Commentary: Taking back Year 4: a call to action.

In this issue of Academic Medicine, Walling and Merando's literature review on the senior-year curriculum finds a broad consensus that this final year underperforms educationally at many U.S. medical schools, but little agreement on how to improve it. The review challenges us to consider how best to develop this key piece of educational real estate, which is too often frittered away on auditions, interview odysseys, and electives of uncertain educational value. In this commentary, the author approaches this education question from an unorthodox viewpoint, the delivery system and medical workforce perspectives. He proposes taking back major portions of Year 4 from elective clerkships and investing the time in required course work to prepare graduates to practice and lead in a redesigned 21st-century health system, providing superior access and outcomes at sustainable costs. The recommendations draw inspiration from the Institute of Medicine's "Chasm" reports, specifically echoing its 2003 Health Professions Education report that identified five new competencies deemed essential for all 21st-century health professionals. Finally, the author disputes the view that delivery system overhaul lies beyond the purview of educators, pointing to the historical precedent of the greatest medical paradigm shift of all time, the closure of the proprietary medical schools a century ago triggered by Flexner's report. The author closes by calling medical educators to action, to prepare the next generation of physicians to radically redesign health care and lead us out of the present crisis.