Away Rotations in Medical Education: Student Perspectives on Cost, Equity, and Scheduling

Virginia Journal of Medicine
Apr 11
15 min read

Updated: Apr 15

VJM Spring Edition 2026

Authors: Ethan Leoni¹, Rachel Chapman², Layla Ahmadi³, Nurudeen Alli⁴, Alice Snelling⁵, Lynn-Caelle Valere², Komal Kochhar, MBBS, MHA³, David Harris, PhD²

Author Affiliations:

¹Louisiana State University Health Sciences Center School of Medicine - New Orleans

²University of Central Florida College of Medicine

³Indiana University School of Medicine

⁴Rush University School of Medicine

⁵University of Utah School of Medicine

Abstract

Introduction

Away rotations are a critical part of the medical student path to residency, but the application, scheduling, and financial aspects remain highly variable across institutions and specialties. This causes concern about the equity and accessibility of the rotations. The study presented here surveyed medical student perceptions of the away rotation process across specialties and institutions.

Methods

A cross-sectional survey was released to fourth-year medical students at five U.S. allopathic (MD) institutions. Survey content addressed demographics, advising, application complexity, scheduling, and financial considerations. Chi-square tests were performed for categorical data, and qualitative analysis was used to assess free-response items.

Results

1,665 full-time fourth-year medical students completed the survey. Students with home residency programs received more advising, but this did not affect the number of completed rotations when compared to students without home programs. Most students felt the application process could be streamlined, as over half of the survey respondents spent more than 20 hours on applications. Nearly two-thirds of survey participants declined at least one rotation due to scheduling conflicts. More than half of respondents declined a rotation due to cost, and African American, Hispanic, and Asian students were significantly more likely than White students to turn down a rotation for financial reasons.

Discussion

Away rotations present significant time and financial costs for medical students, with some differences disproportionately affecting underrepresented groups. Standardized advising and applications, increased financial support, and consistent application and offer timelines are necessary to improve equity in the away rotation process.

Introduction

Away rotations are a longstanding component of undergraduate medical education, allowing students to explore specialties, demonstrate clinical skills, and establish relationships with potential residency programs. In competitive fields, these rotations function as informal auditions that may influence residency interview offers and match outcomes.^1,2,3 Despite their importance, processes surrounding away rotation advising, application, scheduling, and financing vary widely across institutions and specialties, creating a significant burden for students and raising concerns about equity and accessibility.

The away rotation application process imposes a substantial time burden, requiring extensive effort to navigate inconsistent requirements and timelines. Application opening dates range from January to June, and offer release dates span an even wider timeframe, with both varying dramatically not only across specialties but also across programs within the same specialty.^2,4 Common requirements include transcripts, CVs, photographs, immunization documentation, and licensing examination scores, though specific requirements differ markedly.¹ Approximately 76% of students report difficulty finding updated information on program websites, and nearly half report that offers were released later than advertised.¹ Students consistently cite frustration with the lack of standardization, insufficient transparency on available positions, and limited communication regarding application status.²Students spend time assembling materials, coordinating institutional requirements, and managing overlapping deadlines: time otherwise devoted to clinical learning and residency application preparation. These burdens may disproportionately affect students with fewer institutional supports or limited scheduling flexibility.^5,6

The financial burden represents one of the most significant barriers to equitable participation. Beyond application fees ($25-$300 per program), students absorb costs for travel, housing, and meals, with total costs averaging over $1,500 per rotation and often exceeding $5,000 for multiple rotations.^1,2 These considerations fundamentally shape application behavior, with 35-45% of students reporting that cost limitations restricted the number of programs to which they applied or prevented them from completing desired rotations entirely.^2,7 While some institutions offer scholarships, only 43.5% of programs in competitive specialties provide funding ($1,000-$5,000 stipends).³ Students applying to competitive specialties face particular disadvantages, as these fields strongly encourage multiple rotations despite imposing the highest financial burdens.^8,9,10 For underrepresented students in medicine, first-generation students, and those financing education through loans, costs may limit rotation choices and consequently residency program options.^6,7

