Empowering fourth-year medical students: the value of the senior year.

In this issue of Academic Medicine, Wolf et al explore the purposes and value of the senior year of medical school as viewed by graduating students at their institution. Using data from student focus groups and questionnaires, they report that students all found there to be significant value in but identified different purposes for the fourth year. The authors of this commentary believe that study adds to the discussion of fourth-year curriculum reform an important voice that has been lacking-that of students.Previous articles focusing on the perceived lack of clarity of educational purpose in the senior year curriculum have reflected a faculty perspective and have led some to call for increasing the structure of, decreasing the elective time in, or even completely eliminating the fourth year. In this commentary, the authors ask for a pause in this debate to consider the implications of the student perspective as well as important trends in the medical education continuum that affect the senior student (e.g., milestones that will set new expectations for first-year residents, increasing pressure associated with matching to a residency). They propose that providing students with time for career exploration and for focusing on areas of interest would allow them to individualize their preparation for residency and to be more sure of their career choices. They share the University of Washington School of Medicine's planned new fourth-year approach as an example of a flexible, individualized senior year curriculum.

In every period of medical education reform in the United States, there are calls to reconsider the purpose and value of the senior year of medical school. The fourth year lacks the explicit structure and set of known outcomes that characterize the first three years of medical school; the only constant across institutions is the expectation that students will take Step 2 of the United States Medical Licensing Examination (USMLE), select a specialty, and interview for residency positions. Policy makers, medical educators, and residency directors have diverse opinions on the year’s value. Some call for eliminating the senior year entirely to save money and fill the workforce pipeline,[1] whereas others characterize the year as a critical period for preparing students for residency.[2]

Given that curricular time and physical space are among the most jealously guarded faculty prerogatives in a medical school, it is understandable that calls for fourth-year reform often focus on reducing student elective time. By definition there is no department or faculty champion to defend that turf, so electives are low-hanging fruit. Yet, despite such calls, the amount of student elective time has remained within a narrow range over the past 30 years, shifting from an average of 25.4 weeks in 1979, to 19.1 weeks in 1999, to 22.3 weeks in 2008–2009.[3]

Although the number of schools offering the option of a three-year curriculum is small, it shows signs of increasing. There are good reasons for medical schools to examine and consider a three-year curriculum. As noted above, three-year programs save students time and money, and they create a faster pipeline to respond to workforce needs. They may also focus more students on careers in primary care. Further, analyses of long-term outcomes for three- versus four-year programs suggest equivalency for graduates.[4]

But should year four simply be tossed? In this issue of Academic Medicine, Wolf et al[5] add an important perspective to the conversation with their study of graduating medical students’ views of the purpose and value of their senior year. Surprisingly, data on students’ perspectives have not been published previously, despite the widespread recognition of medical students as self-directed adult learners. Many previous studies and commentaries have focused on the perceived lack of clarity of educational purpose in the year’s curriculum. However, those studies reflect a faculty perspective and may have undervalued the student perspective that senior year is a “formative component of their careers, not just … a summative pursuit of their medical degrees.”[5] Intangibles—such as developing confidence in one’s knowledge base, learning to function effectively as a team member in a workplace, and achieving emotional preparedness for the rigors of residency training—have received less attention than have specific curriculum elements.

Wolf and colleagues’ effective and thoughtful study design used a mixed-methods approach: The authors conducted focus groups and a survey of graduating medical students at the University of Colorado School of Medicine. They identified six themes from the focus group discussions concerning the purpose and value of the senior year. Like medical educators and residency directors in previous publications, the medical students in Wolf and colleagues’ study listed career development and preparation and career identification high among the fourth year’s purposes. However, the students also identified value in flexibility and individualization, pursuit of personal interests, exploration of diverse practice settings, and the influence of emotion (gaining confidence and addressing fears about preparedness) in shaping the purpose of their senior year. Wolf et al reach two critically important conclusions: Students uniformly identified value to the senior year, but the purposes they identified for the year varied. In particular, the perspectives of students who started their final year with a known specialty choice were very different from those of students who needed more time and more intensive clinical experiences to discern their career choice. These conclusions highlight the need for curriculum designers to build flexibility and opportunities for individualization into the fourth year.

Whither Senior Year?

