The structure, content, and purpose of the fourth year of medical school remain controversial among medical educators. A review of the fourth year of medical education highlighted the need for clarification of goals and structure and called for further research on the curricular experiences and educational outcomes in the fourth year.1 Some have advocated for eliminating the fourth year entirely, citing tuition costs and lack of data supporting benefits of a four-year curriculum.2,3 Over the past few decades, elective opportunities have decreased, and more requirements have been added as a move toward more rigor.4 However, the fourth year is still criticized for a lack of cohesion, integration, and adequate preparation for internship.5
Despite criticisms of the fourth year, students generally feel it is useful. A recent study found that students “uniformly identified the fourth year as having purpose and value.” They articulated varied and individualized achievements during the year.6 Studies have shown that fourth-year students are aware of specific deficits, like the musculoskeletal examination and procedural skills, and of broader deficits which include medical decision making, differential diagnosis, and fund of knowledge.7–9 Students can use the fourth year to address these deficits. Alternatively, students may prepare for internship, audition for residencies, conduct research, create unique experiences, or sample courses that will be henceforth unavailable. Fourth-year students are formalizing career plans, yet for many it is the first time they can select their medical school curriculum. The 2013 Medical School Graduation Questionnaire asked whether “the final year was helpful in my preparation for residency,” and 79% agreed.10 Furthermore, the fourth year offers the chance for students to reflect on clerkships, to self-assess, and to “try on” the roles of career choices.
The issue of student preparedness for residency is of critical importance to program directors in ensuring quality patient care. The Accreditation Council for Graduate Medical Education recently released a new accreditation system with milestones which help program directors describe their residents’ developmental progression.11 Some milestones are fundamental to the ability to function safely as an intern. Therefore, the Association of American Medical Colleges released the “Core Entrustable Professional Activities for Entering Residency” that should be expected of all MD graduates.12 Previously, Langdale and colleagues13 identified 13 core competencies that all program directors agreed were expected of medical students at the start of the internship.
The Committee Task and Process
The Clerkship Directors in Internal Medicine (CDIM)/Association of Program Directors in Internal Medicine (APDIM) Committee on Transition to Internship (CACTI) was appointed by the CDIM and APDIM councils to investigate the fourth year of medical school with the goal of better advising students on preparing for internship. At early meetings, the group decided to assess the current course requirements and offerings to students as a first step. All CACTI members are clerkship directors or program directors.
The committee first divided and grouped content areas, and individual committee members performed literature searches for selected topics with reference to fourth-year medical students. Two authors (S.G. and M.M.) then performed an assessment of medical school Web sites using checklists to collect data. They reviewed Web sites of Liaison Committee on Medical Education (LCME)–accredited medical schools in the United States for information about fourth-year curricula to obtain a baseline of educational requirements in the fourth year of medical school. Relevant information was found for 136 schools. The review was initially performed in 2013 and was updated in August 2014. Additionally, information from 5 schools was updated from direct faculty contacts or from published literature.14 S.G. and M.M. compared data and reached consensus on all sites. In the following sections, we present the observations that resulted from this search of the literature and of medical school Web sites to provide an overview of the opportunities currently available to fourth-year medical students in the United States.
Common Fourth-Year Courses and Experiences
We have categorized the courses that fourth-year students can choose and have commented on current practices and defined outcomes when available.
Finishing core clerkships
This review did not address the core clinical clerkships, which are generally part of students’ third year, but these clerkships may be delayed until the fourth year. Many reasons exist for students needing to complete core clerkships during the fourth year. Some students take leaves of absence, whereas others defer clerkships to make time for electives. Students pursuing other advanced degrees (e.g., PhD or MPH) or engaging in research may start their clerkships off-cycle. A small percentage of students require remediation of either a clerkship or a high-stakes examination, such as the United States Medical Licensing Examination (USMLE). These students may require increased structure in their fourth year to address deficits and to allow focused study time for exams. Regardless of the reason, the fourth year can be a time to complete required work and stay on schedule for graduation with peers.
How frequently students delay starting clerkships remains unclear. Over the last three years, 4% to 8% of U.S. medical students have not passed the USMLE Step 1 on the first attempt,15 which typically delays the start or completion of clinical clerkships. Each year, a small number (1%) of students fail required clerkships and need to remediate during the fourth year.16
We are not aware of any published data about whether deferring clerkships affects students’ subsequent performances. No large objective reports on the outcomes of students requiring remediation were found.
