Coates, Wendy C. MD; Crooks, Kimberly PhD; Slavin, Stuart J. MD; Guiton, Gretchen PhD; Wilkerson, LuAnn EdD
Since the 1970s, a nationwide trend has developed in which the fourth year of medical school has been loosely structured, allowing students to take predominantly elective courses with few mandated courses. This format was intended to allow students the opportunity to explore potential careers and fields of interest.1 As early as 1985, however, Swanson2 described the emergence of the “preresidency syndrome” that shifted the focus of the fourth-year electives from a broad-based educational experience to a job-hunting tool. Fourth-year students often take multiple “audition electives” in their desired specialty, devote a brief period (as few as four weeks) to “research” in their chosen field to strengthen their resume, and devote time to relax between the rigors of the clerkship year and internship. It is likely that this preresidency syndrome is fueled by students’ lack of access to specialty faculty mentors early enough in their third year to have a meaningful impact on elective selection and residency applications. Some students may find it necessary to repeat audition electives until they can identify someone who knows them well enough to write a compelling letter of recommendation.3
Although there has been a trend toward curriculum reform for the first three years of medical school,4–7 there has been little attention focused on fourth-year curriculum reform. One notable exception is the Pathways program at Drexel University College of Medicine in which recommended senior electives are grouped for specific career pathways.8 Some specialty societies have issued fourth-year curriculum recommendations to students who are considering those specialties.9–11 A novel approach to take control of the fourth-year curriculum is for individual residency programs to issue credit for the first year of residency to fourth-year students who arrange their courses to meet the requirements set forth by the programs.12,13
As part of a comprehensive curriculum reform at the David Geffen School of Medicine at the University of California–Los Angeles (UCLA), a “College phase” was introduced to the fourth-year curriculum in 2001 to address the need for improved career advising and mentoring for senior medical students. The College concept, detailed below, was first described at UCLA by Slavin et al14 and was developed by consensus committees of senior medical educators and student representatives at the school of medicine. Under this program, fourth-year students would affiliate with a network of faculty whose specialties reflected a particular type of thought process. These colleges would serve as the foundation for their curricular program and mentoring needs as they transitioned to their eventual careers. Initially, students were not supportive of the College concept, because they feared it would be considerably more structured than the previous fourth-year curriculum. They viewed it as removing their freedom to create a totally personalized senior year. In fact, our initial proposed program model included a two-week “foundations” course between the third and fourth years, but the students vehemently resisted this proposal. We compromised by reducing the initial encounter to a one-week experience, with the idea that a second week could eventually be added near the conclusion of the fourth year as a postmatch preparation for internship.
Another barrier to the development and implementation of the College Program was the cost. Although we had foundation support for the initial three-year period (2001–2004), it was important to gain the support and commitment of the dean to continue the College Program after the extramural funding period. To do so, we developed a projected five-year budget that was accepted by the dean.
When the broad concept of the College Program had been devised and the curricular and budgetary compromises were made, specific career groupings were described to form the colleges. Suitable leaders for each college were selected from a pool of applicants who were nominated by their chairs, peers, or themselves. A committee of senior faculty members at the school of medicine elected a chair for each college to an initial term of three years. Each college formed an advisory committee of medical educators within the specialties within its purview to devise a mission statement, curricular content, and mentoring strategies.
Definition of a College
As we touched on earlier, a college is a curricular and administrative structure organized around a set of related specialties that share similar traits in their medical practice. Each college is led by a chair, who functions as that college’s “dean”—mentoring, advising, developing curricular programs, and writing medical school performance evaluations. A cadre of mentors from representative departments and a group of self-selected students form the college community. There are six UCLA colleges: Acute Care (time-based decision-making specialties, such as anesthesiology, emergency medicine, and critical care), Applied Anatomy (structure-oriented fields, such as surgery, radiology, and pathology), Medical Leadership (dual-degree programs in public health or business administration), Medical Specialties (subspecialties focused on clinical reasoning and advanced fellowship training), Primary Care (longitudinal care specialties, including family medicine, internal medicine, and pediatrics), and Urban Underserved (for students in the Drew–UCLA Medical Education Program, which is focused on care of underserved communities).
Each college is responsible for delivering specific curricular activities, advising students on elective selection, overseeing students’ scholarly projects, and providing career mentoring. During the first week of the fourth year, each college offers an intensive “foundations” block designed to prepare students for their subinternships in the specialties represented by their college. The weeklong foundations course uses a variety of instructional formats to engage students in skill-building laboratories, clinical reasoning exercises, and career planning. Examples include full-scale, high-fidelity human simulation15; laboratories using surgical robotic equipment; problem-based learning seminars; cadaver and animal laboratories16; interactive lectures; and supervised patient contact. Students work closely with the college mentors during this intensive week and establish the rapport that will assist them in their career and residency selection processes. It also affords the students an opportunity to form a collegial relationship with their peers. The College Program provides structure to the fourth year by guiding students to enroll in required or recommended electives and subinternships that support their college’s mission. After the foundations block, the college maintains contact with the students through the individual mentor–protégé pairings and a required dinner seminar series that is offered as a longitudinal experience during the course of the fourth year. Topics for seminars include basic science updates, additional skills or simulation labs, group mentoring activities, community service opportunities, well-being exercises, sharing of students’ scholarly work, and discussion of the residency application process.
