The "systems based practices" and "practice based learning" are the domains that you will have the most rough time with.
No matter how high you scored on your USMLE, how many honors you got, the first few months of internship will make you feel dumb. Not because you are dumb but because your responsibilities are efficiently finishing progress notes, writing accurate notes for maximal billing, calling consults early, following up a million orders, satisfying colace/senna and diet orders for nurses, getting people discharged early, getting yelled at by patient's wanting more Dilaudid....
But as for practical real medical skills, perhaps you can spend a fourth year rotation on MICU or SICU. The residents will do all the big procedures but you can probably learn some ultrasonography skills, IV placement, and get the lay of the land on code blues as a "first responder," and get a feel more what to do when patients decompensate.
I recall my first intern response to a phone call on Day 1 of it all for an emaciated vasculopathic patient with hypotension... two 16 gauge IVs stat! (just like in USMLE Step 2 and 3!) LOL. What funny looks I got from the nurses for that statement.
All that knowledge on vasculitis... forget about it for now.
