Elective rotations: how to choose where to go

The fifth-year student receives the list of internship electives: dermatology at a busy outpatient clinic, intensive care at a large hospital, family health in a small town, surgery at a service in another state where they dream of doing their residency. There are few weeks and many doors. Choosing by the reputation of the place, by a colleague's recommendation or by the spot that was left over is the most common path, and not always the best one.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

The elective rotation is one of the few moments in the course when the student decides what they will learn. This guide shows what studies say about electives and career choice, how to define goals before looking for a spot, how to assess supervision and the service, when it makes sense to leave your own school and how to make the most of each week.

Key points

• Electives in the clinical cycle helped students explore the career and confirm or rule out an area.
• Clear goals before the rotation increase the chance of learning what you went there for.
• Electives outside your school aimed at residency selection are common, expensive and of uncertain result.
• Supervision, patient volume and the student's role matter more than the name of the institution.
• A well-chosen elective can also help fill gaps in your training.

What an elective rotation is

A part of the course chosen by you

In medical schools, the elective rotation is a period, usually two to eight weeks, in which the student chooses the area and sometimes the practice site. It usually takes place during the internship, but some schools offer electives earlier, including in the basic cycle, focused on research, public health or specific skills. The rules vary widely: some schools have a closed list of affiliated services, others accept proposals from the student, as long as there is a supervisor and a schedule of activities.

An elective is not just a showcase

It is common to think of the elective only as a showcase for residency. It also serves to get to know an area before deciding, to practice a skill that the required curriculum left weak, to experience another model of service or to deepen an interest that does not fit anywhere else in the course. Choosing the specialty itself is the subject of another guide in this series; here the focus is the practical decision of where to spend these weeks.

Types of elective

• Exploration: getting to know up close an area you have not yet experienced in the required internship.
• Deepening: spending more time in an area you already like, with more responsibility.
• Gap: training something that stayed weak, such as procedures, emergency care or primary care.
• Context: working in a service very different from the teaching hospital, such as a rural unit or a referral service.
• Research: dedicating the period to a project, when the school allows it.

What the studies show

Electives and career exploration

At an American medical school, students began doing three two-week clinical electives during the year of required rotations, and a qualitative study interviewed 15 of them about the experience (Sheu et al., 2022). All said that at least one elective helped them firm up their decision about the specialty, and they highlighted focused learning, skill development and a good relationship with supervisors (Sheu et al., 2022). The authors also observed a positive learning environment and a favorable effect on well-being (Sheu et al., 2022).

The same article notes that many students change their minds about the specialty over the course, and that this shift usually happens when the student starts living the clinical routine of each area (Sheu et al., 2022). An elective well placed in the calendar can bring that experience forward.

Goals that get met

In a study with 37 students from five classes who took a global health elective, the researchers compared the stated objectives before the trip with the experiences reported afterward (Holmes et al., 2012). The five most cited objectives were achieved, and one learning outcome appeared without having been planned: reflection and personal growth (Holmes et al., 2012). The lesson applies to any elective: writing down what you want to learn helps you notice what you actually learned.

Does the elective change your career?

A study using data from Australian students compared those who did international electives in low- and middle-income countries with those who did them in high-income countries (Law and Walters, 2015). The type of elective did not significantly change the preference for primary care or for rural practice at the end of the course (Law and Walters, 2015). The preference the student already had weighed more. An elective helps you test and refine choices; on its own, it rarely turns your career upside down.

Define the objective before the placement

Start with a question

Before opening the list of placements, answer in writing: what do I want to know or know how to do by the end of this internship? The answer changes everything. If you want to get to know an area, you need variety and access to the service's real routine. If you want to train procedures, you need volume and a preceptor willing to supervise. If you want to be noticed by a residency program, you need direct contact with the team that selects.

Good objectives are specific

"Learn cardiology" is too broad for four weeks. "Follow the heart failure outpatient clinic, present cases to the preceptor every day and discuss the interpretation of the electrocardiogram with the team" already guides the choice of service and the conversation with the supervisor. Write three to five objectives like this and take them to the first conversation at the internship.

