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Students’ Perspectives on the Fourth Year of Medical School: A Mixed-Methods Analysis

Wolf, Stephen J. MD; Lockspeiser, Tai M. MD; Gong, Jennifer PhD; Guiton, Gretchen PhD

doi: 10.1097/ACM.0000000000000183
Research Reports

Purpose Little is known about the purpose and value of the fourth year of medical school from the perspective of medical students. In this study, the authors systematically explored the year’s purpose and value as determined by students.

Method In April 2011, the authors conducted semistructured focus groups with graduating fourth-year students at the University of Colorado School of Medicine to understand their perspectives on the purpose of the fourth year. Using results of a thematic analysis of the focus group data, the authors developed and administered a 10-item questionnaire to all graduating fourth-year medical students in May 2011. Questionnaire data were analyzed using descriptive statistics and exploratory factor analysis.

Results A total of 17 students participated in two focus groups. Six themes related to the purpose of the fourth year emerged from the focus group data: career development and preparation, pursuing personal interests, career identification, exploration of diverse practice settings, influence of emotion, and flexibility and individualization. The questionnaire was completed by 134 of 148 students (91% response rate). Factor analysis of the questionnaire data identified five factors: strengthening one’s residency application, developing skills, pursuing personal interests, exploring diverse practice settings, and identifying a career.

Conclusions Medical students uniformly identified the fourth year of medical school as having purpose and value, but their views on the fourth year’s purpose differed. This finding underscores the importance of the individualization of the fourth year. Students’ perspectives should inform any decisions made about modifying fourth-year curricula and structure.

Supplemental Digital Content is available in the text.

Dr. Wolf is associate professor and director of medical education, Department of Emergency Medicine, and associate dean for curriculum, University of Colorado School of Medicine, Aurora, Colorado. He is also staff physician, Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado.

Dr. Lockspeiser is assistant professor, Department of Pediatrics, University of Colorado School of Medicine, and staff physician, Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado.

Dr. Gong is assistant professor, Department of Family Medicine, and assistant director, Office of Evaluation, University of Colorado School of Medicine, Aurora, Colorado.

Dr. Guiton is associate professor, Department of Internal Medicine, and director, Office of Evaluation, University of Colorado School of Medicine, Aurora, Colorado.

Editor’s Note: A commentary on this article by E.M. Cosgrove, M.J. Ryan, and M.D. Wenrich is available on pages 533–535.

Funding/Support: The Office of Undergraduate Medical Education at the University of Colorado School of Medicine (Aurora, Colorado) provided financial and resource support for this research.

Other disclosures: None reported.

Ethical approval: The Colorado Multiple Institutional Review Board (COMIRB) at the University of Colorado School of Medicine provided exempt protocol status for this research.

Supplemental digital content for this article is available at

Correspondence should be addressed to Dr. Wolf, Department of Emergency Medicine, Denver Health Medical Center, 777 Bannock St., Mail Code 0108, Denver, CO 80204; telephone: (303) 602-5175; e-mail:

In the United States, the fourth year of medical school is relatively unstructured in comparison with the first three years. Significant elective time allows students to individualize this year of their education, but it also creates great uncertainty, and sometimes concern, about value. An ongoing discourse exists as to the optimal use of the fourth year.1 Some authors have called for more structure—through colleges, pathways, or other prescribed course work—with the intent of generating greater coherence or fostering the pursuit of an academic interest.2–4 Others have proposed eliminating the time or accelerating students’ entrance into graduate medical education.5–7 Both a qualitative analysis of the views of medical education experts8 and a recent literature review9 concluded that there is significant value to the final year of medical school. Furthermore, both supported designing the year’s course work and structure to complete students’ medical school experience and facilitate their transition to residency.8,9

Little is known, however, about students’ views of this final year. An understanding of their perspectives will be critical to inform any decisions made about reforming the fourth year of medical school. Given this gap, we set out to systematically explore the year’s purpose and value as determined by students. The research question we posed was: Are there consistent themes in students’ perspectives regarding the purpose and value of the fourth year of their medical school education?