We included discipline-specific courses with the names “subinternship,” “acting internship,” “externship,” and “advanced clerkship” in this category. The primary goal of a subinternship is to approximate the role of an intern for a defined period of time. This exposure allows the student to prepare for the coming year and to help sort out remaining career uncertainties.
Subinternships were required by 122 of the 136 (90%) schools. For 61 medical schools (45%), a subinternship was required, but students were allowed to choose the discipline of their subinternship from among four or more options. Most commonly, the choices were in the disciplines of core clerkships, but some schools broadened options to any four-week clinical, inpatient experience, including anesthesiology and surgical subspecialties. Fourteen schools (10%) required a subinternship but allowed students to choose from two or three disciplines. A subinternship specifically in medicine was required at 14 schools (10%). At 27 schools (20%), two or more subinternships were required, and at 23 of them (17%) one of the subinternships had to be in medicine. Only 14 schools (10%) did not require any subinternship.
We did not find any data regarding the optimal duration or structure of subinternships. However, the subinternship experience has long been considered to be where core clinical skills are solidified. These include most of the core entrustable professional activities (EPAs) for entering residency (List 1).12
List 1 Entrustable Professional Activities (EPAs) for Entering Residency10 Cited Here
EPA 1: Perform a history and physical examination.
EPA 2: Prioritize a differential diagnosis.
EPA 3: Recommend and interpret common tests.
EPA 4: Enter and discuss orders and prescriptions.
EPA 5: Document a clinical encounter.
EPA 6: Provide an oral presentation.
EPA 7: Form clinical questions and retrieve evidence.
EPA 8: Give or receive a patient handover.
EPA 9: Collaborate as a member of an interprofessional team.
EPA 10: Recognize a patient requiring urgent or emergent care and initiate evaluation and management.
EPA 11: Obtain informed consent.
EPA 12: Perform general procedures.
EPA 13: Identify system failures and contribute to a culture of safety and improvement.
Fourth-year capstone courses, sometimes known as intern preparatory, transition, or “boot camp” courses, are a fairly recent addition to the required curricula of many medical schools. No mention is made of them in a comprehensive survey of medical school curricular requirements published in 2001.17 Many of these courses were started in response to the perception that recent medical school graduates are unprepared for the situations they will encounter during internship.18
Capstone courses were required by 80 of the 136 schools (59%). The setting and structure of these courses were quite variable, but they were usually placed toward the end of the fourth year. The duration of these courses ranged from several days to four weeks, with a few schools having periodic sessions throughout the year. Capstone courses could offer mixes of lectures, small-group discussions, team-based exercises, role-play, clinical experiences, and simulations.14,18–22
Topics covered by these courses varied, but certain themes were common: management of common or serious medical conditions, review of pertinent basic science concepts, practicing procedural skills, functioning as part of a hospital team, professionalism, communication skills, and miscellaneous topics. List 2 specifies topics included in these courses. The best-received sessions give students a chance to practice skills needed in time-pressured situations, such as answering calls from nurses or management of cardiopulmonary decompensation.18,20,22
List 2 Content of Fourth-Year Capstone Courses From a Review of the Web Sites of 136 Liaison Committee on Medical Education–Accredited Medical Schools, 2013–2014 Cited Here
Common or serious medical situations
- Sepsis and shock
- Venous thromboembolism
- Periprocedure management
- Acute renal failure, acid–base, and fluid management
- Diabetes mellitus acute management
- HIV complications
- Acute cardiovascular disease
- Common infections
- Palliative care
Basic science concepts
- Evidence-based medicine (EBM)
- Medical decision making, clinical reasoning
- Landmark articles review
- Pharmacology review
- Pain and pain control
- Immunology—autoimmunity and immunosuppression
- Substance abuse
- Critical care physiology
- Oncology—genetics and chemotherapeutics
- Pathophysiology connections to common conditions
Procedural and interpretive skills
- Procedures (e.g., lines, blood gas, suturing, lumbar puncture)
- Advance cardiac life support (ACLS)
- Airway and ventilator management
- Critical care simulations
- Physical exam skills (e.g., neurological exam)
- Electrocardiogram reading
- Radiology review—chest, abdomen
Hospital and team functioning
- Team building
- Order and note writing
- Safe transitions of care, sign-out, discharge
- Teaching as an intern
- Giving and receiving feedback
- Duty hours
- Quality improvement and patient safety
- Interactions with medical team, nursing, social service, etc.
