As a 4th year, I'd say my advice is to pound out a couple months of the harder stuff you'll do during fourth year early on (e.g. a sub-I, like a good ICU month or comparable, and an ER month if your program requires it). This serves four purposes: 1) get experience doing something hard which will make you a better/more efficient med student who can deal with sick patients, 2) show residency programs you are not lazy and give you some credibility and confidence when interviewing, 3) potentially generate a letter of recommendation (one from a sub-I will hold weight), and 4) get those rotations out of the way so late 4th year can be more cushy. Balance this with other goals you may have for early 4th year: visiting rotations, step 2 if you want to improve upon step 1, and cool stuff you won't otherwise see.
For each person the answer will be different. Here's what I did: July "off" and took step 2 at the end just to get it out of the way; August was an elective in the other specialty (child and adolescent psych) that I had to rule out before I was 100% sure about my choice (peds); September was a NICU Sub-I (counts as a "medicine" Sub-I); October was a visiting elective at an institution I'm considering; November was ER; December is a cushy elective in Radiology; January will be interviews; Feb will be my required surgery Sub-I; March onward is pretty much electives or minor requirements. As I hinted before, I think having done a NICU Sub-I and gotten honors and a good evaluation in it gives me confidence and credibility in my interviews. If you are considering peds and you want to do an ICU sub-I, obviously PICU or NICU would be good choices. You might want to go with PICU because that's at least a little more in the realm of family practice, in case you end up doing that. Doubt you'll take care of NICU babies in FP, and you don't learn as much in NICU that can be generalized to other realms of medicine.
Just my 2 cents.
bpkurtz
