than two. The guidelines even say that they shouldn’t take the place of good judgement so they sound pretty flexible. Besides, if there’s a slot and nobody else wants it you might as well take it.

 

[Redpancreas]

I am a non-surgical resident who never applied to aways so bear that lack of perspective in mind. That said, I strongly feel you should go with A and B. You have not rotated at C to really know whether it's a good match for you. The unknown is always undefeated. Instead, I would take the certainty A and B offer you. Like you said, the priority is to match and A/B give you the chance to get letters for ERAS. I wouldn't worry too much about the September place (B) cutting it close to dates that your ERAS application goes out. In my experience, faculty do all of this letter writing stuff last minute anyways. It's not like they're writers with monthly deadlines for rough drafts and stuff. Having your experience fresh in their mind at B could be a plus.

I like how you are still trying to negotiate with C. People sometimes ask if turning down a rotation is a knock on you when you're evaluated for a residency program spot there. At least in your case you've made it known your decision is not due to a lack of interest in the program, but realistic logistics (not getting a letter when you need it) which they hopefully understand. Keep in contact and continue to make your motivations transparent.

 

[Redpancreas]

Yeah I’m positive any program I’ve ever been part of wouldn’t care less if a student did more than two. The guidelines even say that they shouldn’t take the place of good judgement so they sound pretty flexible. Besides, if there’s a slot and nobody else wants it you might as well take it.

And again, I know nothing about surgical fields/aways but I assume good judgement meant practicing safe social distancing for COVID right? Not trying to make a political statement but with most of us and 40% of the US fully vaccinated (mainly due to vaccine hesitancy), I don't think extra travel/rotations will be as frowned upon as much it was last year.

 

[Welshman]

And again, I know nothing about surgical fields/aways but I assume good judgement meant practicing safe social distancing for COVID right? Not trying to make a political statement but with most of us and 40% of the US fully vaccinated (mainly due to vaccine hesitancy), I don't think extra travel/rotations will be as frowned upon as much it was last year.

I hope but given the number of people who have to OK it, and knowing those people at my school and their statements on the matter so far, I don't think I would get my institution's approval. Which I believe is needed for an away?
While it's certainly logical and most physicians are rational actors, things like hygiene theater were big at my school; they're also big on principles of social justice and equality (noble efforts for sure but roadblocks when trying to bend the rules). It never hurts to ask though.

The coalition guidelines say no more than one away in something you can study at your home program, and no more than one away in each area of interest. There is a caveat that if you don’t have a hospital, and you have to do aways to graduate, you are allowed to… so the one rotation limit really only applies to people who have somewhere to go.

For the rest of us, we can safely do one away in each area of interest, so long as the hospitals are not making us check that “this is the only rotation I have done this year” box. I am doing five aways so far, and all of my rotations are in different specialties/subspecialties because of the coalition recommendations. I would have obviously preferred to have all of them in what I plan to match in, but that doesn’t work this year.

3/5 aways in specialties outside your intended field is quite a lot, this seems like it would work well in DR/IR since they're very related but perhaps not as well elsewhere unless you completely flout the service you're on to work with another and use all you're free time for the month trying to get facetime which seems like it would be detrimental my own efficacy after 3 months... Also paying double rent for 5 months can be expensive if roommates don't like sublets lol... Are you doing this because you have required rotations not at your school or because you just want to explore?

 

[AzBasRad]

I hope but given the number of people who have to OK it, and knowing those people at my school and their statements on the matter so far, I don't think I would get my institution's approval. Which I believe is needed for an away?

While it's certainly logical and most physicians are rational actors, things like hygiene theater were big at my school; they're also big on principles of social justice and equality (noble efforts for sure but roadblocks when trying to bend the rules). It never hurts to ask though.

OP, you have the right mindset. No need to ruffle any feathers with your school's admin and risk professionalism comments this close to residency applications.

 

[calivianya]

I hope but given the number of people who have to OK it, and knowing those people at my school and their statements on the matter so far, I don't think I would get my institution's approval. Which I believe is needed for an away?
While it's certainly logical and most physicians are rational actors, things like hygiene theater were big at my school; they're also big on principles of social justice and equality (noble efforts for sure but roadblocks when trying to bend the rules). It never hurts to ask though.



3/5 aways in specialties outside your intended field is quite a lot, this seems like it would work well in DR/IR since they're very related but perhaps not as well elsewhere unless you completely flout the service you're on to work with another and use all you're free time for the month trying to get facetime which seems like it would be detrimental my own efficacy after 3 months... Also paying double rent for 5 months can be expensive if roommates don't like sublets lol... Are you doing this because you have required rotations not at your school or because you just want to explore?

Both, honestly. My school does not give us any rotations for fourth year. I have to arrange the entire year myself, at whatever site will take me. They specify that the hospitals we use as third year sites are for third years only, and the only way we can get rotations at those hospitals is if we apply through VSAS like everyone else. Besides, most of those sites are 1,000 miles away from me since I got sent to a super far away site for third year, so those aren’t any better for me in any way. We are also limited to no more than 12 weeks per facility, so we can’t just park somewhere and stay all year.

A bunch of my classmates just find local doctor’s offices, but I am really tired of glorified shadowing and would like to do some actual learning with residency programs. If I had the money, I’d do every single rotation as an away just to get a better education. Five is already getting pretty pricey.

I do have all five in different states in all different parts of the country, because I would like to get a feel for more places to help decide where I’d like to go. I have no regional preference right now.

 

[Matthew9Thirtyfive]

Both, honestly. My school does not give us any rotations for fourth year. I have to arrange the entire year myself, at whatever site will take me. They specify that the hospitals we use as third year sites are for third years only, and the only way we can get rotations at those hospitals is if we apply through VSAS like everyone else. Besides, most of those sites are 1,000 miles away from me since I got sent to a super far away site for third year, so those aren’t any better for me in any way. We are also limited to no more than 12 weeks per facility, so we can’t just park somewhere and stay all year.

A bunch of my classmates just find local doctor’s offices, but I am really tired of glorified shadowing and would like to do some actual learning with residency programs. If I had the money, I’d do every single rotation as an away just to get a better education. Five is already getting pretty pricey.

I do have all five in different states in all different parts of the country, because I would like to get a feel for more places to help decide where I’d like to go. I have no regional preference right now.

Wtf kind of school is this? You’re paying hundreds of thousands of dollars for that?

 

[Welshman]

Wtf kind of school is this? You’re paying hundreds of thousands of dollars for that?

His sig says DO class of 2022, and I have heard that fourth year at some DO schools can be like this. Regardless I agree, it seems totally wrong to then extract full tuition... like almost illegal


Also, thanks for all of the advice guys, its really helped

 

[Matthew9Thirtyfive]

His sig says DO class of 2022, and I have heard that fourth year at some DO schools can be like this. Regardless I agree, it seems totally wrong to then extract full tuition... like almost illegal


Also, thanks for all of the advice guys, its really helped

Ah yeah I’m on my phone so don’t see sigs. That should be illegal.

 

[calivianya]

Wtf kind of school is this? You’re paying hundreds of thousands of dollars for that?

I agree! I also agree that it should be illegal. I am at a well-established, older DO school.

What’s worse is they just told us they charge our tuition by year, not by semester… so since we only have two semesters for fourth year instead of three, our payments are going UP per semester this year. For a second I thought this would be the cheapest year, but yeah - that’s not going to happen.