The concept of an preliminary intern year can be confusing and depends on the specialty you’re applying to.
So..who has to apply for a separate intern year?
Certain specialties require you to apply for an intern year separate from your advanced program. These specialties include: radiology (both diagnostic and interventional), ophthalmology, anesthesia, radiation oncology, neurology, PM&R, and dermatology. Some of these specialties have categorical programs (combined with an intern year) but depending on the specialty are either more or less common.
Explore your options
A preliminary year can be in the form of a transitional year, preliminary medicine year, or surgical year. Depending on your advanced specialty choice and personality, you can decide which you want to pursue.
I chose a Transitional year (TY) and therefore can share my experience. TY programs vary widely in terms of rotations they provide. For instance, my program was relatively internal medicine heavy and we had the following rotations: 4 months of IM wards, 1 month of emergency medicine, 1 month of ambulatory medicine, 5 months of electives (with choices including neurology, nephrology, GI, radiology, anesthesia, pulmonology, cardiology, heme onc, etc), 1 month of MICU, and 1 month of night float. Other programs provide different electives or may require you to do more or less wards, night float, may require a general surgery month, OBGYN, pediatrics, etc. It can be extremely variable depending on the program. When you interview, make sure to ask which rotations the program offers and which are required. Depending on the location, TYs tend to be a little more competitive because they are often less intense than a preliminary medicine year or surgical year.
Though I don’t have personal experience with either a preliminary medicine year or a surgical year, I can provide a perspective based on what I know from experiences of colleagues of mine. A preliminary medicine year includes a certain number of internal medicine wards months, electives (usually in medicine subspecialties), MICU, and night float. You are unlikely to do a surgery month, OBGYN, pediatrics, anesthesia or rotations outside of internal medicine in a preliminary medicine year. A surgical year is primarily spent in surgical subspecialties, ICU, trauma, etc. and people who are pursuing interventional radiology, anesthesia, ophthalmology, or just want to experience a surgical year tend to choose a surgical year.
Applying
Once you've decided which preliminary year you want to pursue, you'll need to start the application process. Check out our post (Preparing for residency applications as an MS3 & MS4) for more in depth information on residency applications. While you don't need to apply to as many preliminary programs as you do for your advanced specialty, do not underestimate how competitive it can be. Remember, you are competing with every student pursuing advanced specialties that require preliminary programs including dermatology, radiology, radiation oncology, anesthesia, etc! Not to mention, these students tend to have very competitive applications.
I would recommend creating two versions of your personal statement: one for your advanced programs that is more specific to that specialty and one for your preliminary programs that is more general with a small paragraph at the bottom discussing the importance of your preliminary year for your future career. ERAS allows you to upload multiple versions of your personal statement. Though it is not necessary, I found success with this approach. Remember, the versions do not have to vary all that much, just small adjustments to make it more general for a preliminary program application can go a long way.
In terms of letters, you can submit up to 4 per program but you can upload more than that to the ERAS system. For instance, if I am applying to a preliminary medicine program or TY program, I can assign 1 internal medicine letter, 1 family medicine letter, 1 OBGYN letter, and 1 radiology letter (my chosen specialty). Likewise for a surgical preliminary year, I would recommend choosing surgical letters (OBGYN, general surgery, urology, etc.) to demonstrate your surgical skills. Though you don't need to stress about getting different letters if you don't have faculty that know you well enough to write you a good letters, it can be helpful to have more clinical letters if you are going into a specialty such as radiology. All that being said, the quality of the letter is much more important than the specialty of the letter writer.
Where should you complete your preliminary year? People have different thoughts on this and it depends on your goals. If you want to avoid having to move multiple times and you want to stay at the same institution for your advanced residency and your preliminary year, that's one option. You can also consider staying at your medical school for your preliminary year as well for the same reason. If you want to explore a new city, go out of your comfort zone, or experience a new place for a year, that's a great option as well! Again, it all depends on what your goals are. There's no wrong answer here. It can become tricky to anticipate where you will match for your advanced program and match up your preliminary year accordingly, but apply broadly and this shouldn't be a problem.
My experience
Personally, I chose a transitional year because I wanted a more broad/diverse experience. According to the ACGME, a transitional year requires at least 1 month of emergency medicine, 1 month of ambulatory medicine (clinic), at least 2 months of electives (most programs have more), and at least 24 weeks in either internal medicine, OBGYN, emergency medicine, family medicine, surgery, pediatrics, or primary critical care.
My recommendation would be to choose the preliminary year that you will find the most interesting, will be most applicable to your future specialty, and will give you the most time to have a life. Often, most people don’t choose a surgical year because it tends to be a lot busier and more difficult compared to a TY or preliminary medicine year. However, it might be the way to go if you are choosing interventional radiology, ophthalmology, or anesthesia, where the skills you would learn would be very helpful. Personally, I wanted to have a well-rounded year where I would have time to study for USMLE STEP 3, spend time with family and friends, and get a broad clinical experience that I could apply to my radiology training. I was told by my mentor when I was applying that your intern year ultimately does not affect your future career that much and you should try to choose one that will give you a well-rounded experience without having to work crazy hours. Overall, I’ve been pretty happy with my decision and would definitely choose a TY over again.
Hope this helps and wishing you the best of luck on the interview trail!
-C