Mentors for each college were identified by the college chairs. In general, the mentors were medical educators within the school of medicine whose purpose was to provide for students a window into the mentor’s own career. The student affairs office representatives and each college chair were available to the mentors to answer questions related to graduation competencies and available electives. In addition, students were free to contact their college chair for general information about requirements. There was no systematic formal training for mentors across all colleges; however, the college chairs met monthly with the deans of education and student affairs to share best practices, and they brought these ideas back to their advisory boards.
Although most students select the college that is most aligned with their career path, some enroll in an unrelated college with the intention of obtaining additional training in an area of interest or perceived weakness. Mentors are willing to “adopt” students from other colleges if a specific career path is not covered in the student’s home college. Students are allowed to participate in the longitudinal experiences offered by colleges other than their home college. This is especially helpful to students who select a college outside their intended career grouping or whose career plans change during the fourth year. After the College Program was implemented, we surveyed students who had experienced the pre-College curriculum as well as students who had completed the College Program to compare students’ perceptions of the fourth-year medical school experience.
Survey of Pre- and Post-College Medical Students
We conducted a telephone survey to assess fourth-year curricular and mentoring experiences for two graduating classes, pre- and post-College implementation. We selected a stratified random sample of 50 students from the pre-College graduating class of 2001 (total students = 148) with the goal of obtaining a sample of 30 (21% of the total class), replacing any student who declined to participate or whom we were unable to contact with the next one from the list. The sample size for the preintervention group was necessarily small given time constraints involved in contacting students during their final month of medical school and to ensure stratification based on the residency in which the student had matched. A stratified random process was also used for the College intervention group from the class of 2003 (total students = 144), but with the goal of achieving a total sample of 70 (49%) because interviews were started two months before the end of medical school. Stratification for this group was based on college selected.
In the 25-question survey, graduating students shared their views on mentoring and advising and overall impressions of the quality and value of the fourth-year activities. Survey items were based on the stated purpose and goals of the College Program and items from the Association of American Medical Colleges (AAMC) Graduation Questionnaire17,18 related to career advising. The survey was pilot tested with a small group of senior medical students enrolled in a teaching internship.
For the purpose of our study, the following definitions were employed:
* Advisor: Faculty who provided assistance in scheduling clinical electives and provided advice on residency application
* Role model: Someone the student used as a positive example of how to approach a career in medicine
* Career mentor: Someone who played an active role in helping the student with career plans
The control group was the graduating class of 2001, the final class to graduate before implementing the College Program. The intervention group was the graduating class of 2003, the second class to experience the new College Program. This was done deliberately to allow the new College Program to stabilize and improve according to the initial class’s feedback. The telephone survey consisted of three sections and was conducted using a semistructured response set followed by probes for elaboration: experience with advisors, role models, and mentors; quality of the fourth-year activities; and effects of the fourth-year curriculum. In addition, preintervention students were asked to comment on the perceived usefulness of proposed College activities, whereas the College cohort was asked to indicate the actual usefulness of those activities.
Response sets consisted of yes or no answers, numeric reporting, a three-point agree/disagree/neutral scale, a four-point Likert-type rating scale (1 = excellent; 4 = poor), and open-ended comments. Rating-scale responses were grouped into two categories for analysis (excellent–good; fair–poor). Pre- and postintervention responses were analyzed with two-tailed t tests.
Eleven items from the AAMC Graduation Questionnaire related to advising, mentoring, and fourth-year experiences were used as a secondary outcome measure. Responses from the classes of 2001 and 2003 were compared with one another and with the national results for 2003.
The telephone survey was conducted during the final month of medical school, after the residency match and before graduation to allow students to take their residency match success into account in answering the questions. Preintervention participants received movie tickets as an inducement for the 15-minute interview. The interviews were conducted by a research assistant who was familiar with the medical school curriculum but unknown to the students. The study was certified as exempt by the institutional review board from the UCLA Office of Human Subjects.
The use of a randomized sampling approach with replacement resulted in a random sample for both cohorts of the intended size, 30 preintervention and 70 postintervention, yielding a 100% response rate for the interviews. In the preintervention period, 10 out of 30 (33%) students were not able to identify even one advisor. This phenomenon was remedied in the postintervention group, where 68 (97%) students had at least one advisor, and almost two thirds identified two or more advisors. Students participating in the College intervention were two times more likely to have identified a role model and a career mentor than students in the preintervention period (Table 1). The College cohort was also much more likely than those in the preintervention group to report “adequate accessibility” of advisors, role models, and career mentors.
