Fourth Year

The second half of your third year and first half of your fourth year is your time to make your dream of orthopedic surgery a reality. This period can be split into three major sections:

1) Application and sub-I preparation (Jan-Apr)

2) Sub-I performance/Virtual Open Houses (May-Nov)

3) Interviews/match. (Dec-Mar)

We have laid out a general timeline to help you understand the process. We know this looks like a lot, but this is just to give you a bird’s eye view. Each box on our timeline is further explained below, and each topic has articles or educational resources to help you dive deeper.

January to April: Application and Sub-I Preparation

It’s official, you are applying orthopedic surgery! If you have not already, we recommend making a professional social media account and introduce yourself. January is a great time to start preparing for fourth year. In addition to ending your third-year clerkships strong, start preparing by selecting/coordinating your sub-I’s, aggregating your sub-I requirements (VSLO), getting ready for sub-I’s, building your step 2 dedicated plan, and compiling your ERAS requirements. We know its a lot which is why we recommend starting as soon as possible.

Selecting/Coordinating your Sub-I’s

With the transition of Step 1/COMLEX 1 to P/F and the addition of preference signals, Sub-I’s have now been more emphasized. Thus, choosing your perfect Sub-I’s is important. Check out this article with tips on selecting sub-I rotations. The Orthopaedic Residency Information Network (ORIN) and Residency Explorer are two great resources to learn more about different programs to help you select your sub-I’s. Away rotations are normally scheduled between May and September. On average students do four rotations (including home if applicable). We highly recommend you discuss your sub-I selections with at least one advisor (ie. Program Director) as they can gauge your competitiveness and provide an outside perspective on your selection and total number they would recommend. Lastly, we highly emphasize you coordinate your away rotations with students at your institution. Ideally, no student should rotate at the same program at the same time. Check out this sample spreadsheet you and your fellow home students can adapt to coordinate your aways. Work with each other, not against!

Sub-I requirements (VSLO)

Each year, VSLO opens in February. Once you obtain access, spend time getting comfortable with the platform and exploring programs of interest. When looking at programs, you will see many requirements such as immunizations, headshots, and CV. Check out our blog post on VSLO preparation. It also may have been a while since you updated your CV, check out this article on updating your CV.

Step 2 Dedicated Studying

The transition of Step 1/COMLEX 1 to P/F has only increased the emphasis on Step 2 scores. In the past, some students would take Step 2 after the ERAS deadline. Now, many programs require you to have taken Step 2 before. Thus, make sure you have room in your schedule to take Step 2. We recommend you take Step 2 before you start your sub-I rotations around May-July. Check out this article on Step 2 study tips.

Sub-I Preparation

In addition to selecting the right sub-I’s, excelling on sub-I’s directly can influence you matching. Thus, we recommend you take some time to start preparing. Check out this introductory powerpoint on Ortho Aways 101 to get you started. We acknowledge that some schools provide an introduction to Sub-I’s and some do not. To standardize preparation, we have created a virtual Sub-I Summit that was held on March 24, 2024 from 9:30AM-1:15PM ET. This summit had four panels focused on what we believe are the four most important areas: soft skills, taking call, navigating the operating room, and excelling in clinic. If you missed the Sub-I Summit this year or want to watch again, check out the recordings on our Sub-I Summit page. The next Sub-I summit will be held next March/April 2025 and will be announced on social media.

Additionally, we have partnered with OrthoACCESS. OrthoACCESS provides a free and virtual orthopedic surgery medical student curriculum teaching high yield orthopedic principles and pathology. They also include additional learning materials to maximize your learning success. We recommend registering for their 2024 Synchronous Curriculum that will start around May-July 2024. Check out the Comprehensive Education Section of our Resource Center to learn about additional educational resources you can use in preparation for sub-I’s. If you are a podcast person, check out our Podcasts Section of our Resource Center. Great for long commutes! Lastly, if you have time to work on key skills, check out our Skills Section of our Resource Center.

