Abstract

As residency applications loom, medical students may feel pressure to consider participating in away rotations. For some, there is good reason to: program directors (PDs) in fields such as emergency medicine or orthopaedic surgery cited participation in away rotations as either an important factor or the most important factor in residency applicant consideration.1,2 By contrast, only 10% of general surgery PDs consider an away rotation as an important factor, making the decision for general surgery applicants more ambiguous.1 However, with the transition to virtual interviews, the majority of PDs expressed concerns that there would be a disadvantage with the virtual format in terms of being able to showcase their programs adequately, assess the interpersonal skills of the applicant, and provide an adequate understanding of their program to the applicant. This may suggest that an away rotation may prove to be a valuable experience in ways it has not in the past.3 In this article, we, the Collaboration of Surgical Education Fellows (CoSEF),4 provide a framework for thinking about away rotations in general surgery. As there is no right answer, we want to help you make a decision that aligns best with your personal and professional priorities. REASONS TO DO AN AWAY ROTATION Get Greater Exposure to the Field Regardless of where you attend medical school, you may not be exposed to all facets of this broad specialty; perhaps you want to learn at a Level I trauma center with a high penetrating volume or see a rural general surgery practice. Exposure to a new hospital system, electronic medical record, or patient population may help you make a more informed decision when choosing programs to apply to. Learning more about your likes and dislikes during an away rotation may also help you get more out of each interview day and allow you to give more thoughtful consideration when ranking programs. Explore a New Place to Live Many students receive only one acceptance to an MD-granting school, and many matriculate outside of their home state, meaning they may live far away from family.5 Whether students have childcare needs, a long-distance spouse/partner, or a need to help care for an ailing family member, an away rotation can be a fantastic opportunity to rotate close to home. Additionally, it can simply be nice to be closer to a support system, particularly during the stressful months preceding residency applications. Alternatively, an away rotation could be an opportunity to learn more about a new region in the country. This can help you learn what sort of geographic environment you may be looking for before you have to signal regional preferences. Demonstrate a Strong Interest Although the Electronic Residency Application Service (ERAS) now allows for explicitly signaling interest in a program or area, the adage that "actions speak louder than words" possibly still holds some merit; completing one or more rotations in a region can help demonstrate a sincere interest. PDs have an increasingly difficult job as more applicants with fewer objective metrics (eg, test scores) are applying to each program. Only about 40% of applications are reviewed holistically on average,3 making it possible to "slip through the cracks" at your dream program. While doing an away rotation does not guarantee a review of your application or an interview, some programs do review and interview candidates during their rotation, which can help your application be thoroughly considered. Therefore, it can be important to research whether rotating students are interviewed during their rotation when applying to rotations. Demonstrate Your Strengths and Make Connections Some applicants will easily stand out on paper, whether from impressive publications or stellar Step 2 scores. While these are all well-earned accolades, there are certainly applicants with other impressive qualities that may not stand out as well on ERAS. If you have an excellent bedside manner or are a tenacious patient advocate, these qualities might be best demonstrated to those who have a chance to work with you directly. While this may be possible to convey in a letter of recommendation, there have been well-documented issues of gender bias and objectivity in letters of recommendation, which may make them difficult for PDs to interpret.6–8 An away rotation may allow your intangible strengths to shine directly at a program of interest. For applicants who are first-generation students or who are traditionally underrepresented in medicine, an away rotation may also be a great way to connect with mentors outside of your home institution as well. It can be valuable to spend some time researching which programs are best for this; some programs may even offer scholarships to visiting underrepresented in medicine students that may help cover the cost of rotating at a new institution. REASONS NOT TO DO AN AWAY ROTATION Remember, an Away Rotation Does Not Guarantee an Interview or a Match In surgery, perseverance, grit, and determination are admirable qualities, and it is human nature to root for the underdog, particularly when the underdog is ourselves. While an away rotation can be a tool to let a program see strengths that are not well-captured on ERAS, some programs may still have particular criteria for who they select for interviews. Unfortunately, many away rotation spots are filled on a first-come first-served basis, without more than a cursory review of applicant qualifications. This can lead to students being accepted to rotate somewhere that may not consider them for an interview, even if they perform well on a rotation. If a program has a strict Step score cutoff, does not interview non-US Seniors, or has otherwise drawn an inflexible line in the sand, it is likely not worth rotating there hoping to change the program's mind. Not all of these "lines in the sand" will be publicized by programs, so it is important to read each program's website thoroughly, or even reach out to the program coordinator to learn more about important application metrics. We hope that these will become more readily available and transparent in future years to allow applicants to make informed decisions. If Financial Resources Are Tight Although virtual interviews have helped make the interview and match process more equitable, medical school tuition and residency application fees can be very expensive. Travel to a new city, transportation, and housing costs are not insignificant, and there are often fees associated with doing an away rotation. For some, this expense may not be worth it, particularly in general surgery for which away rotations are not required.1 Certainly, there are ways to make the experience cheaper (such as subletting your place, swapping with another student on RotatingRoom.com, or staying with family in the area for free) but do not discount how much the expenses can add up during a rotation. If It Could Hurt Your Application There are two potential pitfalls when applying to away rotations: (1) your performance on the rotation pales in comparison to how you look on paper, or (2) you have to turn down a program for a rotation. It is important to think critically about how well you adapt to new situations and mesh with new teams. An away rotation can feel like a month-long interview process where you must be at the top of your game day-in and day-out. Most programs would not be unreasonable as you settle into a new hospital and new electronic medical record; however, it is possibly easier to leave a bad impression during a month-long observation period than it is during an afternoon during a virtual interview. The converse is fortunately also true; if you make a good impression on residents and attendings during an away rotation, they may advocate for you more strongly when ranking applicants. This makes an away rotation a high-risk/high-reward situation. Additionally, overapplying to programs in the Visiting Student Learning Opportunities system and having to turn down an offer to rotate somewhere has the potential to communicate a lack of interest to the school. Some of our colleagues at CoSEF have successfully interviewed at programs they turned down for a rotation, so this may not be universally true, particularly if the PD's office is not very involved in selecting visiting students. To avoid being in this position, it is best to apply to a few programs early to give them ample time to respond before applying to additional opportunities. If a scheduling conflict does arise, give programs at least 6 weeks' notice so that they may schedule another rotator for highly sought-after visiting rotations. While these pitfalls discussed earlier are important to be aware of, there is a lot to be gained by being a visiting medical student. Many of us at CoSEF who did away rotations had a positive experience and thought it was very useful for selecting our current programs, creating connections in the field, choosing a subspecialty, and even applying for fellowships. Ultimately, in a field like general surgery where there is no requirement, the decision is up to you. It can be a tough rotation, but also extremely rewarding. ACKNOWLEDGMENT C.E.M.D.: conceptualization, drafting initial manuscript, and editing. A.A., R.B., S.L., C.A., T.S., C.S., J.L.H., and J.M.W.: conceptualization and manuscript editing.