student drawing blood

Fourth-Year Clerkship


About the Fourth-Year Clerkship

The fourth year of medical school advances the clinical education that started with the first LACE course to the point of competency that merits the granting of the Medical Doctorate degree. There are nine (9) required courses over a period of eleven (11) four-week blocks.

By the first portion of the fourth year, the MS-4 student should have obtained a basic understanding of which specialty programs they wish to consider, and then budget enough time to interview at those residency programs. The requirements and timing for course selection follows this philosophy. Your advisors will need to sign off on your course selections.

The logic of which courses are taken first is a crucial factor in matching for residency.

Our Advisor Guide, which we give to our faculty advisors is attached as Appendix #15.

Required Courses (4)

Sub-Internship (Sub-I)
  • At least one Sub-I in one of the following six core fields: Internal Medicine, Surgery, Pediatrics, Family Medicine, Psychiatry, OB/Gyn
  • Sub-I must be an inpatient rotation
  • Sub-I may occur outside of first four blocks, starting in the 2020-2021 academic year
  • Recommend not to schedule during interview season
    1. If scheduled during interview season: standard two-day rule for absence applies; six days maximum for interview purposes only
    2. If scheduled during interview season, student needs a vacation block available later in the year to make up rotations should they exceed allowed absences
  • UCR sponsored radiology course
  • May not be substituted with non UCR radiology course
  • Course is designed to prepare a non-radiologist to utilize
  • If going into radiology, recommend traditional radiology electives in addition to required UCR radiology course
Critical Care
  • ICU, CCU, PICU, NICU all considered appropriate to meet requirement
  • Do not recommend during interview season (October, November, December, January)
    1. If scheduled during interview season: standard two-day rule for absence still applies; six days maximum for interview purposes only
    2. If scheduled during interview season, student needs a vacation block available later in the year to make up rotations should they exceed allowed absences.
  • Internship preparation course

Electives (5)

Clinical rotations
  • UCR local affiliates, University of California system
  • Away via VSLO; throughout US and International
  • Extramural elective request form if not one of the above
Research and Scholarly Activity blocks
  • No more than total of two blocks (eight weeks) of non-clinical rotations
  • Must fill out the appropriate request forms (Appendix 12)

Vacation Blocks (2)

  • These should be used strategically, such as to take time off to travel and interview for residency positions in mid-year (October, November, December, or January)
  • Starting in 2018, UCR SOM requires that at least one (1) of the two (2) vacation blocks MUST be taken during October, November, December, or January.

Important Considerations for Fourth Year Planning:

  • Maximum number of blocks allowed in one subspecialty field is two (eight weeks)
  • Maximum number of non-clinical elective blocks is two (eight weeks)
  • All rotation requests must be sent to 4th year coordinator Kathleen Witty.
  • Proposed rotation schedule must be approved/signed by your assigned specialty advisor prior to submission to fourth year coordinator
  • Rotations must be verified 90 days in advance to start of rotations, and confirmed 30 days prior to start of rotation to ensure timely completion of all onboarding
  • No add/drop requests within 30 days of rotation start date. All add/drop requests must be sent to fourth year coordinator. Failure to attend a rotation or changing a rotation without prior approval will result in “no credit” for that rotation
  • All fourth year grades will be based off of your evaluations: Honors, high pass, pass, fail
  • Rotations through certain affiliates require a specific process: RUHS and RCH use Clinical Nexus. Please consult 4th year coordinator (not site) if unsure
  • Students not meeting deadlines are at risk of not fulfilling graduation requirements and delaying graduation. Students must register for all rotations within the (above) stated guidelines prior to beginning work. Post-hoc credit for work completed or in progress will not be granted under any circumstances.
  • All students must turn in signed agreement of fourth year expectations (Appendix 13)

Example Schedules

Example 1
Sub Internship Elective Elective Elective Critical Care Vacation Elective Radiology Back
Vacation Elective
Example 2
Elective Elective Critical Care Sub Internship Vacation Elective Sub Internship (Elective) Elective Back
Vacation Radiology
Example 3
Elective Vacation Sub Internship Elective Vacation Critical Care Radiology Sub Internship (Elective) Back
Elective Sub Internship (Elective)

Sub-Internships (Sub-I)

The Sub-Internship (Sub-I) gives students an opportunity to assume more responsibility for their patients and improve their core competencies. Students are expected to use these sub-i opportunities to refine their physical exam, diagnostic skills, and medical knowledge. Students must complete at least one four-week sub-internship that is selected from one of the six core subjects (Internal Medicine, Surgery, Pediatrics, OB/Gyn, Family Medicine, and Psychiatry). Students are encouraged to take sub-i level electives in non-core disciplines, but these sub-i rotations will not count toward the core sub-i graduation requirement.

