This is a guide for anesthesiology away rotations for medical students, a specific topic that frequently shows up in SDN and reddit threads. It is a collection of frequently asked questions that have been answered previously on SDN. I wrote this in service to future medical students interested in anesthesiology, and in the hopes that other students, residents, and attending physicians contribute. I realized it would have been useful to have this guide around this time last year so I'm posting this in December as it is the best time for 3rd year students to start planning their 4th year and choosing a specialty.
About me: I am a medical student that completed 3 anesthesia away rotations in summer-fall 2018. My board stats are average for the specialty (see NRMP charting outcomes).
Disclaimer: This is for advice only from a medical student standpoint, and is originally posed to SDN. I am not a program director, or in any way associated with the residency selection process. My experiences may not be representative depending on process changes since this writing. It is meant to be a free-use guide, and it should be modified over time to account for changes in medical education and residency matching.
BASIC INFORMATION:
1. An away rotation is a 2- or 4-week elective rotation typically completed in the final year of medical school before residency matching. The student rotates as a visitor at a hospital outside of their program. They are optional depending on specialty.
2. VSLO (prev. VSAS) is a website built to standardize the away rotation process. It is normally how you apply for an away rotation. You need your medical school to give you access to the site before you can begin browsing programs and sending applications. Normally medical students obtain access during winter (Jan/Feb) of their third year.
3. Requirements such as standard vaccinations (there is a standard vax form on VSLO), drug screening, and background checks should be completed in spring of 3rd year. Additionally, there is often a minimum requirement of USMLE Step 1 at several programs (220 is the most common cutoff score, up to 240). Some programs have additional requirements such as letters of recommendation. If you absolutely want to go to a specific program you should be aware of the rotation requirements as early as January of your third year.
4. Fees are a normal part of the process, and you need to know that these rotations can be expensive. There is a small application fee in addition to needing to set up your own housing (rotating room or air bnb), figuring out transportation, and buying your own food. Depending on the program, there might be an additional fee if you are a DO or IMG/FMG. You can find fee information on the program page in VSLO.
WHAT TO EXPECT:
1. ACADEMIC RESIDENCY PROGRAM: these are often structured rotations and may have didactics, rounds, or other activities. You will encounter faculty, anesthesiology residents, and CRNAs/AAs with their respective students. The advantage of this type of rotation is you get to speak with academics and program directors, and perhaps improve your chances at matching by obtaining key letters in the field. However, do not expect to get good experiences in basic anesthesia: drawing and pushing medicine, mask ventilating, intubating, placing IVs, placing NG/OG tubes, using ultrasound, or generally running OR cases. There is simply too much competition at these programs (which often support a residency and a CRNA/AA program) for procedures to learn these skills. Most of your OR experience will be shadowing and observing. They may also offer subspecialty rotations such as pediatrics, pain, or critical care.
2. COMMUNITY PROGRAM WITH/WITHOUT RESIDENCY: surprisingly, many additional rotation options may be found on VSLO that are not associated with residency programs. These are typically unstructured rotations, and normally do not have didactics or planned learning activities. You will mostly encounter CRNAs and AAs as well as your attending anesthesiologists. However, you should not expect to frequently work with anesthesiologists or learn anesthesiology from physicians at these programs. This means you will have to take initiative to do more, ask plenty of questions, and learn more on your own. There is also less variety in these programs than at academic programs (typically no pediatric or pain exposure). You can also obtain letters from these programs, but they may not be as high quality as a residency program letter. These are great rotations if you want to improve your skills or determine if anesthesiology is a good fit.
FREQUENT QUESTIONS
1: Why do medical students go on away rotations in anesthesia?
The most common reason is they want to go into the specialty, and:
There is some belief that you do not need to do an away to match into anesthesia, regardless of your situation, and particularly if you have solid board scores (USMLE Step 1 230+) and great letters. A small consensus on SDN is that away rotations are not yet required to match and sometimes may hurt an applicant’s chances in the residency match. Therefore it is more appropriate to approach these questions from the viewpoint of when you would not need to visit another program. The single most important reason to not need to do an away rotation is:
Students currently applying to the field may realize that some programs are much more difficult to match into than others, even after accounting for great board scores; simply matching into anesthesia is not difficult for some applicants, and for them the goal is matching where they prefer. This is where aways can come in handy.