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We conducted a mixed-methods study using focus groups of and a questionnaire completed by graduating fourth-year medical students at the University of Colorado (CU) School of Medicine (SOM) in spring 2011. We used an inductive approach without a set conceptual framework in order to obtain the most in-depth understanding of students’ perspectives on the purpose and value of their last year of medical school.

The CU SOM is a public medical school within the CU system. The fourth-year curricular experience is traditional in structure, except for its May start date (about one month prior to that of many medical schools). During the fourth year, our students are required to complete 32 weeks of curriculum, including at least one 4-week subinternship and two 2-week didactic courses that cover foundational curriculum. Students have approximately 24 weeks for general elective course work and may use some of that time to complete their required scholarly project. They may enroll in more elective time if they choose to do so, but in general they have significant flexibility, with up to 20 weeks to interview, study for board examinations, or take time off.

The gender composition of the 2011 graduating class of the CU SOM was similar to that of U.S. medical schools (53.5% male versus 51.6% male nationally), but our class included a greater proportion of white students (86.1% versus 62.1% nationally) and had slightly older students (12.5% were 33 or older versus 6% nationally).10–12 The Colorado Multiple Institutional Review Board at CU SOM granted exempt status for this study.

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Qualitative method and design

For each focus group, we randomly selected 12 fourth-year medical students, after stratifying the class of 2011 by gender and chosen career in order to minimize bias. Each random selection included 6 students going into primary care and 6 students going into other fields. We defined primary care as family medicine, internal medicine, pediatrics, and obstetrics–gynecology.13 Students were invited to participate by electronic communication. Other than food and refreshments, incentives to participate were not offered.

The focus group sessions occurred in April 2011 (one month prior to graduation) and lasted approximately 120 minutes. They were semistructured, using predetermined, open-ended questions and probes intended to explore participants’ views of the purpose and value of the fourth year of medical school (see Supplemental Digital Appendix 1 at We made minimal changes to the questions and probes following the first focus group session. Each focus group had a facilitator (G.G.), a recorder (J.G.) trained in focus group methodology, and one observer (S.J.W. or T.M.L.). The sessions were audiotaped and transcribed for coding and subsequent reference. We planned to conduct repeat focus groups until thematic saturation was reached.

Two authors trained in qualitative methodology (T.M.L. and J.G.) independently coded the focus group transcripts for themes. They each defined codes and assigned quotes to categories, and then they met to reconcile differences and refine coding categories and themes. Although our primary research focus was on students’ views of the purpose and value of the fourth year, participants’ comments moved us to consider a variety of relevant elements, including the nature of self-assessment, emotional valence in decision making, and access to mentors. All of us met regularly to discuss emergent themes, examining them critically and considering alternative explanations. We required whole-team consensus to identify final themes. The triangulation of data from multiple focus groups, analysts, and perspectives contributed to the credibility and dependability of the qualitative findings. This approach allowed us to benefit from our different perspectives as we had two educational researchers (J.G. and G.G.) and two clinician educators (T.M.L. and S.W.).

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Quantitative method and design

We used the focus group themes we identified to inform our development of a 10-item questionnaire asking students about their perspectives on the purpose and value of their fourth-year experience (see Supplemental Digital Appendix 2 at Using a four-point Likert-type scale (ranging from 1 = not at all to 4 = very), students rated the importance of 10 purposes for the fourth year in their choices of courses and scheduling. We also included an “other” item to allow students to indicate specific purposes that did not appear on the survey. The questionnaire was administered in paper-and-pencil form to the class of 2011 in a curricular session in May 2011, less than one month prior to graduation.

We conducted all quantitative analyses using SPSS version 19 (IBM Corp., Armonk, New York). We calculated descriptive statistics and examined zero-order correlations, in part to demonstrate the validity and reliability of the questionnaire. Results for the 10 items investigating purpose indicated that students used the full range of responses (i.e., 1–4) for all but one item, for which their scale use was limited (2–4). The “other” option provided an additional validity check for the choices included. Of the six individuals who selected “other,” three provided comments, none of which identified unrepresented purpose.