- Common nurse calls—chest pain, dyspnea/hypoxia, fever, high/low blood pressure, decreased urine output, GI (gastrointestinal) bleeding, abdominal pain, confusion, abnormal labs
Communication and professionalism
- Presentation skills
- Dealing with mistakes
- Dealing with death—family notification, etc.
- Discussing prognosis and code status
- Difficult patients and families
- Conflict resolution
- Impaired colleagues
- Informed consent
- Language barriers and translator use
- “Meet the resident” sessions
- Time management, organizational skills
- Work–life balance, coping with stress
- Personal finances
- Legal issues and malpractice
- Career development
- High-value care
- Health care economics, health care reform
- Coding and billing
Short-term improvements in medical knowledge, procedural skills, and overall performance (based on supervisor evaluation of interns) have been found in some studies,19,21 but the most commonly described benefit of these courses is enhanced student confidence.14,18–22 Data regarding longer-term effects are limited. In two small, nonrandomized studies of preparatory courses for students entering surgical residencies,19,20 students who did not participate in the preparatory course “caught up” with the prepared students within a few months of starting internship. This suggests that these courses may ameliorate the “July effect” but likely do not have a lasting benefit. One study showed that internal medicine interns outperformed historical controls on an assessment of procedural and communication skills following a brief preparatory course delivered at the beginning of the internship.23
Medical educators cite numerous reasons for students to conduct scholarly work during medical school. These include a revisiting of the basic sciences, gaining appreciation of the scientific method, developing procedural and writing skills, and examining academic careers.
Research or “scholarly activity” was required at 51 of the 136 schools (38%). Course lengths varied from one week to a full year of research. A few schools required students to identify a research project in their first year and conduct research throughout medical school.
Anticipated outcomes from these scholarly activities varied considerably. Some schools required only participation, whereas other schools expected presentation and dissemination of the work. However, we found little information about the outcomes of these experiences in terms of encouraging further research or academic careers. Research experiences may help students to articulate clinical questions and retrieve evidence more effectively (EPA 7 in List 1).
The goal of fourth-year basic science courses is reimmersion in basic sciences now that the students have some clinical underpinnings. Prior research from U.S. medical schools in 1985 found that 17 of 130 schools (13%) had a requirement for fourth-year students to take at least one basic science course,24 and this percentage increased slightly to 19% in a study done in 2007.25
The survey of 136 medical school Web sites showed that 17 (15%) had a requirement for students to take at least one basic science course in the fourth year. The most common course required was Pharmacology.25
There is some short-term evidence indicating that basic science knowledge related to disease causation can improve clinical diagnosis.26 It is postulated that returning to the basic sciences in the senior year of medical school will improve students’ understanding of the pathophysiology of disease and therapeutic interventions. However, further research is required to evaluate lasting outcomes.
Clinical experiences in specific locations
In these experiences, students encounter diverse patients in a specific setting. They may allow students to experience team structures and systems (EPAs 9, 10, and 13 in List 1) that differ from traditional ward teams. Students may also perform procedures that would otherwise be unavailable to them (EPAs 11 and 12 in List 1).
In 1995, the Josiah Macy Jr. Foundation published a report highlighting the need for medical students to receive formalized training in medical emergencies.27 Since then, emergency medicine (EM) has become a key component to the clinical curriculum at many medical schools.28 EM experiences offer learners exposure to undifferentiated patients of high acuity in a way that few other specialties can.29
Sixty-one of the 136 U.S. LCME-accredited medical schools (45%) required completion of an EM clerkship for graduation. It was a fourth-year clerkship at 42 of the schools for which it was a requirement (69%). Only 11 schools (18%) required the EM clerkship exclusively during the third year, and another 7 (11%) allowed the EM clerkship to be taken during a time period that extends from the third year through the fourth year. Most of these rotations were exclusively EM, but 6 schools (11%) included the required EM rotation during the surgery or internal medicine clerkship. Another 3 (5%) combined the EM clerkship with the intensive care unit (ICU) rotation to create an acute care clerkship. Forty-six of the required EM clerkships (75%) were four weeks in length. However, the majority of schools that required EM during the third year shortened the EM requirement to less than four weeks.