Think about the stage of the course

An elective early in the clinical years serves exploration better. Near the end, it makes more sense to go deeper into an area or fill a gap before graduation. If you have already decided on the specialty, an elective in a neighboring area may be more useful than repeating the same routine: the future surgeon benefits from intensive care, and the future clinician benefits from emergency care.

Look at your gaps

Review what you saw in the mandatory clinical rotations. Did you spend little time in primary care? Have you never followed a busy emergency room? Do you feel unsure with small children? An elective is the most concrete chance to correct this before taking on patients as a doctor.

How to evaluate a service

Supervision first

The most important factor in an elective is who will teach you. Ask who the preceptor will be, how many students and residents they supervise at the same time and whether there are fixed times for case discussions. A famous service with an absent preceptor teaches less than a modest service with someone who corrects your history taking every day.

The student's role

Find out what the student does at the service. Do they examine patients, write progress notes, present cases, take part in procedures under supervision? Or do they spend the weeks watching from behind residents? Talk to people who have already been there. Students from previous classes usually give the most honest description.

Volume and variety

Too much volume without supervision becomes manual labor; too little volume becomes boredom. Ask how many patients the student usually follows and what kind of situation comes up often. For exploration, variety matters more. For skills training, supervised repetition matters more.

Assessment and recognition

Check how you will be assessed, who signs the assessment and whether the internship will be recognized by your school. Agree on this before you start. An elective without formal records can still be worth it for the learning, but proving it later takes work.

Logistics

Housing, transport and schedules count. An excellent service two hours away by bus each day may yield less than a good service next to home. Add up the time and the cost and compare with what the internship offers.

Elective outside your school

The elective as a showcase

In several competitive specialties, students do electives at other institutions hoping to make a good impression on the service where they want to do their residency. The American literature calls this an audition rotation, and it has strengths and limits that apply to the Brazilian context.

How many do it and how much they spend

In a survey of 2,817 residency applicants in the United States, 67.4% reported having done at least one rotation outside their own school, and the average was 2.1 rotations per student among those who did any (Winterton et al., 2016). The estimated average cost per rotation was 958 dollars, and most students said they did them both for the training and for the selection (Winterton et al., 2016). The authors concluded that these rotations are frequent, expensive and only partly educational (Winterton et al., 2016).

Does it work for getting into residency?

A survey of 1,335 final-year students at 10 American schools compared those who did an audition rotation with those who did not (Higgins et al., 2016). Among those who did, 71% were accepted at one of their top three choices, against 84% among those who did not (Higgins et al., 2016). The study is observational and those who do auditions tend to compete in more competitive areas, but the result shows that a showcase elective does not guarantee a spot (Higgins et al., 2016).

What the programs say

In a survey of residency program directors in gynecology and obstetrics, 77.2% said their institution offered rotations for outside students, but only 26.6% of these directors personally evaluated candidates during the rotation (George et al., 2023). Only 34.7% guaranteed an interview to those who did the rotation at the service (George et al., 2023). The authors ask that programs make clear what the purpose of these rotations is (George et al., 2023).

How to decide

The numbers come from another selection system, but the question is the same in Brazil: what will this service teach me, regardless of residency? If the answer is "little", the showcase elective becomes an expensive bet. If the service teaches well and is also where you want to work, great: you learn and show who you are. Rotations abroad enter this same calculation and have their own guide in this series.

How to make the most of the weeks

In the first week

Introduce yourself to the preceptor with your goals in writing and ask what they expect from you. Learn the routine of the service before trying to change anything. Ask where the local protocols are and how the team prefers to receive case presentations.

During the rotation

Take on patients, within what the service allows, and follow them from start to finish. Read about each case the same day. Ask for feedback halfway through the rotation, not only in the last week: there is still time to correct course.

