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Between June 2025 and March 2026, Andrew Kalra, MD, traveled to dozens of cities, spent tens of thousands of dollars, and applied to every integrated cardiothoracic residency — or I-6 — in the country.
From the moment he turned the corner into fourth year, the pace never relented. He launched into studying for boards, and immediately after passing Step 2, he started his subinternship and away rotations. The 5-month cross-country audition circuit ended just in time to build his application of essays and gather the all-important letters of recommendations.
With just 56 spots at 36 institutions, Kalra took every possible I-6 interview — almost all were in person. December found him flying from one institution to the next for 15-minute grill sessions with famous surgeons, sometimes on consecutive days, and even two-a-day when he could stack an in-person interview with a virtual one. In the end, he completed more than 25 interviews and accepted second-look interviews at multiple schools.
Fourth year has a reputation for being “the victory lap” — a time when gunning trainees can finally exhale. But that reputation was built in a different era of medical education. Strong candidates in less competitive specialties may still have a moment to breathe.
But for the competitive specialties, such as specialty surgery, orthopedics, dermatology, and otolaryngology, the fourth year has transformed into a high-pressure audition circuit. Candidates spend months and tens of thousands of dollars trying to set themselves apart and prove they’re a good fit for a program. The pressure doesn’t lift until they hold the match in their hand.
“For me at least, it wasn’t a victory lap,” Kalra said.
About Medscape Insights
Medscape continually surveys physicians and other medical professionals about key practice challenges and current issues, creating high-impact analyses. For example, The Unique Culture of Medical School 2025 Report found:
- 41% of students surveyed rated their school as highly competitive.
- One respondent noted there was no flexibility for struggling students. “It is sink or swim.”
- Another respondent said students are now more interested in setting themselves apart with research and clinical volunteering than focusing on their studies.
Integrated Surgical Residencies
Experts in the surgical subspecialties say that the fourth-year transformation is at least partially due to the rise in integrated surgical residencies.
In the 2010s, there was a sharp uptick in interest in these spots that allowed students to bypass the general surgery residency and specialize in plastics or cardiothoracic right out of medical school. But spots were limited and immediately competitive.
The competition was only compounded by more recent transitions to pass/fail scoring for medical school courses and the USMLE Step 1. With fewer metrics to rely on, students grasped for new ways to set themselves apart.
“There’s so many high achievers, there’s got to be a way of…objectively differentiating,” said Bruce A. Mast, MD, plastic surgeon and professor of surgery at the University of Florida in Gainesville.
The Big Audition
One way students are leveraging the fourth year to differentiate themselves: away rotations.
For 2-4 weeks, students do a short-term clinical elective at another institution. These rotations started as a purely educational opportunity but have turned into a long-form audition for residency.
Over the fourth year, students rotate through as many as five institutions where they’d like a residency spot. They spend 2-4 weeks at each rotation, trying to demonstrate their fit, gain exposure, and garner a letter of recommendation. “They really go there and work their butt off to try to make as good an impression as possible,” Mast said. In fact, “now a lot of the students call them audition rotations, which kind of puts more pressure on you, right?”
It’s a way for students to show interest and build credibility before the interview process even starts.
According to the American Medical Association (AMA), 54% of 2026 graduating medical students completed an away rotation, and one third of graduates completed at least two away rotations. The strategy is less common for specialties like pediatrics or family medicine. For a specialty like ob/gyn, away rotations aren’t required or recommended, but some students do use them to gain a competitive edge.
In the more competitive subspecialties, though, these away rotations are all but mandatory. Neurosurgery applicants are expected to have two to three away rotations, according to the AMA. Orthopedic surgery expects up to four. Plastics recommends two-way rotations (split-site rotations at two different facilities). Dermatology and otolaryngology, two of the most competitive specialties, don’t require away rotations, but they are recommended.
On top of leaving their homes and support systems, this audition circuit requires students to move every 4 weeks without financial assistance. “It’s not like these places offer you some additional money; they just don’t. It’s just up to the student,” said Larry Kaiser, MD, professor of surgery at the University of Pennsylvania in Philadelphia.
One orthopedic surgery resident reported spending $2000 per away rotation on necessities such as lodging, travel, and transportation. While $2000 is average, a 2016 study reported that it’s not unusual for students to spend $5000-$10,000 per away rotation. And that’s on top of normal expenses, such as rent at their home institution.
Some students receive financial support from their families, but many others rely on credit card debt. For some students, finances become a limiting factor on how many away rotations they can do, Kaiser said. “It’s not a great system.”
High-Stakes Interviews
For Kalra, stress and costs only increased as interview season approached.
There’s pressure around everything: writing the essay, getting strong letters of recommendation. And even with new cost structures, students still apply to an average of 80 programs, which can easily climb to $2000 in application fees.
Once interview invitations are out, the real frenzy of high-stakes decisions begin. While many specialties have heeded the Association of American Medical Colleges (AAMC)’s recommendation to use virtual interviews, the most competitive specialties have reverted to in-person ones. The majority of programs in ENT, neurosurgery, plastic surgery, cardiothoracic surgery, and orthopedic surgery require students to travel for the interview.
“I tried to take as many as I could,” Kalra said. But he couldn’t take them all. Some interviews overlapped, and programs weren’t willing to be flexible. “I think some of the programs want you to choose them, you know, over another one.”
Other times, he wasn’t sure he could make it from one interview to the next until the last minute, which meant paying last-minute flight prices. The AAMC estimates that every in-person interview costs between $400 and $3500. The money, the rushing between cities, the intense interviews, “that took a toll,” Kalra said.
The Beginning of Burnout
Kaiser and Mast agree that the high achievers they counsel through this process usually carry the stress of fourth year well. They tend to already be good at managing their own stress and navigating high-pressure situations. “You know, that’s almost a self-selection process” for the careers they’re heading into, Kaiser said.
Still, the data show that everyone has limits. Medical school students and doctors both have higher rates of depression and burnout than their nonmedical peers. And they often struggle to recognize these problems and seek help. It’s very possible that the degree of anxiety over fourth year is underreported and can crescendo into full-blown burnout over the course of residency.
Kalra’s anxiety stuck around until late March when he finally held an envelope in his hand, a secured spot at the University of Southern California’s I-6 program and proof that all his months of work had paid off.
But he’s first to admit he was fortunate. There are plenty of talented students who put in the same amount of effort but didn’t match.
In 2026, dermatology’s match rate was only 49%. Orthopedic surgery was 49%. Plastics had a match rate of 65%. And neurosurgery was 69%.
It’s not uncommon for truly remarkable students not to match, Kaiser said. “That’s when the real stress begins.”
Sources in the story had no financial disclosures.
Donavyn Coffey is a Kentucky-based journalist reporting on healthcare, the environment, and anything that affects the way we eat. She has a master’s degree from New York University’s Arthur L. Carter Journalism Institute, New York City, and a master’s in molecular nutrition from Aarhus University in Aarhus, Denmark. You can see more of her work in WIRED, Teen Vogue, Scientific American, and elsewhere.