There is not current data that show higher applicant ranking or an increased chance of matching due to away rotations; there is no definitive list of programs that would like to see an away rotation, or where an away has been shown to help in the match. As a result there is not a one-size-fits-all answer to this question, so applicants will need to do their own research, and ask current applicants or previous alumni (both amazing resources to ask before locking in rotations). Anecdotally, students on the interview trail frequently mention that they receive invitations to interview at programs they visit, and there are residents who suggest that they would have never matched at a particular program had they not done an away there. Regardless of a student's performance on these rotations, it appears that away rotations frequently influence residency interviewing and matching at some programs.
4: How do I get an away rotation at a specific program after applying?
I will not create a list of programs that have away rotations due to yearly changes. Overall, almost all of the major and minor academic residencies have opportunities to rotate, and it's best that applicants understand that the process of securing rotations at prestigious programs can be as difficult as securing an interview there during match season. Applicants first need to research where they would like go using, for example, last year's anesthesia match spreadsheet.
The best way to obtain an away rotation is by contacting the student coordinator (medical education coordinator) of the program by phone or email and explaining your desire to rotate at their program. Then you complete an application in VSLO and notify them that your application is submitted. This exchange should be done before they start to accept applications. The other reason to get in contact with the office is to determine exactly when they start accepting applications and offering rotations, since this information is often unavailable on VSLO. The worst way to obtain a rotation is to spend a fortune on away applications and wait for a response from someone.
5: How do I shine on away rotations?
Similar to 3rd year clerkships, you work hard and make few mistakes. There is one major difference in the anesthesiology away in that you need to take the initiative to introduce yourself to everyone, especially CRNAs/AAs/residents who will be the intermediaries in your evaluations for attendings. It is also important to take initiative and ask for cases and procedures instead of hiding out in one room or staying in the control room. You need to be constantly finding things to do or interacting with people. This can be awkward if your rotation is unstructured.
Here is a great example: Hopkins Away Rotation
6: When should I begin the process?
If you're a 3rd year medical student you should begin the process of applying as soon as you have access to VSLO (Jan/Feb most often), and you should have already researched programs before this. There is a rolling admissions at most programs based on first-come-first-serve (see #4), with preference to the medical students affiliated with the programs. If it's the last month of 3rd year or the first month of 4th year and you're just beginning to think about an away, it's too late. Many programs open in April or May, and some will secure spots outside of VSLO before this.
7: When should I do an away?
The best advice is to schedule an away just before interview season (before October) if it is your intention to match into anesthesiology. If you schedule a rotation during interview season you may be offered a courtesy interview that month. It may be difficult to schedule a spot in June or July because this is when CA-1s start learning anesthesia, which means medical students will be completely ignored; often programs don’t even allow students to rotate these months. On the other hand, January-July may the best time to do an away if your intention is to learn: there will not be any residents or other students competing for procedures, and you will be allowed to do more.
8: What are the alternatives to anesthesia aways?
The most important alternative is doing a rotation at your home hospital. You should also consider contacting anesthesiologists at nearby facilities, especially if you have already completed credentialing at those hospitals. This can be a better source of letters than away rotations. Another alternative that may be much more useful is an ICU rotation. Many anesthesiologists work in ICU, but beyond this an ICU rotation may be more educational and helpful during internship and residency than a rotation in anesthesiology.
PRESENT AND FUTURE CONSIDERATIONS
When I started writing this guide I wanted to make sure the information in it would be relevant as long as possible. My hope is that other students can contribute with their own experiences. With this in mind, I wanted to talk about some other considerations that have changed my understanding of the importance of visiting programs.
The first consideration is letters. The advice that predominated in the last two decades is: get high scores on boards and get great letters from any physicians that can attest to your qualifications. The main problem is anesthesiologists are notoriously unavailable, often unable to judge your clinical aptitude, and as a result may make poor letter writers. Students should have a backup plan for their letters. Surgery and Internal Medicine letters are frequently mentioned as valuable to programs. The point is that it's unwise to rely on your anesthesia visiting rotations to get your recommendations.
Second, educational experience. A common complaint seen on anesthesia rotations is that students aren’t getting any good experiences in the OR. Frequently these rotations end up with students shadowing residents who perform most of the procedures and never interact with students. This is particularly true in this specialty where there are many different providers of anesthesia, and anesthesia students at different levels competing for experiences. My advice is to avoid prestige, or even residency programs altogether, in favor of community rotations if you want a real anesthesia experience. If you only want to see if you fit in with a residency try to get a 2-week rotation.
