Fourth time is the charm: How to make the most of the emergency medicine R4 year

Authors: Ashley Rider MD and Danielle Miller MD (Stanford University)

PGY-4 has a satisfying ring to it, doesn’t it? You might have chosen a four-year program for a variety of reasons. Maybe it was for career exploration and a bit more time to figure out your professional goals? Perhaps it was for a future in academic emergency medicine, and you “heard” four years of training was advisable? Maybe you were enamored with the program’s culture? Or, let’s face it, you may have chosen your program based on geography, and the length of training was irrelevant. Or lastly, upon deep reflection of the last decade of your life, you have come to appreciate your training in four year chunks—undergraduate, medical school, and residency. Whatever the reason, you are here now. And if you find yourself searching for the charm in fourth year, here are four ways to ACE this year.


1. Find your SPACE

Fourth year is more than just an extra year to decide your professional trajectory (although the space to contemplate is a nice perk). Consider this your opportunity to find your niche, whether that be in academics, the community, military, or elsewhere. It might be a chance to ignite the fire for an eventual fellowship, or perhaps the time to gain a bit of expertise for a future role in an ED of your choice.

Regardless of where you plan to end up, try to identify a project interest, QI initiative, or research endeavor that you find rewarding this year — consider how to turn your project into scholarship with the extra time. Many residency programs offer a chief year or mini-fellowships–take advantage of these opportunities to stretch beyond your comfort zone and pursue something you haven’t yet had the opportunity to explore. For example, you might have the chance to deliver lectures and find you love teaching junior providers. Maybe you choose to do a deep dive into operations and develop a project with your administrative leaders. Love ultrasound? All things sports medicine? Can’t imagine yourself at sea level? Take the time to do an elective or side project to explore these interests. Ultimately, the leadership roles or projects that you are involved in make you more marketable as you enter the workforce. Four year programs give you an extra year to make an authentic career decision and to cultivate a niche.


2. Keep up the PACE

There are so many ways to grow professionally during fourth year of residency. First, take advantage of any funding and time off to attend conferences such as ACEP, SAEM, ACEP Leadership and Advocacy, CORD, FemInEm, ALiEM Wellness Think Tank, SMACC, Essentials of EM, and many more! Who knows the next time you’ll be able to make it to one of these meetings, and who knows who you’ll meet when you are there! These experiences are incredible opportunities for networking if you put yourself out there. Plus, all the EM conferences are held in lovely cities–use those Southwest Airlines Wanna Get Away deals to explore!

If you are in a four year program, it has probably been constructed with the assumption that much of that extra year comes with the gift of elective time. Use it! Terrified of epistaxis? Do an ENT rotation and make that scope your new appendage. Never got the hang of dental blocks? Forever cure your 4am tooth pain patient with a killer inferior alveolar after a dental clinic rotation. Can’t kick the international itch? Away you go on a global health elective somewhere distant. If you do things right, electives can be a gift of time, bandwidth, and access to resources that you may never have again. Consider yourself a more well-rounded physician for it.

Finally, with your medical license now in hand, consider moonlighting opportunities. This can be an enormous opportunity for growth, with the safety blanket of returning to your residency to ask attendings all of your unanswered questions. In working on your own, you chisel your self-directed learning muscles and identify your knowledge gaps. Consider urgent care if you are not feeling ready to work on your own in a busy ED. Urgent care is somewhat of a low-resource environment, where you have to decide if that iStat, EKG, and X-ray are enough. It is a place that makes you very comfortable not calling consultants, because there aren’t any. And the patients don’t self-triage to urgent care–you will see the entire spectrum of emergency medicine over time. Plus, the extra income is a nice perk to start paring down those loans during residency.

3. Build a strong BASE

Consider your fourth year preparation for being an attending. Identify your weaknesses and read! This is the time when you will establish practices that you will carry into your career as an attending physician. Shop around for the learning resources you will use beyond residency, such as go-to websites and podcasts. While on shift, be the manager of the ED. Work to optimize flow and the non-technical skills that really matter as an attending. Communication skills, conflict negotiation, and team leadership are important skill sets required of all practicing emergency physicians. Increasing responsibility in your final year of training will give plenty of opportunities to develop these skills.

Also use your time to prepare for board examinations, which are right around the corner. The more quality time with RoshReview now, hopefully, the less you’ll have to put in later. Consider this a year-long board prep course, turn over every rock of your uncharted professional territory. To address knowledge gaps, take advantage of any access you have to board prep materials and structured learning environments. You might also consider your final in-service exam a “dry run” for the ABEM written boards. By starting to think about this high-stakes test during fourth year, you’ll be well-prepared for the boards after graduation.

4. Do it with GRACE

This is our favorite. Take a breather! This should be a year when you get to also invest in yourself before going off to the next step. If there is a hobby that has been collecting dust over the past three years, now is the time to get back into it! If you have a partner, they have probably missed you during training and now is the time to give back. Maybe it’s the year for you to have a baby, get a dog, or go on a grand vacation. Expand your world as the bandwidth widens. Take the time to reconnect with dear friends that have escaped you, call your family regularly, or spend quality time with your amazing co-residents. And finally, consider using the year to give back to the residency. From grassroots wellness initiatives to coordinating events that deepen the residency culture, sometimes the least official means are the most cherished. Ask yourself: What will be my legacy?

This is just the beginning–we hope that your fourth year proves remarkable in so many other ways. May you enjoy every moment!

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