Making the fourth year more meaningful.

A medical student advisee recently met with me to plan his fourth-year rotations. He ranked near the top of his class after his third-year rotations, and I anticipated we would be discussing which residency programs he should consider and how he could best use the fourth year to prepare for his internship. I suggested a subinternship experience in critical care and emergency medicine, and electives in medical and surgical subspecialties. However, as I looked at the preliminary schedule he had prepared, I was surprised to see several away rotations in the same specialty—all audition rotations for the specialty into which he hoped to match.

“Why are you taking all these away rotations?” I asked.

“Everyone has told me I need to do this so that the programs will get to know me. It is very competitive for the good programs. I want to be sure to match. I don’t feel like I have any other choice.”

“But you have excellent grades and board scores. I don’t think you need to do this. You will almost certainly match into one of your top choices. The fourth year should be an opportunity for you to explore other topics and learn skills that you may not have a chance to during residency,” I said. “What else would you like to learn this year?”

But he remained focused on his original concern and replied, “Can we talk about programs where I should apply?” We went back and forth discussing elements of the fourth year—the uncertainty of the Match interview process, the benefits of exposure to fields that would broaden his perspective, and the need for flexibility to complete scholarly projects and to solidify skills that would be needed before the start of internship. We also discussed several residency programs I was familiar with and how they might fit his interests. It was an excellent discussion about the fourth year. However, I realized that my perspective on the fourth year was heavily influenced by my experience as a former program director, and that students might have very different views. What are some of those views?

In this month’s Academic Medicine, Wolf et al[1] describe graduating students’ perspectives on the fourth-year curriculum at the University of Colorado School of Medicine. This mixed-methods study, using focus groups and a survey, suggests that students look to the fourth year for career identification and professional development as well as for the opportunity to explore diverse practice settings and personal interests. They also seek flexibility and individualization. In addition, students referred to the role of emotions, like fear and anxiety about competence, in motivating fourth-year course selection. This is valuable information for those of us who advise medical students.

Cosgrove et al[2] from the University of Washington School of Medicine, in their Commentary on Wolf and colleagues’ report,[1] reinforce many of these themes as they describe the goals for their school’s new fourth-year curriculum. That curriculum will stress preparing for residency and national board exams, making career choices, exploring practice settings and topics of personal interest, and engaging in socially responsive service-oriented learning.

Residency program directors describe somewhat different goals for the fourth year. Lyss-Lerman et al[3] interviewed 30 program directors about the fourth year at one institution and found that the program directors recommended a subinternship in the student’s chosen career area as well as internal medicine rotations, internal medicine subspecialty rotations, and critical care, emergency medicine, and ambulatory medicine rotations. They suggested minimizing additional time in the student’s chosen field.

Walling and Merando[4] present another view. In their review of the literature about the fourth year from 1974 to 2009, they note an overemphasis on the Match and a lack of focus in the fourth-year curriculum. They suggest that the goals of the fourth year should reflect the medical school’s mission, address the transition to residency, and complete the medical school experience. They also recommend that the fourth year be designed to accommodate the residency application process and medical licensing examinations.

Stevens[5] suggested using the fourth year to address reform of the health care delivery system by training students in interdisciplinary teams and presenting required educational experiences in evidence-based medicine, patient safety, and quality improvement. He also advised reducing elective time to make room for this new curricular experiences.

What conclusions can we draw from these articles?

There is a consensus that the fourth year should have the flexibility to accommodate the residency selection process. Students must be able to present themselves well to prospective programs with completed application materials, and have the opportunity to interview to their best advantage. Although the residency selection process diverts the attention of students away from their training goals, the practical considerations of an increasingly competitive Match cannot be ignored. Except for cases in which students have entered a joint medical school–residency program with guaranteed acceptance into residency, any reform of the fourth year will be limited by the important interruptions caused by residency applications. If the number of medical students continues to increase and the number of residency slots remains relatively stable, the Match will become even more stressful for students and will encroach upon other options for reform of the fourth year. Students will also need increased emotional and logistic support from their institutions.

There is also general agreement that during the fourth year, students should become prepared for the activities of internship. Some promising initiatives that can help to smooth the transition of education from the undergraduate to the graduate medical education program include “boot camps,”[6] in which specific skills that will be needed in internship are identified and students learn and practice the skills.

Finally, there are many who would agree that the fourth year could also help to fulfill the unique focus of the medical school’s program, such as emphasizing community service to underserved populations, as in the example described by Cosgrove et al,[2] or by encouraging research and other scholarly activities.

But at many medical schools, there continues to be discontent with the fourth year and concern that there is much wasted time. Why is this?

I believe the problems with the fourth year of medical school may reflect a larger problem—the failure to articulate a vision for the outcome of medical school education. If we do not have a consensus for the end product of medical school education, is it any wonder we would have confusion about identifying when a student has reached this goal? Although students progressively attain expertise during their undergraduate and graduate medical educations, we have not identified the competencies for medical school graduates the way we have for residents.

Fortunately, there is a promising project currently under development that attempts to describe core behaviors that would be expected of all medical school graduates. These behaviors, called core entrustable professional activities for entering residency,[7] would provide a road map for students about which minimum outcomes they should achieve before starting their residencies. If these proposed guidelines are adopted by all medical schools, there will be an opportunity to identify the placement of educational experiences to meet these outcomes and the inclusion of options that would go beyond minimum requirements. Reform of the fourth year could occur in the context of overall medical school curriculum reform.

The current reexamination of the fourth year of medical school also comes at a time of renewed interest in shortening medical education. Emanuel and Fuchs[8] have suggested that medical education could be shortened by 30%, including reductions in the clinical experience. If we do not have a clear vision of the value of the fourth year of medical school, it could become a target for elimination. I believe that at a time of great change in our health care system and with the enormous growth in science, medical knowledge, and information systems, the training of our future physicians may need to become more intensive, require more resources, and in most cases require more time than what we have needed in the past. There may be some students who can master all the necessary core entrustable professional activities and the other skills and knowledge needed to pass licensing exams in three years, but I suspect that for most students, four years or more may be required. However, we will not know how much time is needed until we agree upon the desired outcomes.

I also hope that we can look beyond minimal requirements and consider what we aspire to for our educational programs. The students studied by Wolf et al[1] reported that they would like the opportunity to explore new ideas and experience personal growth. In addition to these goals, we could also encourage students to partake of the excitement and joy of scholarship, critical thinking, and the development of their professional identities. The fourth year of medical school could be a unique opportunity for growth that sets a medical student on a path to a fulfilling and productive medical career. As we consider how we advise our upcoming clinical medical students, we should pause to imagine what a pleasure it would be to discuss how each student could begin to meet his or her potential as a physician during fourth-year rotations, rather than focusing our advice only on the residency application process or passing of board exams. The current limitations are of our making, and we owe it to our students to create a better final year of medical school.