A comparison of self-assessment surveys suggests that students gain confidence with acute care knowledge, disease management, and procedure skills after completion of any EM clerkship. Furthermore, students completing a four-week EM clerkship showed a significant increase in confidence with procedures compared with those who completed a two-week EM clerkship.30
Fourth-year rotations in the ICU prepare senior students for experiences in the ICU during internship and residency. This is important because students might not otherwise be exposed to critical interventions, such as mechanical ventilation.
There are limited data about the frequency of senior students selecting ICU rotations in their fourth year. Fourth year students have been found to be less prepared to care for unstable patients than for those less ill.31 Students feel anxious about caring for ICU patients and feel less so after an ICU rotation.6 A literature search yields abundant curricular descriptions at a variety of medical schools and practical advice for students preparing for the rotation. Forty-six of the 136 schools (34%) required ICU rotations. These could include medical, cardiac, surgical, pediatric, neonatal, and trauma ICUs.
Studies that demonstrate better performances among interns who had prior ICU experience as students are lacking.
A survey of program directors demonstrates that many feel students should have an ambulatory medicine experience in the fourth year.32
A 2010 CDIM survey33 found that 85% of the 82 responding schools (response rate 75%) offered ambulatory rotations in internal medicine to third- and fourth-year students, with 72% requiring them. For about half, these were freestanding experiences, some of which were multidisciplinary or longitudinal. However, most reports described ambulatory experiences on core clerkships.33 The most common length was three to four weeks. Our Web site review revealed that an ambulatory care rotation was required during the fourth year by only 47 of the 136 schools (35%).
The importance of a positive learning climate, clear educational goals, patient satisfaction, and cost-effectiveness in ambulatory education have long been recognized.34 However, creating opportunities for these rotations is often difficult, as the presence of students in clinic can be costly because of lost productivity.35
Prior studies have outlined important features of ambulatory experiences that contribute to quality educational experiences, such as the ability to evaluate diverse patients, effective teachers, and effective orientation to the clinic.36 Several studies have addressed the question of the role ambulatory experiences may play in students’ choice of primary care careers, but the results have been mixed.37
In 2002, a consensus article was published proposing standards for the neurology core clerkship curriculum.38 Prior to that time, neurology was not generally included in the core clinical clerkships. Since this time, there has been a push to have the neurology clerkship required at all institutions during the third year of medical school.39,40
From our analysis of the curricular requirements listed on the Web sites of 136 LCME-accredited medical schools, 102 (75%) required a clerkship in neurology or “neuroscience” for graduation, with 77 of those (75%) requiring it as a third-year clerkship. This is a significant change from 1997, when 68% of neurology clerkships were exclusively in the fourth year of medical school.41 We found that only 15 (11%) listed this clerkship as exclusively a fourth-year requirement, and 11 schools (8%) required the clerkship to be completed during a time frame that extends from the third through the fourth year. Of the 102 schools for which neurology was a requirement, 78 (76%) had a four-week clerkship, which is consistent with the data from 1997.41
A recent study suggests that students are more enthusiastic about neurology when it is a required third-year clerkship than when it is a required fourth-year clerkship, but the timing of the clerkship did not appear to make a difference on overall achievement.39
In addition to required courses, students may elect other experiences. In the past, students’ first elective experiences were in the fourth year of medical school, but increasingly students are able to sample electives earlier.
Many students will pursue clinical electives, either within or outside their future specialty. Increasingly, electives cross the inpatient/outpatient boundary and more accurately reflect the activities of attending physicians. Within disciplines, clinical electives can provide students a closer look at a focused area within a potential career choice and can help them develop both process and content skills useful in residency. An example would be delivering cardiology consultations to a variety of medicine and surgery services. Students may also select rotations outside their planned residency to gain expertise at a specific skill, such as radiology for interpreting x-rays, or anesthesia for intubation. Students often take electives early in the curriculum for career exploration.