Questions related to the quality of the fourth year (Table 2) were consistent with the curricular and mentoring goals of the College Program as well. Although students in both groups reported high satisfaction levels with their fourth-year curriculum, the College intervention group was significantly more satisfied with advising for both elective scheduling and the residency application process. Group responses to questions related to the fourth year were compared using t tests. A Bonferroni correction for overall error rate at 0.05 was implemented.
The College students did not perceive any restriction in flexibility of fourth-year scheduling, despite increased curricular requirements. The survey included three questions on fourth-year outcomes. Pre- and post-College students felt slightly less prepared for career choice and residency selection. A much higher percentage of College students (49 of 70, 70%) reported feeling connected to faculty members than did the control group (14 of 30, 47%), who reported feeling connected to the student affairs office (28 of 30, 94%). Connections among classmates remained similar.
The preintervention group was asked to speculate on the extent to which planned College activities might have been an added benefit to their fourth year. A small percentage of the pre-College group reported that they believed the various College activities would have benefited them with one exception, more access to career mentoring, which was seen as potentially beneficial by 15 of 30—50% of the sample. The majority of the College group reported that all of the activities had been beneficial (Table 3). They valued their access to career mentoring and elective advising, longitudinal clinical experiences, ongoing contact with peers and faculty, research opportunities, and the one-week foundations course.
The AAMC Annual Graduation Questionnaire was completed by all students in the preintervention (class of 2001) and the postintervention groups (class of 2003). The change in the percentage of responses falling into the agree or strongly agree categories as well as a comparison with national percentages in these categories were considered as additional outcome measures of the College Program. The percentage of agree and strongly agree responses for five items dealing with fourth-year experience and preparation for residency were higher for the College group than the preintervention group, with the size of increase ranging from 3.1% for adding additional requirements to the fourth year to 29% for receipt of appropriate advising for elective choice (Table 4).
The percentage of satisfied or very satisfied for the six items dealing with advising and career planning increased in a similar fashion for the College group, with increases ranging from 9% on information about careers to 21.3% on academic counseling. For 9 of the 11 items, the College intervention group reported a higher percentage of agreement or satisfaction than students nationally. For the remaining two items, readiness for residency and value of the fourth year for residency, the UCLA College Program group percentage was at the national mean. Approximately two thirds (47 of 70) of the College Program group (class of 2003) were satisfied or very satisfied with all career planning services compared with slightly less than 50% nationally.
The fourth year offers tremendous potential for meaningful learning and an opportunity to work with a career mentor, a factor that has been demonstrated to produce a higher career trajectory and improved well-being.19 Despite their initial resistance to the proposal to implement the College Program, the students who actually participated appreciated and benefited from the increased structure in a revised fourth-year curriculum, particularly because it provided additional career advisement experiences at a time when students are most in immediate need of direction.
As they begin their fourth year, students have mastered the basic sciences and have completed core clerkships. They are not yet burdened by the rigors of internship and residency. Up until this point, all students in a given class have experienced a relatively uniform learning experience, and they have had limited choices in their course selection. The fourth year offers extreme flexibility and opportunity for a number of specialized learning experiences, such as foreign travel, research, teaching opportunities, humanities in medicine, and the ability to focus on a particular type of health care delivery system. A plethora of clinical electives enables students to explore fields that relate to their future careers or to round out clinical knowledge to correct deficits or that may not be part of their intended residency training. Without adequate faculty guidance, this degree of choice has drawbacks. It can yield an unfocused approach to the senior year and set up a system where students can take multiple audition electives. This limits the effectiveness and variety of their final clinical experience in medical school.
With the advent of the College Program, all students have guaranteed access to career-specific advisors who guide them in choosing fourth-year courses. Each College has a structured curriculum to prepare students for their future. These activities account for up to 50% of the senior year. All colleges require that the students meet medical school graduation requirements, but they may have recommendations as to how this goal is accomplished. For example, each student must take at least one inpatient subinternship where they are responsible for assuming the same workload as a typical intern on the service. A given college may require that this subinternship be in a critical care setting or that it mirror a specialty that is reflected in the individual college’s mission. Certain electives may be required to meet the requirements of a college. Some examples include a devoted research block, a longitudinal experience, community service, or a particular clinical discipline that emphasizes procedures or time-based decision making. One college offers organized medical travel to an underserved location.