Overall Objectives
  1. Take an accurate history, perform a thorough physical exam, interpret laboratory data, generate an appropriate differential diagnosis, and present your case at all ward rounds.
  2. Demonstrate the ability to read and learn on your own. You must be able to apply this newly learned information to the clinical context of each problem or assessment of your patient.
  3. Devise treatment plans to treat the patient's acute issues and work-up the differential diagnosis in a manner that does not include unnecessary tests.
  4. Organize and communicate your findings through daily progress notes and oral presentations.
  5. Behave in a professional manner at all times. Be sure to interact in a respectful manner with your colleagues, nurses, and hospital support staff.
  6. Acknowledge errors, flaws in reasoning, and take the appropriate action to remedy the problems.
  7. Accept constructive criticism. Understand that this is how doctors in training become better doctors.
  8. Be an active and integral member of a team.
  9. Keep your patient as a priority and respect his or her autonomy.

Sub-i’s are core subjects.

At least one must be done at UCR SOM affiliate or University of California system.

UCR SOM core subjects are:

  • Family Medicine, Inpatient Service
  • Internal Medicine Inpatient Service. Also available are the following subsets of IM:
    1. Critical Care Medicine, Internal Medicine
    2. Inpatient Endocrinology, Diabetes, & Metabolism, Internal Medicine
    3. Inpatient Gastroenterology Consult Service, Internal Medicine
    4. Inpatient Geriatric Medicine, Internal Medicine
    5. Inpatient Hematology & Oncology, Internal Medicine
    6. Inpatient Infectious Disease, Internal Medicine
    7. Inpatient Nephrology, Internal Medicine
    8. Inpatient Pulmonary Disease, Internal Medicine
  • OB/GYN. Also available are the following subsets of OB/GYN:
    1. Gynecologic Surgery
    2. Labor and Delivery
  • Pediatrics (As above in Internal Medicine, but Pediatric)
  • Inpatient Psychiatry
  • Surgery. Also available are the following subsets of Surgery:
    1. Trauma Surgery
    2. Thoracic Surgery
    3. Vascular Surgery
Details Specific to the Sub-Internship
  1. Follow your own patients. You should report directly to the resident or faculty. You must be capable of performing the H&P, daily rounds, and discharge on your own patients. You are expected to propose orders and call consults.  Assume the role of the intern to the highest degree possible.
  2. On a regular day, you are expected to be ready for morning rounds with the resident or faculty.
  3. Offer to participate in procedures performed on your patients.
  4. You must average one day off per week, may not work at your site more than sixteen (16) hours in a day, and must be off-duty at least ten (10) hours between shifts.  Please contact your clerkship director if mandated to work outside these predetermined limits. Breaches of duty-hour restrictions are not tolerated.
  5. You must complete the assigned history and physical examinations and discharge summaries including all key components.
  6. If you have problems with non-patient care issues within your clerkship rotations, attempt to resolve those with your resident or attending. If that fails, contact the clerkship coordinator or the clerkship director. If that fails, contact the associate dean of clinical education. If there are issues that cannot be discussed with the resident or attending, feel free to contact the clerkship director, associate dean for clinical education, senior associate dean of education, or the office of the associate dean of student affairs directly.
  7. A completed year four elective application, complete with a course outline, schedule, and objectives, must be presented to the year-4 clerkship coordinator at least 30 days prior to the start of the block. Most clinical sites have deadlines of their own which must be met prior to your submission of the completed request to the year-4 coordinator. All students without completed requests will, by default, be scheduled for vacation. If both vacations have been used, a grade of incomplete or in-progress may be issued for the block.


The sub-i grade will be assigned by the Fourth year Clerkship Director based upon your rotation evaluation. The grade distribution will include the following: honors, high pass, pass, fail.