Growing evidence suggests the away rotation system disproportionately disadvantages certain student groups. Variability in access to advising, institutional support, and financial resources exacerbates disparities based on race, gender, socioeconomic status, and institutional characteristics.^1,2,6,11,12 Students without home residency programs may need to complete away rotations to obtain specialty-specific evaluations and letters of recommendation.^2,8 These compounding disparities raise concerns that systemic barriers based on institutional characteristics and socioeconomic status may influence students' ability to fully participate and demonstrate commitment to their intended field as they apply to residency. Prior studies demonstrate specialty-specific inequities in access to away rotations;^{1,2,8,9,10,12} however, no comprehensive assessment exists across multiple specialties and institutions. Understanding how these inequities manifest nationally is essential to ensuring that away rotations serve as opportunities for professional growth rather than mechanisms reinforcing structural disadvantages.

Given the central role of away rotations in residency preparation and admissions, and growing concerns about equity, cost, and administrative burden, this study conducts a comprehensive, multi-institutional, and multi-specialty evaluation of medical students' perceptions of the away rotation process. We focus on three critical domains: (1) equity across demographic groups, including differences by race, gender, and home institution; (2) financial costs associated with applying for and completing away rotations; and (3) time and administrative burden required to navigate the application process. This research seeks to inform institutional and national strategies to improve transparency, accessibility, and equity within the away rotation process.

Methods

Study Design

This survey study received an exemption from the University of Central Florida's institutional review board (primary site) and from partner institutions that required additional approval. Five medical schools participated in this cross-sectional survey: Indiana University School of Medicine, Rush University School of Medicine, Louisiana State University School of Medicine, Spencer Fox Eccles School of Medicine, and University of Central Florida College of Medicine.

The survey was developed by current medical students and refined based on feedback from medical school faculty. Survey content included categorical and free-text demographic items, as well as categorical, free-response, and Likert-scale questions assessing advising experiences, the application process, scheduling logistics, and financial factors influencing away rotation decisions.

One student contributor from each IRB-approved institution distributed the survey link to enrolled students from their institution. Recruitment methods included class-specific online messaging groups and school-wide communication listservs. The survey was administered using the University of Central Florida Qualtrics from July 2025 to September 2025.

Participants

Eligible participants included U.S. MD students from IRB-exempted institutions. Participation was voluntary, confidential, and anonymous, with a $5 Amazon gift card incentive for the first 500 participants. Participants provided electronic informed consent via the Qualtrics survey.

Data Analysis

The study team analyzed data between October 2025 and January 2026. Responses from each school were combined into a single dataset and de-identified. Incomplete responses were omitted. Duplicate responses with identical identifiers were removed, retaining only the initial response. Analyzed responses were limited to those from participants who had entered their fourth year of medical school.

The Statistical Package for the Social Sciences (SPSS) was used to summarize demographics and dependent variable responses. Chi-square analysis was used to assess the statistical significance of relationships between categorical variables (defined as p < 0.05). Free-response questions were analyzed qualitatively, with a focus on identifying recurring themes.

Results

Participant Characteristics

A total of 1,665 fourth-year U.S. medical students completed the survey. Participants had a mean age of 27.4 years (median 26.0, SD 5.6). Most respondents identified as male (55.4%) or female (43.8%), and the most commonly reported race/ethnicity was White (67.4%), followed by Black/African American (18.2%), Hispanic (5.0%), Asian (3.6%), and American Indian/Alaska Native (2.2%).

Table I. Survey Participant Demographics

Table Description: Demographic characteristics of survey participants (n = 1665).

Advising and Institutional Guidance

Students from schools with a home residency program were more likely to report receiving away rotation advising and specialty-specific guidance compared with students without a home program (χ² = 51.4, p < 0.001; χ² = 13.3, p < 0.001, respectively). Students with home programs were also more likely to rate these advising sessions as ‘very helpful’ compared to students without home programs (χ² = 14.9, p < 0.001). However, home program status was not associated with differences in the number of applications submitted (p = 0.522), the number of away rotations completed (p = 0.085), or the recommended number of rotations (p = 0.183).

Figure I – Advising Sessions by Home Program Status

Figure Description: Percentage of participants reporting preparation sessions for away rotation applications, stratified by home program status.