Third, applicant screening during the interview process. With the merger of ACGME and AOA residency matching systems in 2020, it is a given that more applications will be sent out, and fewer invites will be sent back because programs easily meet their interview quotas. Many students are sending applications to all residency programs in the hopes of increasing their baseline chances of matching. This creates a problem for residencies in sifting through the available applicants quickly. Away rotations in anesthesiology may become more important in the next decade, as it appears that selection committees are looking for more standardized approaches in screening applicants in or out. The approaches that other specialties have taken (standardized letters in EM), are now appearing on some anesthesia program websites, and access to these letters would most likely accompany an increased demand for away rotations. For now, be aware that away rotations are extra-curricular, and that the potential benefits may not outweigh the expense and effort that goes into securing one and rotating for a month.
Fourth, my own anecdotal experience based on this interview season. I received 2 letters from a community program because I had the most exposure to anesthesiologists there. I had the option for a generic chair letter at other programs, but I was advised against taking a letter that could not speak to my clinical skills or qualifications. I received positive feedback about my letters at five of my interviews. I received invitations to interview at both residency programs where I did an away. At one of these interviews I was informed that I had initially been screened out of their interviewing region, and would not have been interviewed if not for the away. Candidates should be aware of regional screening during interview season (programs invite the candidates most likely to rank them high, which statistically tend to be regional). Therefore, if you want to be in a region outside of your med school’s geography you should strongly consider doing an away there. Overall, it can be an incredible advantage to do an away, and many applicants this year are utilizing this advantage. It is critical that applicants not just review NRMP statistics, but also think about changes in the match that will make their experience different from previous years, understand their own weaknesses (such as DO/IMG), and understand a little about how programs choose who to interview every year.
Thank you to the applicants who were friendly during this season. I wish the best to everyone attempting to match this year and in the future, and commend you for your careful research into your future career.
About me: I am a medical student that completed 3 anesthesia away rotations in summer-fall 2018. My board stats are average for the specialty (see NRMP charting outcomes).
Disclaimer: This is for advice only from a medical student standpoint, and is originally posed to SDN. I am not a program director, or in any way associated with the residency selection process. My experiences may not be representative depending on process changes since this writing. It is meant to be a free-use guide, and it should be modified over time to account for changes in medical education and residency matching.
BASIC INFORMATION:
1. An away rotation is a 2- or 4-week elective rotation typically completed in the final year of medical school before residency matching. The student rotates as a visitor at a hospital outside of their program. They are optional depending on specialty.
2. VSLO (prev. VSAS) is a website built to standardize the away rotation process. It is normally how you apply for an away rotation. You need your medical school to give you access to the site before you can begin browsing programs and sending applications. Normally medical students obtain access during winter (Jan/Feb) of their third year.
3. Requirements such as standard vaccinations (there is a standard vax form on VSLO), drug screening, and background checks should be completed in spring of 3rd year. Additionally, there is often a minimum requirement of USMLE Step 1 at several programs (220 is the most common cutoff score, up to 240). Some programs have additional requirements such as letters of recommendation. If you absolutely want to go to a specific program you should be aware of the rotation requirements as early as January of your third year.
4. Fees are a normal part of the process, and you need to know that these rotations can be expensive. There is a small application fee in addition to needing to set up your own housing (rotating room or air bnb), figuring out transportation, and buying your own food. Depending on the program, there might be an additional fee if you are a DO or IMG/FMG. You can find fee information on the program page in VSLO.
WHAT TO EXPECT:
1. ACADEMIC RESIDENCY PROGRAM: these are often structured rotations and may have didactics, rounds, or other activities. You will encounter faculty, anesthesiology residents, and CRNAs/AAs with their respective students. The advantage of this type of rotation is you get to speak with academics and program directors, and perhaps improve your chances at matching by obtaining key letters in the field. However, do not expect to get good experiences in basic anesthesia: drawing and pushing medicine, mask ventilating, intubating, placing IVs, placing NG/OG tubes, using ultrasound, or generally running OR cases. There is simply too much competition at these programs (which often support a residency and a CRNA/AA program) for procedures to learn these skills. Most of your OR experience will be shadowing and observing. They may also offer subspecialty rotations such as pediatrics, pain, or critical care.