Lastly, our MSOS resident volunteers have put together incredible blog posts that expand upon important sub-I advice. Check our articles on Preparing for Call and Preparing for a Case. More blog posts to come!

Compiling your ERAS Requirements

Every year, ERAS deadline is in September. For most, that deadline is during a Sub-I rotation. We recommend you aggregate and fill out all documents needed for ERAS BEFORE Sub-I’s so that you can primarily focus on your Sub-I performance. The application can be split into overall application, letter of recommendations, USMLE/COMLEX score reports, professional photos, MSPE (dean’s letter), and medical school transcript. ERAS has many resources for all steps of the application that you can find here.

  • Overall Application: We recommend filling out the ERAS Applicant Worksheet. This worksheet includes all aspects from the applications from signals to meaningful experiences. Preference signaling is a relatively new addition to the application process. Proper designation of your 30 signals can highly influence your match outcome. Check out this article on Strategic Preference Signaling. Personal statements take much longer than you may think. It is best to start your draft as soon as possible. Check out these articles on Starting your Personal Statement, Writing an Effective Personal Statement and Do’s/Don’ts of a Personal Statement. Check out these incredible articles from the Inside the Match team on ERAS Work and Volunteer Experience Section and Hobbies and Awards Section.

  • Letter of Recommendations (LOR): Most programs require 3-4 LOR’s. Check out these article on Asking for a Strong LOR, LOR Tips for Success. Specific for ortho, we recommend having as many of these LOR’s come from orthopedic surgeons. One can be from a non-orthopedic surgeon but try to keep it to only one. Many programs have now adopted the electronic Standard Letter of Recommendation (eSLOR) from AOA. We recommend mentioning this to your letter writers before they start.

  • USMLE/COMLEX 1&2 score reports: This can be found on the NBME website. Remember to save those score reports on your computer. You will also need these reports for residency and if you do not save you will have to pay after a certain duration.

  • Headshot: Get that professional headshot!

  • MSPE (Dean’s Letter) and Medical School Transcript: Follow-up with your medical school on these two as soon as possible. Make sure to review your MSPE before they submit, checking for typos, grades, and evals.

May to November: Sub-I Performance/Virtual Open Houses

Sub-I Performance

Sub-I’s are a great opportunity for you to showcase yourself as well as learn a lot about a program where you may spend 5-years! Most residency programs are looking for hard-workers, team players, and problem solvers. Below you will find general advice for your rotations and resources we recommend you use during your sub-I’s. If you have time before your sub-I to prepare, take a look at the section above on sub-I preparation. Lastly, Sub-I’s can be expensive, we’ll end this section with general advice on how you can save money during this time.

  • General Advice:

    • Be yourself! Do not try to conform your personality to what you think the program is looking for. You are choosing a program as much as they are choosing a resident.

    • Be respectful! Do not trash-talk other students, residents, attendings, or other programs

    • Help the team! If you are not in a case, always be available and enthusiastic to help with tasks

    • Don’t be a “Legend”! You do not want to be remembered as that student who accidentally did a fasciotomy on a patient when cutting the drapes. Be very intentional with your words and actions.

    • Always carry shears! These should never leave your side.

  • Resources: We recommend you utilize our resources on preparing for cases and call. If you prefer video content, take a look at OrthoACCESS’ videos. If you prefer a textbook, check out Orthopaedia’s free online textbook. Below are more resources to use during Sub-I’s with descriptions on when/how to use them.

    • Orthobullets: Good to use as a general resource for all environments of call, clinic, and OR and for all sub-specialities.

    • The Handbook of Fractures: Great resource to learn details about fracture pathology and management. Good to use on call to learn more about a fracture that comes in.

    • AO Surgery Reference: Great resource that goes over general surgical approaches for fractures that can be used as preparation for fracture cases.