Application Process Complexity and Time Burden

Most respondents reported substantial administrative burden during the away-rotation application process. A large majority felt the process could be simplified or streamlined (88.2%), and most reported that programs required at least some supplemental materials, with nearly half indicating that “most” programs required supplemental items (48.7%) and 20.2% reporting “all” programs required them.

Respondents also reported a meaningful time burden for preparing and submitting applications. The most common time category was 10–20 hours (24.0%), followed closely by 20–30 hours (21.4%) and 30–40 hours (20.9%). 14.1% of students reported spending more than 40 hours. In open-ended responses, students commonly described the process as time-intensive and poorly standardized, emphasizing repetitive administrative steps such as re-uploading the same documents across programs, inconsistent program requirements, and unclear communication around timelines.

Figure II – Time Spent on Applications

Figure Description: Time spent preparing and submitting away applications reported by participants (in hours).

Scheduling Logistics and Lost Opportunities

Scheduling challenges were common. Students frequently attributed lost rotations to misaligned offer timelines, including late notifications and overlapping offers. Nearly two-thirds of respondents (64.5%) reported forfeiting at least one away rotation due to scheduling conflicts.

Although most students indicated that their home institution schedules were sufficiently flexible to accommodate away rotations (81.9%), the timing of application decisions remained a major barrier. Specifically, 64.8% of students reported receiving decisions ≤2 months before the start date, including 32.2% within 1 month.

Equity-related Differences and Financial Burden

Male applicants reported receiving more away-rotation acceptances than female applicants (χ² = 6.6, p = 0.01). However, they also applied to more rotations than their female counterparts (χ² = 9.7, p = 0.02). Male applicants averaged 8.3 applications, whereas female applicants averaged 7.9 applications. Men averaged 2.4 acceptances (0.29 acceptances per application), whereas women averaged 2.24 acceptances (0.28 acceptances per application).

Figure III – Application Amounts and Application Numbers versus Sex

Figure Description: Number of away rotation applications, overall and stratified by sex.

Respondents reported notable expenses related to both applying and attending away rotations. For application costs alone (e.g., VSLO and fees), most students reported spending $100–$250 (29.9%) or $250–$500 (38.2%), with 17.4% spending more than $500. For total attendance-related costs (travel, housing, food, and tuition), the most common category was $2,500–$5,000 (36.7%), followed by $5,000–$10,000 (27.6%); 7.6% reported spending more than $10,000.

Figure IV – Away Rotation Costs

Figure Description: Cost of away rotations reported by participants.

Financial considerations influenced decision-making for most participants: 75.9% reported that finances influenced which offers they accepted, and 54.9% reported declining at least one away rotation due to cost. Most students reported that their away rotation program offered scholarships or subsidies (74.6%) in addition to logistical support with housing or transportation (82.3%), and 76.4% reported seeking some form of financial assistance.

When examining cost-related attrition by race, African American students were more likely than White students to report turning down an away rotation due to cost (χ² = 14.4, p < 0.001). Asian and Hispanic students were also more likely than White students to turn down an away rotation due to cost (χ² = 4.3 and 4.6, p = 0.038 and 0.033, respectively). In contrast, there was no significant difference by race in the proportion of respondents who reported seeking financial assistance (p = 0.404).

Cost-related comments frequently emphasized up-front, non-refundable expenses such as application fees, housing deposits, and travel. Comments further discussed that the uncertainty surrounding scheduling decisions contributed to perceived “wasted” spending and missed opportunities.

Figure V – Students Turning Down Rotations

Figure Description: Percentage of participants who turned down away rotations due to cost, stratified by race/ethnicity.

DISCUSSION

This multi-institutional survey highlights that while away rotations remain a critical component of the residency application process, they are associated with substantial financial, logistical, and advising-related challenges that contribute to inequitable student experiences.^1,2,4,8,10 Across specialties and institutions, students reported high costs, inconsistent advising, time-consuming application processes, and unpredictable scheduling timelines, underscoring the need for systemic reforms.^1,2,4,5

Advising Disparities and Structural Advantages

Students attending medical schools with home residency programs reported greater access to valuable away rotation advising and specialty-specific guidance. This structural advantage reflects greater proximity to faculty mentors and institutional familiarity with the away rotation process.^4,8,10 However, no differences were observed in application volume or number of away rotations completed based on home program status. These findings suggest that while institutional affiliation influences access to advising, students with and without home programs ultimately complete a similar number of away rotations, likely shaped by shared constraints such as financial burden and scheduling limitations.⁴ This analysis does not assess whether students secured rotations at preferred institutions. Additionally, although students with and without home programs complete a similar number of away rotations, those with home programs are typically required to complete a home rotation in their intended specialty, which may confer a cumulative advantage in the residency match process. For specialties with historically low match rates, students may pursue multiple away rotations regardless of home program status, reflecting heightened concern about match success.