In the current period of considerable change and focus on efficiency and cost-effectiveness in health care and medical education, it is tempting to consider the radical approach of a three-year educational experience. We ask, though, for the medical education community to pause to truly consider whether such a change is worthwhile, particularly in light of Wolf and colleagues’ interesting new data and important trends in the medical education continuum.

As the movement advances to incorporate competencies and milestones to define and gauge trainees’ progress toward goal achievement, specific expectations for the preparedness of incoming residents will increase. Students must be fully prepared for this crucial transition to residency. In addition, if the medical school curriculum is shortened to three years, students’ time to pursue potential career directions—service, primary care, global health experiences, research—will be cut short, as will their time to delve deeply into subjects of particular interest and complete meaningful scholarly projects. Further, such an accelerated schedule, with reduced breaks, may increase students’ stress. Adding to this stress, students may feel obligated to make permanent career choices before they are ready. And, in a time when growing numbers of medical graduates—resulting from new U.S. MD- and DO-granting medical schools, enrollment expansion at existing schools, and offshore schools—are in competition for a fixed number of residency slots, the reality of supply and demand dictates that students must apply to more residency programs and spend more time interviewing for those programs than in the past. Students must make decisions expeditiously about career pathways while casting a wide net for advanced training options in those pathways. Fitting all of this into a bare-bones three-year curriculum would not only be challenging but, we believe, also antithetical to making career choices based on thoughtful consideration and genuine interest.

An Alternative Approach

We agree with Wolf et al that the senior year is genuinely meaningful for students. Like many medical schools nationally, our institution—the University of Washington School of Medicine (UW)—is deep into curriculum renewal and ready to move to a new model by 2015. Here, we share our new approach to the fourth year as an alternative that bypasses the route of a shortened total curriculum while moving beyond the “senioritis syndrome” that besets some schools’ senior years.

The UW model is unique nationally. Our medical school serves the five-state Washington, Wyoming, Alaska, Montana, and Idaho region and has a dual focus on excellence in primary care and excellence in scientific discovery. Whereas our settings and directions may be more diverse than those of other medical schools, our approach provides a broad template for others to consider in planning their own fourth-year curricula.

In our new curriculum, we define the following purposes for the fourth year:

Preparing for residency through increased responsibility for patient care to the point of feeling confident

Making wise and judicious career choices

Creating defined time for guidance and preparation for USMLE exam inations and residency applications and interviews

Having the time to study/explore a topic or specialty in depth

Developing an understanding of different practice settings to prepare for later decisions

6. Having the time to foster and nurture socially responsible activities and interests such as service learning

To achieve these goals, our new fourth-year curriculum will provide students with seven months of increased time for career exploration and for focusing on their areas of interest, gained by shortening the basic science phase and eliminating some senior requirements. The additional time will enable students to explore life opportunities, such as working in rural or global locations, and to undertake meaningful scholarship that will help them develop the skills necessary to function as lifelong learners. Our students will also have more time to prepare for the transition into residency as well as to pause before the intensity of residency training.

Although we agree with Stevens[6] (“Taking back year 4: A call to action”) concerning the need to prepare students for the world of accountable care, we believe that quality, safety, and cost must be integrated into the entire medical school curriculum, not segre gated into course work added at the end. In a fourth-year curriculum that offers flexibility and options for individualization, students could develop and hone skills introduced during the first three years, such as practice and care management, in addition to pursuing other skills and activities that they themselves identify as essential as they prepare for advanced training and practice. An expectation of this approach at UW is that students must reflect on their needs and goals for the fourth year and work closely with faculty advisors to discuss their progress and refine their goals. Without a reflective component and careful guidance, the fourth year could easily revert to a period without purpose or expected outcomes.

Each student’s pathway through the new UW curriculum will vary according to his or her needs. Although standardization is desirable in defining competencies and milestones, students must have the flexibility to choose the experiences that will help them build knowledge and skill and meet their individual goals. Thus, in our curriculum renewal, we named the senior year curriculum phase “Exploration and Focus,” connoting students’ ability to first explore and then focus.

We applaud Wolf et al for their important addition to a crucial topic. Their study should be replicated with a broad representation of medical schools, both public and private. A longitudinal study that follows students in their fourth year of medical school and their first year of residency should also be considered. The door is open for a national dialogue on improving the senior year of medical education without simply calling for its elimination.