2. COMMUNITY PROGRAM WITH/WITHOUT RESIDENCY: surprisingly, many additional rotation options may be found on VSLO that are not associated with residency programs. These are typically unstructured rotations, and normally do not have didactics or planned learning activities. You will mostly encounter CRNAs and AAs as well as your attending anesthesiologists. However, you should not expect to frequently work with anesthesiologists or learn anesthesiology from physicians at these programs. This means you will have to take initiative to do more, ask plenty of questions, and learn more on your own. There is also less variety in these programs than at academic programs (typically no pediatric or pain exposure). You can also obtain letters from these programs, but they may not be as high quality as a residency program letter. These are great rotations if you want to improve your skills or determine if anesthesiology is a good fit.
FREQUENT QUESTIONS
1: Why do medical students go on away rotations in anesthesia?
The most common reason is they want to go into the specialty, and:
- want letters of recommendation from anesthesiologists
- want to explore a program in person before interviewing
- want to increase their chances of being selected for a residency program
- to find out if you are a good fit for the specialty
- to learn skills and knowledge frequently encountered in the specialty
- to meet key people in the field
- to visit a location in addition to rotating
There is some belief that you do not need to do an away to match into anesthesia, regardless of your situation, and particularly if you have solid board scores (USMLE Step 1 230+) and great letters. A small consensus on SDN is that away rotations are not yet required to match and sometimes may hurt an applicant’s chances in the residency match. Therefore it is more appropriate to approach these questions from the viewpoint of when you would not need to visit another program. The single most important reason to not need to do an away rotation is:
- You are a US MD student at a school affiliated with an anesthesiology residency program (home program)
- You are a US MD, DO, IMG, or FMG student that does not have a home program
- You are a marginal candidate in terms of step score (USMLE Step 1 < 220)
- You have not completed a rotation in anesthesia and would like to do so
- You would like to see programs outside of your home anesthesia program
- You desire to match in a different geographic area of the US from your medical school
Students currently applying to the field may realize that some programs are much more difficult to match into than others, even after accounting for great board scores; simply matching into anesthesia is not difficult for some applicants, and for them the goal is matching where they prefer. This is where aways can come in handy.
There is not current data that show higher applicant ranking or an increased chance of matching due to away rotations; there is no definitive list of programs that would like to see an away rotation, or where an away has been shown to help in the match. As a result there is not a one-size-fits-all answer to this question, so applicants will need to do their own research, and ask current applicants or previous alumni (both amazing resources to ask before locking in rotations). Anecdotally, students on the interview trail frequently mention that they receive invitations to interview at programs they visit, and there are residents who suggest that they would have never matched at a particular program had they not done an away there. Regardless of a student's performance on these rotations, it appears that away rotations frequently influence residency interviewing and matching at some programs.
4: How do I get an away rotation at a specific program after applying?
I will not create a list of programs that have away rotations due to yearly changes. Overall, almost all of the major and minor academic residencies have opportunities to rotate, and it's best that applicants understand that the process of securing rotations at prestigious programs can be as difficult as securing an interview there during match season. Applicants first need to research where they would like go using, for example, last year's anesthesia match spreadsheet.
The best way to obtain an away rotation is by contacting the student coordinator (medical education coordinator) of the program by phone or email and explaining your desire to rotate at their program. Then you complete an application in VSLO and notify them that your application is submitted. This exchange should be done before they start to accept applications. The other reason to get in contact with the office is to determine exactly when they start accepting applications and offering rotations, since this information is often unavailable on VSLO. The worst way to obtain a rotation is to spend a fortune on away applications and wait for a response from someone.
5: How do I shine on away rotations?
Similar to 3rd year clerkships, you work hard and make few mistakes. There is one major difference in the anesthesiology away in that you need to take the initiative to introduce yourself to everyone, especially CRNAs/AAs/residents who will be the intermediaries in your evaluations for attendings. It is also important to take initiative and ask for cases and procedures instead of hiding out in one room or staying in the control room. You need to be constantly finding things to do or interacting with people. This can be awkward if your rotation is unstructured.
Here is a great example: Hopkins Away Rotation
6: When should I begin the process?