Given the overburdened residency admissions process, similar strain may be facing those assessing the high volume of away rotation applicants. Improvements in advising and streamlined applications may help reduce applicant stress and the number of applications per available slot, decreasing the administrative burden for students and institutions and, ideally, contributing to more holistic review.^4,18 Future studies should investigate the extent to which home program status influences access to preferred away rotations, how these experiences affect residency match outcomes, and how these patterns vary across specialties.

Financial Burden and Inequities

The financial burden of away rotations emerged as a prominent barrier. Students commonly incur substantial costs for travel, temporary housing, and related expenses, consistent with prior work demonstrating that away rotations are both common and costly.⁵ In our cohort, most students reported that financial considerations influenced which offers they accepted, and more than half declined at least one rotation due to cost, which is consistent with specialty-specific studies demonstrating that cost constrains participation and shapes applicant behavior.^1,2

Importantly, African American, Asian, and Hispanic students were significantly more likely than White students to decline an away rotation for financial reasons, despite no observed racial differences in seeking financial assistance. This pattern is consistent with published concerns that access to financial resources and structural inequities can influence away-rotation participation and downstream match-related opportunities.^6,12 Moreover, the cost of away rotations is particularly concerning, as prior studies suggest financial strain not only influences student decision-making but may also negatively impact overall well-being.^15,16

A 2022 study found that 22% to 62% of graduate medical education surgical programs fund away rotation scholarships for underrepresented students;¹⁹ however, the gap identified in this survey between financial barriers and scholarship utilization among Black, Hispanic, and Asian students raises concerns about awareness and accessibility of financial aid. This represents a meaningful opportunity for targeted interventions to improve uptake of available resources, particularly given variability in financial support across programs and specialties.³ Earlier dissemination of funding information and clearer, standardized reporting of available support may reduce cost-related attrition and improve equitable access.

Transparency, Scheduling, and Process Inefficiencies

Students consistently described the away rotation application process as complex, time-intensive, and poorly standardized. The vast majority felt that application requirements could be simplified, and many reported that program requirements were unclear or inconsistent. Administrative preparation time was substantial, with over half of respondents spending more than 20 hours and a notable proportion spending over 40 hours navigating the application process. This represents a significant opportunity cost during a critical period of clinical training, potentially detracting from time available for patient care, exam preparation, and other residency application activities.

Scheduling inefficiencies further compounded these challenges. Nearly two-thirds of respondents reported relinquishing at least one away rotation due to scheduling conflicts. Although many students perceived their home institutions as flexible, inconsistent communication, misaligned offer timelines, and late notifications—often just weeks before start dates—suggest that these conflicts are driven more by variability across away rotation programs than by home institution limitations. Prior student perspectives indicate that declining an away rotation may effectively forfeit a residency interview invite at that institution,²⁰ raising concerns that the lack of standardized timelines forces suboptimal decisions with financial and professional consequences. These barriers likely disproportionately affect students with fewer financial resources, caregiving responsibilities, or less flexible curricula.

Sex-based Differences in Applications and Acceptances

Male applicants reported both submitting more away rotation applications and receiving more acceptances than female applicants. Acceptance rates per application were similar for men and women (0.29 vs 0.28), suggesting this difference is more related to higher application volumes among men than differential selection processes or competitiveness. These findings are hypothesis-generating and highlight the need for future analyses examining application and acceptance rates by sex between specialties to assess whether structural or cultural factors differentially shape application behavior and selection outcomes.¹¹

Implications for Institutions and National Stakeholders

Collectively, these findings point to several actionable opportunities for reform. Medical schools could implement standardized, early advising curricula for away rotations, particularly for those without a home residency program, and ensure proactive dissemination of financial support options. However, given that advising alone did not mitigate disparities in rotation outcomes, institutional efforts must be paired with broader structural reforms.