We conducted an exploratory factor analysis of the questionnaire data to determine whether students’ responses to the individual items formed thematic groupings. Factor analysis is a statistical method that examines correlations among variables to find a smaller number of dimensions of “factors.” The specific analytic technique we used was principal axis factor analysis, which examines only the shared variance among items. We conducted a varimax rotation to generate interpretable factors. The number of factors extracted was determined by examining eigenvalues > 1 and using the scree test as criteria. Factors were divided by the number of items summed so that each was scaled to the item level. We assessed the reliability of the factors using Cronbach’s alpha.

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Qualitative data and analysis

A total of 17 fourth-year medical students participated in two focus groups (n = 6 and n = 11). Eleven (65%) of the participants were female, and 8 (47%) were entering a primary care specialty. All participants were highly engaged in their group’s discussion. Thematic saturation was achieved by the end of the second focus group. We identified six emergent themes in the focus group discussions; each is described below.

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Career development and preparation.

Students believed that a primary purpose of the fourth year of medical school was to have opportunities for career preparation and development. Students who had known career directions and chosen specialties at the start of the fourth year valued this time to improve their residency applications through obtaining letters of recommendation or “beefing up” their résumés to make themselves more “competitive” as residency applicants.

Students also used the fourth year to make sure they were prepared for their internship year. They sought courses that would develop basic, “high-yield skills” required during the first year of residency.

Some students looked further along in their career development, choosing courses that perhaps would not be offered during their internship but would be important later in their training. These students described this as getting “early exposure” to topics or skills in preparation for subspecialty or fellowship applications. A few students expressed this as taking courses relevant to their “longer-term path.”

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Pursuing personal interests.

The opportunity to attend to life goals and priorities that were often neglected during the first three years of medical school was noted as an important benefit of the fourth-year experience. Students clearly valued this chance to “reconnect” with prior life roles and responsibilities. One student commented, “[Rest and relaxation allowed me] … time to be a good dad and a good husband.”

In addition to looking back and reengaging, many students looked forward. These students described using their fourth year to stockpile “rest” in anticipation of greater time commitments during residency. They selected courses with the intent of pacing themselves for the “long haul.”

I probably could have used a PICU [subinternship] as well, but that would have been a third [subinternship].… That is plenty. I didn’t want to do any more this year. I’ll be working hard in residency so I switched to more of an elective mode.

While acknowledging the need to learn, students occasionally felt there was benefit to waiting until residency.

I know I’m going to get exposure to this in residency, and that’s the appropriate time for me. I feel like it would add more stress to my fourth year than learning.

Students often put this waiting into context by stating that everybody told them to enjoy their last year because this would be their last break for a while. One student commented, “It’s weird that they tell us not to work so hard.”

Many students valued the opportunity to take a course or practice a skill “for the last time.” They wanted to gain knowledge or experience in areas that they had limited understanding of or exposure to during the earlier years of medical school and that would not be components of their residency training.

[E]ach course had a different [purpose] … some were for experiences that I didn’t think I’d be able to have at another time in my career.

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Career identification.

A subset of students had still been engaged in the process of career selection at the start of the fourth year. These students reported taking multiple subinternships and seeking information and advice from many sources to identify a specialty area. Our school’s earlier fourth-year start date, which provides additional time for career exploration while still meeting residency application deadlines, was considered an advantage by this subgroup.

[Not knowing what residency to apply to is] probably the most stressful feeling to be in. So [our fourth year] is very accommodating. And I have to reiterate that starting early is very nice.

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Exploration of diverse practice settings.

Occasionally, students described the fourth year as a time to explore diverse practice settings, which provided them with a better understanding of medicine or affirmed their commitment to a field.

It was really nice to get out of this system and see how things are done elsewhere.

I still liked the subject in a totally new place, with new people and a new system.

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Influence of emotion.

