The Fourth Year of US Medical Schools: Curricular Content and Student Perceived Value

4th_Year  Two articles in this month’s issue of Academic Medicine address the 4th (the final) year of US medical schools: a study by Elnicki et al describing course offerings by 136 US medical schools, and a study by Benson et al reporting the results of a survey of medical students (47% response rate) from 20 US medical schools regarding their attitudes towards 4th year medical education and the residency application process. To place this discussion in context, the reader should be aware that there has been a lot of debate about the value and goals of the forth year of medical school, and that in the early 1970’s, about 25% of US medical schools had eliminated the 4th year. The major issue for debate has been whether the 4th year should be a time to develop career-specific competencies or broad skill sets that may not be related to a student’s chosen specialty.

The article by Elnicki et al describes a wide variability in course offerings, though sub internships were required by 90% of the schools, and many schools required specific rotations such as emergency medicine (45%), ICU rotation (34%), and ambulatory care (35%). Increasing use of capstone courses was also reported (59%), designed to better prepare students for internship by addressing common or serious medical situations, basic science concepts, procedural, communication and team skills. In terms of student perspectives on the 4th year, Benson et al report that students most value the 4th year as a time to prepare for and strengthen their residency application (interviewing at residency programs, doing away electives), while also recognizing its value for broadening their educational experience.  At first glance, course offerings and student perceived values reported in these studies seem aligned. However, student perceptions can vary by intended specialty, and perceptions of educators, and those of recent graduates who have experienced internships, should also be taken into account if a curricular recommendation or guideline regarding what ought to be in a 4th year curriculum is to be developed. — Sarang Kim, MD

A 4th Year Medical Student Perspective:

Some educators have argued that the fourth year of medical school is unnecessary as it increases student debt while not improving the overall readiness of medical students for residency. Medical students, including this reviewer, typically have not agreed with this statement. As reported by the majority of medical students surveyed by Benson et al, the fourth year of medial school provides a valuable opportunity for students to prepare for their next step in the medical field. At most US medical schools, the third-year is heavily arranged with required clerkships,  giving the student little time to explore his/her interests. During the fourth year, many students embrace the opportunity to explore various fields- both as a way to solidify their interests and to expand their breadth of knowledge and skills. Without the fourth year, students may not be prepared to thrive in their field of interest. To me, the idea of starting residency without the knowledge and skills gained through subinternship, capstone courses (aka “bootcamp”), emergency medicine, ICU, and ambulatory care experiences during the fourth year is frightening; I believe doing away with such experiences would be detrimental to the student and overall adequacy of intern readiness. The fourth year also provides a time for students to reflect on the type of physician they want to become and where they might spend the next several years of their lives as they continue to train towards their goal. By providing opportunities to explore, broaden and sharpen knowledge and skills, and time to reflect and prepare for what’s ahead, I believe that the fourth-year truly serves a meaningful purpose. — Heather Belle, Rutgers Robert Wood Johnson Medical School MD Candidate Class of 2016

Benson, Nicole M. MD; Stickle, Timothy R. PhD; Raszka, William V, Jr. Going “Fourth” from Medical School: Fourth-Year Medical Students’ Perspectives on the Fourth Year of Medical School. Academic Medicine, 2015

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Elnicki, D. Michael MD; Gallagher, Susan MD; Willett, Laura MD; Kane, Gregory MD; Muntz, Martin MD; Henry, Daniel MD; Cannarozzi, Maria MD; Stewart, Emily MD; Harrell, Heather MD; Aiyer, Meenakshy MD; Salvit, Cori MD; Chudgar, Saumil MD, MS; Vu, Robert MD; for the Clerkship Directors in Internal Medicine Association of Program Directors in Internal Medicine Committee on Transition to Internship “Course Offerings in the Fourth Year of Medical School: How U.S. Medical Schools Are Preparing Students for Internship.”  Academic Medicine, 2015

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