At a national level, coordinated efforts among the AAMC, specialty societies, and residency programs could improve transparency and reduce inefficiencies in several specific ways. First, programs could adopt standardized application requirements within VSLO (e.g., uniform document lists and elimination of redundant supplemental materials). Second, establishing specialty-specific timelines for application opening, offer release, and acceptance deadlines would reduce scheduling conflicts and “offer hoarding.” Third, programs could publicly report key selection criteria (e.g., Step score considerations, preferred number of rotations, and evaluation metrics) to improve applicant program selection and reduce application numbers. Finally, centralized, publicly accessible reporting of available financial support (e.g., stipends, housing assistance) within VSLO could help reduce cost-related attrition and improve equity in access.^4,17,21,22Finally, the broader context of residency application inflation and evaluative burden suggests that away-rotation reform should be considered alongside other systemic reforms to improve the UME to GME transition.^17,18

Strengths and Limitations

Strengths of this study include its large sample size, multi-institutional design, and inclusion of students across specialties. However, limitations include reliance on self-report data, potential self-selection bias, and variability in survey distribution across institutions. Based on the timeline, this survey assessed the experiences of students entering their fourth year, which may underestimate the anticipatory burden experienced by students earlier in their training who are planning away rotations without the benefit of hindsight. Despite these limitations, the results provide a comprehensive, cross-specialty perspective on the systemic challenges embedded within the away rotation process.

CONCLUSION

Away rotations remain a valuable but highly burdensome component of undergraduate medical education. This national survey demonstrates that students face significant challenges related to variability in advising, application complexity, scheduling inefficiencies, and substantial financial costs. Financial considerations influence decision-making for the majority of students and disproportionately affect African American, Asian, and Hispanic students, highlighting persistent equity concerns.

Improving standardized advising, streamlining application and scheduling processes, and expanding and publicizing financial support mechanisms represent critical steps toward a more equitable away rotation system. By addressing these structural barriers, institutions and national stakeholders can help ensure that away rotations serve as educational opportunities rather than sources of undue financial and logistical strain. This study provides national-level insight into student perspectives and offers a data-driven foundation for future policy and programmatic reforms to improve access, transparency, and equity in the away rotation process.

Future analysis of this data will include a comparison of logistical, financing, and equity concerns between specialties. A post-match survey is currently underway to assess how these features of the away application process affect residency match outcomes.

References

1. Cyberski T, Tatineni S, Shogan A, Baroody FM. Otolaryngology Away Subinternships: An Analysis of the Application Process and Survey of Current Applicants' Perspectives. OTO Open. 2023 Mar 28;7(1):e49. doi: 10.1002/oto2.49. PMID: 36998567; PMCID: PMC10046704.

2. Zhang XC, Gordon D, Lutfy-Clayton L, et al. Away Rotation Applications in Emergency Medicine: Medical Student Behaviors, Outcomes, and Stressors. J Emerg Med. 2022 Mar;62(3):401-412. doi: 10.1016/j.jemermed.2021.11.008. Epub 2022 Jan 22. PMID: 35078704.

3. Bergman DT, McNamara CJ, Gayne AC, Jr Thomas CR, Kapadia NS. A Comprehensive Survey of 2024 Funding for Radiation Oncology Visiting Medical Student Electives. J Cancer Educ. 2025 Feb;40(1):88-92. doi: 10.1007/s13187-024-02476-z. Epub 2024 Aug 5. PMID: 39103704.

4. Griffith, Max MD, DeMasi, Stephanie C. MD, McGrath, Abigail J. MD, Love, Jeffrey N. MD, Moll, Joel MD, Santen, Sally A. MD, PhD. Time to Reevaluate the Away Rotation: Improving Return on Investment for Students and Schools. Academic Medicine 94(4):p 496-500, April 2019. | DOI: 10.1097/ACM.0000000000002505

5. Winterton M, Ahn J, Bernstein J. The prevalence and cost of medical student visiting rotations. BMC Med Educ. 2016 Nov 14;16(1):291. doi: 10.1186/s12909-016-0805-z. PMID: 27842590; PMCID: PMC5109707.