If you're a 3rd year medical student you should begin the process of applying as soon as you have access to VSLO (Jan/Feb most often), and you should have already researched programs before this. There is a rolling admissions at most programs based on first-come-first-serve (see #4), with preference to the medical students affiliated with the programs. If it's the last month of 3rd year or the first month of 4th year and you're just beginning to think about an away, it's too late. Many programs open in April or May, and some will secure spots outside of VSLO before this.
7: When should I do an away?
The best advice is to schedule an away just before interview season (before October) if it is your intention to match into anesthesiology. If you schedule a rotation during interview season you may be offered a courtesy interview that month. It may be difficult to schedule a spot in June or July because this is when CA-1s start learning anesthesia, which means medical students will be completely ignored; often programs don’t even allow students to rotate these months. On the other hand, January-July may the best time to do an away if your intention is to learn: there will not be any residents or other students competing for procedures, and you will be allowed to do more.
8: What are the alternatives to anesthesia aways?
The most important alternative is doing a rotation at your home hospital. You should also consider contacting anesthesiologists at nearby facilities, especially if you have already completed credentialing at those hospitals. This can be a better source of letters than away rotations. Another alternative that may be much more useful is an ICU rotation. Many anesthesiologists work in ICU, but beyond this an ICU rotation may be more educational and helpful during internship and residency than a rotation in anesthesiology.
PRESENT AND FUTURE CONSIDERATIONS
When I started writing this guide I wanted to make sure the information in it would be relevant as long as possible. My hope is that other students can contribute with their own experiences. With this in mind, I wanted to talk about some other considerations that have changed my understanding of the importance of visiting programs.
The first consideration is letters. The advice that predominated in the last two decades is: get high scores on boards and get great letters from any physicians that can attest to your qualifications. The main problem is anesthesiologists are notoriously unavailable, often unable to judge your clinical aptitude, and as a result may make poor letter writers. Students should have a backup plan for their letters. Surgery and Internal Medicine letters are frequently mentioned as valuable to programs. The point is that it's unwise to rely on your anesthesia visiting rotations to get your recommendations.
Second, educational experience. A common complaint seen on anesthesia rotations is that students aren’t getting any good experiences in the OR. Frequently these rotations end up with students shadowing residents who perform most of the procedures and never interact with students. This is particularly true in this specialty where there are many different providers of anesthesia, and anesthesia students at different levels competing for experiences. My advice is to avoid prestige, or even residency programs altogether, in favor of community rotations if you want a real anesthesia experience. If you only want to see if you fit in with a residency try to get a 2-week rotation.
Third, applicant screening during the interview process. With the merger of ACGME and AOA residency matching systems in 2020, it is a given that more applications will be sent out, and fewer invites will be sent back because programs easily meet their interview quotas. Many students are sending applications to all residency programs in the hopes of increasing their baseline chances of matching. This creates a problem for residencies in sifting through the available applicants quickly. Away rotations in anesthesiology may become more important in the next decade, as it appears that selection committees are looking for more standardized approaches in screening applicants in or out. The approaches that other specialties have taken (standardized letters in EM), are now appearing on some anesthesia program websites, and access to these letters would most likely accompany an increased demand for away rotations. For now, be aware that away rotations are extra-curricular, and that the potential benefits may not outweigh the expense and effort that goes into securing one and rotating for a month.
Fourth, my own anecdotal experience based on this interview season. I received 2 letters from a community program because I had the most exposure to anesthesiologists there. I had the option for a generic chair letter at other programs, but I was advised against taking a letter that could not speak to my clinical skills or qualifications. I received positive feedback about my letters at five of my interviews. I received invitations to interview at both residency programs where I did an away. At one of these interviews I was informed that I had initially been screened out of their interviewing region, and would not have been interviewed if not for the away. Candidates should be aware of regional screening during interview season (programs invite the candidates most likely to rank them high, which statistically tend to be regional). Therefore, if you want to be in a region outside of your med school’s geography you should strongly consider doing an away there. Overall, it can be an incredible advantage to do an away, and many applicants this year are utilizing this advantage. It is critical that applicants not just review NRMP statistics, but also think about changes in the match that will make their experience different from previous years, understand their own weaknesses (such as DO/IMG), and understand a little about how programs choose who to interview every year.
Thank you to the applicants who were friendly during this season. I wish the best to everyone attempting to match this year and in the future, and commend you for your careful research into your future career.