Many students referred to the role of emotion in determining the purpose of the fourth-year experience. Most often, students described the influence of emotion in a simplistic and visceral manner, in which prior clinical and nonclinical experiences were characterized by vague feelings of confidence, comfort, and fit. Although these emotions weighed heavily on students’ perspectives, students often lacked the words to further explain the basis for these broader assessments of knowledge and skill.

By the end of the third year, you … understand what you can’t do by going through it.

I used an internal gauge [to determine] how confident I was.

For me, it’s having a set goal in my mind. This is how I want to perform, and this is how I want to feel when I’m managing the patient, be confident, but not overly so.

Many students specifically referred to fear related to a lack of comfort when discussing fourth-year course selection and purpose.

I did the ICU course because I was scared of it.

I asked myself, “What kind of patient would I be afraid to treat?”

I kind of went with my gut feeling. Where would I feel the most terrified? And so one of those places is the ICU, so I did a NICU rotation … because of my own terror.

Students’ fears were also related to the potential of not being prepared for residency and being judged by others.

I didn’t want to be [the] idiot intern that can’t read an EKG but wants to do cardiology. That’s awkward.

Basically … in the first week of internship, how am I not going to look like an idiot? What do I need to know?

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Flexibility and individualization.

Students uniformly valued the flexibility the fourth year allowed for developing their own schedules.

[Y]ou have breathing room, in case you want to do other things … if you want to do an international elective, you want to do an externship—[Another student: Or do nothing]. Yeah, just do nothing.

[Now] I have this time off [so] I started being introspective. What do I want to read about?

They also placed value on the opportunity to tailor their learning to their self-assessed needs and to individualize their course work.

[It’s] about being autonomous, not only on your rotations but just learn[ing] to take more personal responsibility for what you want. Because you decide your schedule, you … decide when you go on vacation.

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Quantitative data and analysis

Of the 148 graduating fourth-year students in the CU SOM class of 2011, 134 (91%) completed the questionnaire. Descriptive results of students’ ratings of the 10 fourth-year purpose items are shown in Table 1. Overall, the purposes students rated as most important were elements of career development and preparation (range of means = 3.00–3.65) and pursuing personal interests (range of means = 2.84–3.43).

Table 1

Table 1

Factor analysis of the questionnaire data resulted in five interpretable factors accounting for 45.5% of the variance (see Table 2). Four factors loaded with two items, whereas the fifth factor loaded with one item. The items “To address gaps in my skills or knowledge” and “To develop skills needed for residency” loaded with two factors, but each was assigned to only one based on its highest loading. The item “To take time off or have more time for myself” did not load with any factor.

Table 2

Table 2

The five identified factors (and their respective reliabilities) were strengthening one’s residency application (α = 0.712), developing skills (α = 0.586), pursuing personal interests (α = 0.444), exploring diverse practice settings (α = 0.433), and identifying a career (α = 0.158). Reliability measures for each of the four two-item factors were greater than that of the 10-item scale as a whole (α = 0.344), supporting the factor structure.

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Recent calls for medical education reform have placed increased attention on the final year of medical school. Meaningful review of this curricular time requires an understanding of the opinions not only of medical education experts but also of residents and medical students. To the best of our knowledge, this is the first study to describe students’ perspectives on the purpose and value of the fourth year of medical school.

Overall, our study shows that fourth-year medical students find their final year of medical school to have significant value, a perspective similar to the views of medical education experts and residents.8,9,14,15 Our qualitative findings suggest that students approach this year as a formative component of their careers, not just as a summative pursuit of their medical degrees. In our focus groups, students emphasized the importance of having the flexibility to individualize the fourth year and of having emotional comfort with their decisions. Notably, we found that there is a distinct subset of students for whom the fourth year serves the important purpose of career identification. Our quantitative findings support and reinforce our qualitative results. The factors we identified show that students find purpose and value in their fourth year based on their desire to strengthen their residency applications, develop skills, pursue personal interests, explore diverse practice settings, and identify a career.