    • Hoppenfeld’s Surgical Exposures: Great resource to use for reading to prepare for cases and anatomy review

    • Pocket Pimped (Paid): Aggregation of common pimp questions you may be asked in the OR. Great to review case-specific questions before entering OR.

    • Guide to Reading Orthoapedic X-rays: Systematic approach to reading x-rays that is highly useful when presenting at fracture conference.

    • Sub-Speciality Specific Resources: These resources in our Resource Center are great to read based on the service you are rotating on to learn about pathology and decision-making

    • Netter’s Atlas of Human Anatomy: Great surgical anatomy atlas review to visualize before entering a case

    • Landmark Articles: Great articles to review and reference based on service you are rotating

  • Expenses: For Sub-I’s your biggest expenses will be travel, accommodation, and food. If you are doing three-four away rotations, the bills will add up! Many organizations offer sub-I scholarships. Check out our sub-I scholarship list and see if these options work for you. For accommodation, it is ideal to stay with friends/family if applicable. If this is not an option, check out Rotating Room. This service connects medical providers to affordable short-term housing options hosted by medical providers. If not applicable in the region you are doing your sub-I, AirBnB is a good options as well.

Virtual Open Houses

Around August, programs start hosting virtual open houses. The majority are after ERAS submission so may not influence your application/signaling, but they are a great resource to learn more about the programs you did apply. We recommend you take notes and attend programs you signaled/applied to help you generate great questions for interview. As it is hard to keep track of all virtual open houses, check out our Virtual Open House Calendar.

December to March: Interviews/Match

Interviews

Congrats! You have finished the toughest part of fourth year, sub-I rotations. Now it is time for interview practice to prepare crafting your narrative. Check out our 2023 MSOS Interview Panel Recording to learn how to get started. We recommend you start with preparing responses to common interview questions. Check out these articles on Interview Questions/Strategies and Common Interview Questions/Responses. Some interviews are still virtual so we recommend practicing in the virtual environment. Record yourself on zoom and play it back observing your verbal and non-verbal communication. After you feel confident with your responses, get feedback! Message your mentors, fellow students, family, and friends and schedule practice. To keep feedback objective, you can use this sample interview evaluation sheet. The more practice you do, the better your responses will sound and more confident you will be.

For specific programs, be prepared to answer “Why that program”. Additionally, always have questions ready for residents/attending interviewers. Check out these questions to ask Residents and Attendings. We recommend you do your research on programs to create unique “Why that Program” and interesting/targeted questions. Virtual Open Houses and conversations from students, residents, and attendings are a great way to learn about programs.

Remember throughout the interview process, you are not only trying to sell yourself to programs but also learn about them as well. At the end of each interview, we recommend you take notes about the program. These notes will be particularly useful when making your rank list. Check out this article on Tips to Organize Interview Notes.

Match

Around the end of February, your rank list is due. Crafting a rank list can be anxiety inducing. Check out one of our blogs on Making an Orthopedic Surgery Rank List. For those couple matching, check out this great article on Tips for the Couples Match. Remember when making your rank list, rank programs based on where you want to go, not based on your perception of where you think you are on programs’ rank lists.

Should I send a letter of intent? After interviews, if it is clear to you what your number one is, you can consider sending a letter of intent. If choosing this option, we highly recommend only sending a letter of intent to one program as you are stating to them that they are your number one. Check out this article on Crafting your Letter of Intent. You can complement this letter of intent by asking your mentors to reach out on your behalf.

Prepare for SOAP. Even if you think you are the best applicant, have a back-up plan ready. Be ready to decide among these three options if you were not to match: research year, transitional year, or changing specialities. There is no right answer but whatever you feel is the best choice for you. Check out this blogs from Nailed it on “So you Didn’t Match” as well as the resources provided by AAMC.

What to do when you match? Celebrate! All your hard work has paid off and now it is time to relax before the next challenge of residency begins. Check out this article on post-match tips. However, please be considerate of those who have not matched. Unfortunately, many applicants go unmatched. Check in on your friends who have not matched and be there for them.