The College model provides a balance between autonomy and structure for a successful transition to residency training. There is a systematic approach to solidifying clinical and nonclinical experiences for career preparation. Flexibility is preserved because the requirements are broad, and each student, under the guidance of the mentor, may choose to fulfill each requirement in a different way. Despite the increased requirements, College Program students still felt they had enough flexibility, and they did not feel their autonomy in scheduling had been compromised. It was less likely for students to oversubscribe to electives that were only within their intended specialty. With personal guidance, each individual student may be more likely to correct weaknesses and take electives that will eventually benefit their careers. It gives them access to faculty who are intimately involved in their specialties and who can provide timely and accurate advice about career choice, the residency application process, and lifestyle issues in their fields.
The advent of any new program has the potential to displace existing curricular elements. Given the lack of structure in the fourth year at our medical school, the only concern about implementing the College Program was that freedom of choice for individual students might be limited. It was important that any general graduation requirements for the school of medicine be incorporated into the requirements of each college. Because the general requirements stipulate a number of weeks of study that coincides with state licensing requirements and mandates two sub-internship-level courses, each college was able to comply.
Colleges could be described in terms of learning communities. Students spend more than a year with the same group of faculty mentors and students with the same career outlook. Their peers will be future colleagues, and the College Program community provides a means for establishing healthy professional relationships under guidance. The benefits of having a mentor are well described.19–23 Students can expect to have increased social skills within their intended specialty. There is an opportunity to develop a professional development plan so that they can enter their residency with an intended career trajectory and a working plan to accomplish their goals. Besides the overall mentorship benefits enjoyed by students in each college, there is a possibility for goal-oriented mentorship. For example, a student may have improved access to a research mentor to establish an area of expertise during the course of the senior year. Students may find mentors who share personal characteristics, such as gender, ethnicity, and/or marital and family status. Overall, the increased accessibility to mentors personalizes an otherwise daunting experience for our students.
Future study could include longitudinal outcomes data regarding students’ long-term success in their chosen specialty, including career choice, residency selection, and passing of licensing and specialty board examinations. Short-term outcomes, such as comparing typical elective schedules before and after the College Program, could address the efficacy of the College Program in combating the preresidency syndrome.
The College Program led to an increase in satisfaction with the fourth-year experience in most areas that we defined as outcome measures. Students felt more connected with faculty and peers and recognized an overwhelming increase in accessibility to mentors. This enabled them to choose a meaningful elective program and translated into higher satisfaction in clinical and research experiences. Students recognized the value of their one-week foundations course, whereas their pre-College cohorts did not think one would be beneficial. Interestingly, the intervention group perceived decreased preparedness for residency when compared with the control group. We speculate that this represents a more realistic appreciation of expectations than pre-College students. However, when compared with their national peers, the intervention group was slightly more confident than the control group.
When evaluating our data on opinions of satisfaction and preparedness, it is important to consider that the pre-College-era students never had access to the College experience. If they could have experienced their fourth year again with the College paradigm, they could have determined which structure was more valuable. Similarly, those who experienced the College system were never exposed to the lack of mentorship that their predecessors faced. Each one answered the questionnaires within the confines of their unique mentorship experience in the fourth year.
It is likely that there are numerous options to improve mentoring programs for senior medical students, and our model is just one example that is based on specific career direction and self-selection to a college. Drawbacks to this model include the expense of developing and implementing a schoolwide structure. College chairs receive stipends for their considerable time commitment, and there is also a need for administrative support to execute the programmatic portions of the college experience. In addition, the volunteer mentors give of their time without meaningful compensation.
In the future, it would be interesting to look at the mentors’ view of the implementation of the College system. Improved training of mentors as well as funding them for their time in the form of “buy-out” or compensation would add value to our program. Additionally, our original compromise to reduce the proposed two-week foundations week to a single week could be revisited. Individual colleges have evolved to offer unique programs to prepare the students whose needs match their college’s mission. For example, the Applied Anatomy College serves the students who participate in the early match. Thus, their career-building component is accelerated to the late summer. The Primary Care College caters to students whose careers will involve longitudinal experiences, and many of these are built in as options for their students. The Medical Specialties College has a focus on research, and students present substantial projects as part of their monthly evening seminar series. The Acute Care College provides opportunities for practicing rapid evaluation using simulation and with an association with the local emergency medical services agency.
Despite their initial concerns, students whose fourth year included the College Program enjoyed greater success in identifying and developing relationships with faculty advisors, role models, and mentors. Their overall impression of their fourth year was more favorable than that of their preintervention counterparts. In the national AAMC Graduation Questionnaire, College Program participants indicated a greater comfort level for residency preparedness than their pre-College counterparts. Implementation of a program that addresses the unique needs of senior medical students with regard to structured curriculum and mentoring activities was beneficial and was perceived in a positive light by our medical students.
Financial support for the development of the colleges was provided through grants from the Josiah Macy Foundation and Rockefeller Brothers Fund.
The authors thank Ashley Christiani, MD, for reviewing a draft of the manuscript.