Demeanor

Arrive early, leave after handing over what needs to be handed over and treat the whole team with respect. Nursing, technicians and reception quickly notice who is there to learn and who is there to be seen. In small services, that impression reaches the preceptor the same day.

At the end

Do an honest review of your goals: what you accomplished, what was left half done and what came up without being planned. Ask the preceptor for a written evaluation, if possible, and record the rotation on your CV; the Lattes CV has its own guide in this series. Say thank you, keep in touch and recommend the service to colleagues, if it was worth it.

When the elective disappoints

Sometimes the service does not match what it promised. Before giving up, talk to the preceptor and try to adjust the plan. If there is no way out, go to the internship coordination. A bad elective still teaches you something: the kind of service you do not want for your training.

Clinical reasoning in any elective with NEXO

Every elective puts you in front of cases that do not follow the book. The NEXO case of the day is fictional, with a real clinical presentation, and the diagnosis arrives in up to six clues, with the proximity in ICD-10 showing how far each guess was. It is a short way to keep diagnostic reasoning sharp between one shift and the next, in whatever area you choose.

The guide what NEXO is explains the whole game, and the release of the modes is on the NEXO economy page.

If you coordinate a clerkship, a student interest group or a residency program and want cases to prepare students before electives, see NEXO Closer. Medical education researchers can propose studies through NEXO Researcher. Physicians who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

Does an elective help you choose a specialty?

In a qualitative study, all the students interviewed said that at least one elective helped them firm up their decision (Sheu et al., 2022).

Is it worth doing an elective at the service where I want to do my residency?

It can be worth it if the service teaches well. In the United States, those who did an audition rotation were no more successful in the selection than those who did not (Higgins et al., 2016).

What weighs most in the choice?

The quality of supervision and the role the student will have at the service.

How many objectives should I have?

Three to five, specific enough to guide the conversation with the preceptor.

Does the elective change your career?

Rarely on its own. In an Australian study, the type of elective did not change the career preference the students already had (Law and Walters, 2015).

What if the elective is bad?

Talk to the preceptor, try to adjust the plan and, if needed, contact the clerkship coordination.

Checklist for the choice

1. Write down your objectives before looking at the openings.
2. Ask who supervises and how many students they oversee.
3. Find out the student's role at the service.
4. Talk to people who have been there before.
5. Confirm recognition by your school.
6. Add up time and cost for housing and transport.
7. Ask for feedback midway through the rotation.
8. Review your objectives at the end and record the rotation.

Want to keep your clinical reasoning sharp during electives? Play the case of the day on NEXO.

References

1. Sheu L, Goglin S, Collins S, Cornett P, Clemons S, O'Sullivan PS. How Do Clinical Electives during the Clerkship Year Influence Career Exploration? A Qualitative Study. Teach Learn Med. 2022. https://pubmed.ncbi.nlm.nih.gov/33792448/
2. Holmes D, Zayas LE, Koyfman A. Student objectives and learning experiences in a global health elective. J Community Health. 2012. https://pubmed.ncbi.nlm.nih.gov/22367606/
3. Law IR, Walters L. The influence of international medical electives on career preference for primary care and rural practice. BMC Med Educ. 2015. https://pubmed.ncbi.nlm.nih.gov/26560077/
4. Winterton M, Ahn J, Bernstein J. The prevalence and cost of medical student visiting rotations. BMC Med Educ. 2016. https://pubmed.ncbi.nlm.nih.gov/27842590/
5. Higgins E, Newman L, Halligan K, Miller M, Schwab S, Kosowicz L. Do audition electives impact match success? Med Educ Online. 2016. https://pubmed.ncbi.nlm.nih.gov/27301380/
6. George KE, Litman EA, Banks E, Morgan HK, Hammoud MM, Strand E. Away Rotations in Obstetrics and Gynecology: A Survey of Program Directors. J Surg Educ. 2023. https://pubmed.ncbi.nlm.nih.gov/37442695/