6. Ani C, Ani L, Gardner TF. Evaluation of the impact of race/ethnicity on medical student's away rotations and residency match. J Natl Med Assoc. 2025 Aug;117(4):241-247. doi: 10.1016/j.jnma.2025.05.004. Epub 2025 May 17. PMID: 40484770.

7. Benson NM, Stickle TR, Raszka WV Jr. Going "Fourth" From Medical School: Fourth-Year Medical Students' Perspectives on the Fourth Year of Medical School. Acad Med. 2015 Oct;90(10):1386-93. doi: 10.1097/ACM.0000000000000802. PMID: 27002891.

8. O'Donnell SW, Drolet BC, Brower JP, LaPorte D, Eberson CP. Orthopaedic Surgery Residency: Perspectives of Applicants and Program Directors on Medical Student Away Rotations. J Am Acad Orthop Surg. 2017 Jan;25(1):61-68. doi: 10.5435/JAAOS-D-16-00099. PMID: 28002215.

9. Drolet BC, Brower JP, Lifchez SD, Janis JE, Liu PY. Away Rotations and Matching in Integrated Plastic Surgery Residency: Applicant and Program Director Perspectives. Plast Reconstr Surg. 2016 Apr;137(4):1337-1343. doi: 10.1097/PRS.0000000000002029. PMID: 27018690.

10. Bui J, Khoury A, Long J, Haithcock B. Away Rotations at Integrated Thoracic Surgery Programs: Applicant and Program Director Perspectives. J Surg Educ. 2021 Nov-Dec;78(6):1915-1922. doi: 10.1016/j.jsurg.2021.05.003. Epub 2021 Jun 11. PMID: 34127425.

11. Hill KA, Samuels EA, Gross CP, et al. Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation. JAMA Intern Med. 2020 May 1;180(5):653-665. doi: 10.1001/jamainternmed.2020.0030. PMID: 32091540; PMCID: PMC7042809.

12. Hou MY, Hodgens TM, Nguyen M, et al. Cross-sectional study of obstetrics and gynecology-bound students in visiting rotations. BMC Med Educ. 2025 Jul 29;25(1):1125. doi: 10.1186/s12909-025-07690-x. PMID: 40731335; PMCID: PMC12305918.

13. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89(3):443-451. doi:10.1097/ACM.0000000000000134. PMID:24448053.

14. Hill MR, Goicochea S, Merlo LJ. In their own words: stressors facing medical students in the millennial generation. Med Educ Online. 2018;23(1):1530558. doi:10.1080/10872981.2018.1530558. PMID:30286698.

15. Pisaniello MS, Asahina AT, Bacchi S, et al. Effect of medical student debt on mental health, academic performance, and specialty choice: a systematic review. Med J Aust. 2019;211(8):356-362. doi:10.5694/mja2.50362. PMID:31270123.

16. Association of American Medical Colleges (AAMC). Physician Education Debt and the Cost to Attend Medical School (report web page). Washington, DC: AAMC. Available from: AAMC website (accessed 2026 Feb 8).

17. Coalition for Physician Accountability. UGRC Coalition Report: Final Report and Recommendations for Comprehensive Improvement of the UME–GME Transition. Washington, DC; 2021 (published Aug 26, 2021).

18. Carmody JB, Rosman IS, Carlson JC. Application Fever: Reviewing the Causes, Costs, and Cures for Residency Application Inflation. Cureus. 2021;13(3):e13804. PMID:33850672.

19. Bernstein SL, Wei C, Gu A, Campbell JC, Fufa D. An Analysis of Underrepresented in Medicine Away Rotation Scholarships in Surgical Specialties. J Grad Med Educ. 2022 Oct;14(5):533-541. doi: 10.4300/JGME-D-21-00952.1. PMID: 36274775; PMCID: PMC9580313.

20. Foston N. Pros and cons of turning down an audition rotation: What you need to know. The DO. June 12, 2019. Pros and cons of turning down an audition rotation: What you need to know - The DO.

21. AAMC. Visiting Student Learning Opportunities™ (VSLO®) (program overview web page). Available from: AAMC website (accessed 2026 Feb 8).

22. AAMC. How to Use the VSLO® Application Service (fee and requirements web page). Available from: AAMC website (accessed 2026 Feb 8).