Kanter, Steven L. MD
Course and clerkship directors, deans, and other medical educators love to argue about the structure of the senior year of medical school. These arguments tend to be exceptionally spirited and lively because those who are bumping heads are not burdened by clear evidence, formal theory, or solid facts and figures.
Some of us who engage in these academic dust-ups argue passionately for a predominantly elective senior year with maximal student input and minimal curricular requirements. Others enjoy preaching that students do not know enough to elect what to study, so faculty should simply prescribe it. A few contend that a largely elective year is an unnecessary expense for both students and schools.
Some argue that the main purpose of the senior year is to prepare students for the rigors of residency training. Others contend that the senior year has more than mere preparatory value and that it is an integral and important part of medical students’ education. Some extract disproportionate delight from saying that students use the fourth year as an extended vacation, taking minimally-challenging electives, spending countless hours rehearsing for the senior play, and engaging in elaborate plans for the senior picnic. Others respond that, if this is true, it cannot be the students’ fault (after all, if one believes that students cannot make appropriate elective choices, then students cannot be held accountable for electing these other activities) and that blame should be placed squarely on the faculty! Still others maintain that engaging in a meaningful way in activities like a senior play can facilitate social and emotional growth at an important time of transition.
As I watch those of us who oversee educational programs argue these points, implement curricula with different balances of required versus elective experiences, and even tinker with the length of medical school, I wonder if we really know enough to make these decisions.
If we need to know more, where should we turn? Well, if we are to think comprehensively about the senior year, we must extend our discussion beyond arguments about curricular structure and about “who knows what is best” for students. We must broaden our perspective beyond thinking about how a student can expand his or her knowledge base and improve clinical skills. Don’t get me wrong – knowledge and skills are essential – but we must develop a more sophisticated understanding of the role of the senior year in a budding physician’s development, and use that information to refine and clarify the broad goals of that year. For example, work in the psychology of adult development can offer important insights and theories, not only about intellectual growth, but about social and emotional processes, ethical development, and the integration of cognition and emotion. Current thinking in these areas of study could catalyze medical education research that would help us understand what kinds of curricular experiences facilitate emotional, social, and ethical growth in medical students.
Other areas of active psychological research, such as work in the areas of wisdom, expertise, and creativity can inform approaches to the senior year of medical school. While traditional efforts to build a curriculum aim at helping a student expand the amount of his or her medical knowledge, the aforementioned areas of cognitive inquiry suggest that we also should think about how students consolidate knowledge, form richer conceptualizations of cells and body systems and disease, and deepen their understanding of health and illness.
The perspectives of residency program directors, who have the opportunity to observe newly-minted residents, also can provide valuable information about the senior year. In this issue of Academic Medicine, Lyss-Lerman and colleagues report on the results of a qualitative study of the views of program directors across several specialties. Their findings underscore the importance of senior-year experiences to facilitate the transformation from student to resident.
Ultimately, if we are to improve the quality of the senior year, we must develop a more detailed and nuanced understanding of the stage of life of senior medical students and the changes they undergo, borrowing liberally from work on the psychology of adult development and related areas. (Of course, such work has implications for medical education both before and after the senior year of medical school and could help us to develop better approaches to the curriculum across the educational continuum, from student to resident to practitioner.) It is only through better knowledge of these developmental processes that we will be able to make rational decisions about the structure and function of the senior year, about the length of medical school, and about ways to measure success.
So, how do you win an argument about the senior year of medical school? Well, at just the right moment, you could say something like
I can envision a meaningful senior year that is a vital part of a student’s medical education. It would be a year in which he or she collaborates with faculty mentors on decisions about how to identify a set of optimal experiences. It would be a year in which a student focuses on more specialized knowledge, feels just the right amount of confidence to shed at least some of the heavy supervision that characterizes the main clerkship year, and begins a healthy transition from student to resident. It would be a year structured to promote each student’s intellectual, emotional, and ethical development and to enable each student to reach his or her fullest potential. It would be a year of personal growth indispensable to the making of a physician.
And you would go on:
Success in all these areas would be measured, with mechanisms for feedback and improvement. The evaluation of students would no longer be limited to knowledge inventories and skills assessments, but would also include data about reaching important adult developmental milestones.
But the only way that this vision can be achieved is through more and better research that brings together perspectives from the learning sciences, the psychology of adult development, and related areas to synthesize knowledge of intellectual growth, ethical development, and social and emotional maturation.
Of course, if you say something like this, and we begin to pursue such research, we will all miss our passion-filled, evidence-free arguments about the senior year. But at least we will make some progress.
Steven L. Kanter, MD