Broadly speaking, the purpose of the final year of medical school has been described as both “instrumental” (i.e., focusing on matching to residency and residency-specific preparation) and “holistic” (i.e., providing opportunities to round out one’s medical education and time for personal and professional development).14 Interestingly, the literature suggests that medical education experts, including residency program directors, emphasize the instrumental purpose,9,15 which encompasses assuming greater clinical responsibility in preparation for residency, developing skills expected of an entering intern, and completing the residency application process. Residents similarly focus on the instrumental purpose of the fourth year but also highlight the importance of interest and need-based purposes.14 Our study strongly supports the instrumental purpose from the students’ perspective; this was likely influenced by the rising shortage of, and competitiveness for, residency training positions. We also found holistic purpose to be very important to students, as indicated by their ratings of questionnaire items related to career development and pursuing personal interests. Holistic purpose was upheld in our factor analysis. We believe this likely represents the significant value students place on individualizing the fourth year of their medical education.

Although calls have been made to increase standardization and solidify educational goals of the fourth year of medical school,9,14,15 the importance of maintaining or improving individualization has been recognized.14 One proposed framework to achieve both aims includes three key recommendations: specification of competencies and milestones necessary for graduation; individualization of learning plans and processes; and increased support and accountability structures to facilitate achievement of required outcomes and personal goals during the fourth year.14 We believe implementing this type of framework, in combination with effective mentoring and support structures, would improve the effectiveness of the fourth year of medical school by affording students the ability to address all of their identified instrumental and holistic purposes.

Lastly, even though students identified a holistic purpose to the fourth year (e.g., personal and professional development), it was largely focused on developing clinical, rather than nonclinical, competencies and skills. This contrasts with the views of medical education experts, who believe nonclinical competencies to be as important as clinical ones for success in residency training.8,15 One explanation for students’ limited holistic view may be the role that emotion plays in how they assess the skills they have and therefore the skills they seek to develop. Broadly, emotion has been shown to significantly influence how individuals identify, perceive, interpret, and act on information in medical education.16 In our study, students characterized their personal and professional development using ill-defined feelings of comfort, confidence, acceptance, or fear, often with little contextual maturity or detail. Their inability to frame their emotions may be due to their lack of understanding of the specific expectations and structure of residency, or it may be a result of inadequate self-reflection or uninformed self-assessment. Efforts to help students better characterize these emotions and nonclinical competencies may lead them to make more informed curricular choices and more effective use of the fourth-year curricular time.

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Our study was a single-institution study. This and the demographic characteristics of our 2011 graduating class may affect generalizability. In particular, given that our fourth-year curriculum is largely elective, opinions on the formative versus summative value of the experience and importance of flexibility may be overrepresented. Additionally, the focus groups and qualitative analysis used to inform the development of the questionnaire may have missed a relevant purpose for the fourth year because of the small number of participants. However, we felt that saturation was reached after the two focus groups, and students proposed no additional purposes on the survey instrument when specifically solicited. Although we intended our thematic analysis to be grounded in students’ perspectives on purpose and transparent to the students’ word choice and phrasings, alternative explanations for our qualitative themes may have affected our results. For example, qualitative data for the emergent theme of pursuing personal interests were considered to alternatively represent emotional exhaustion, but after consensus discussions and critical examination of our qualitative data as a whole, we believed the data supported the former. Lastly, we conducted our study late in the academic year. This timing likely affected students’ responses as their opinions would evolve over time and in response to their experiences. We believe, however, that this timing was beneficial, ensuring maximal insight and accurate answers from students.

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Medical students view their final year of medical school as having formative value and purpose. Considering this and what is known of the opinions of medical education experts and residency program directors, we propose that the discourse surrounding the fourth year of medical school should address how best to use this time to meet the needs of all stakeholders rather than debate whether there is value to this final year. Future efforts to better define or repurpose the fourth year of medical school should allow for individualization of curricular time while ensuring that students achieve the clinical and nonclinical competencies needed for success in graduate medical education.

Acknowledgments: The authors would like to acknowledge the Office of Undergraduate Medical Education at the University of Colorado School of Medicine, Morgan Valley, and Emma Petroff for their roles in this research.

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