Our general impression is that schools are increasingly finding that electives involving special populations, like rotations in global health or underserved clinics, are popular experiences. A number of schools offer elective experiences in nonclinical areas. Some are advanced basic sciences as described above. Others may involve the humanities, such as medical aspects of music, art, or literature. Some elective rotations are completed at institutions distant from the students’ own school, often to gain experience or reputation at a site the students favor in the upcoming match process.
Although elective rotations are cherished by students, we found few data to support a proper number and mix of these experiences. Students’ motivations for choosing rotations are unclear and probably highly variable.
The value of away or “audition” rotations, during which a student completes an elective at a desired residency site, remains a subject of debate, but many students remain convinced that they improve chances for a residency match at competitive locations. A small, single-site study performed by a plastic surgery residency found that away rotations did not affect match rates of applicants, but that there was an association between the location of an applicant’s away rotation and the location at which that applicant ultimately matched.42 In a study from six orthopedic surgery residencies, a regression analysis demonstrated that the number of away rotations was associated with matching to orthopedic surgery.43 However, plastic surgery and orthopedic surgery are highly competitive disciplines and may not reflect all residency matches.
Discussion and Conclusions
The fourth year of medical school is a transition year for learners moving from undergraduate to graduate medical education. Significant variability exists in curricular expectations for students during their fourth year of medical school. Many believe that the current medical education system provides inadequate instruction in critical areas, although the trend has been toward more required experiences and fewer electives.44 As more structure is introduced into the fourth year, the opinions of stakeholders will need to be determined.
Program directors and several specialty organizations have outlined recommendations for fourth-year medical students in an effort to ensure that medical school graduates are better prepared for internship and residency.45–47 A group of residency directors and undergraduate medical educators in family medicine used a Delphi process to achieve consensus on a fourth-year curriculum to prepare students for the family medicine internship. They identified an ambulatory family medicine month; EM, dermatology, and obstetrics rotations; and an internal medicine subinternship as required components.48 A study from the Association of Professors of Gynecology surveyed members and proposed rotations in general internal medicine, critical care, neonatology, and EM to prepare students for residency training in obstetrics–gynecology.49
There is evidence of consensus about general fourth-year curricular requirements as well. Semistructured interviews of over 30 program directors from various residency disciplines revealed consensus about expected fourth-year clinical experiences and fourth-year student competencies.32 Participants recommended rotations across specialties, including an internal medicine subinternship, a subinternship in the student’s future field, and exposure to critical care, ambulatory medicine, and EM. The opinions of clerkship directors, who observe students’ development directly, will need to be considered in any official curricular recommendations. Additionally, recent graduates’ opinions about worthwhile fourth-year experiences should be sought, once these trainees have experienced internships.
The last few years have seen significant changes in health care delivery and medical education, such as duty hours regulation and the proliferation of electronic medical records. These changes have reshaped faculty and learner expectations about the skills needed for interns starting residency. The curricular content recommended for future internal medicine interns emphasizes the importance of effective communication beyond history taking and physical examination to include communication with members of the health care team and within the health care system and is based on a recent APDIM survey.47 The Association of American Medical Colleges’ new core EPAs for entering residency (List 1) provide a framework to assess progress in both traditional clinical skills and communication within teams and health care systems. The fourth year of medical school provides an ideal venue for students to solidify these skills, whether as specific course offerings or as curricular pieces in other courses.
A number of medical schools are experimenting with new types of courses that offer students experiences that differ from more traditional offerings. Capstone courses are a notable example of innovative programs that are being implemented in a number of schools to help students prepare for internship. These courses can target perceived curricular gaps or areas currently receiving increased national scrutiny. Some examples are patient safety (EPA 13 in List 1) and high-value care. Novel courses can cross disciplines and target areas that may have been missed or underrepresented, such as end-of-life care. Finally, they can return students to content that may need refreshing, such as the principles of evidence-based medicine (EPA 7 in List 1).
The purpose of elective rotations remains uncertain. Educators want to see medical students use this time for good educational purposes with likely future benefits, understanding that students’ needs and motivations vary. Limited data suggest that there may be some benefit to away rotations for matching into highly competitive fields. However, the value of elective experiences for making career choices and for reflection on prior experiences is difficult to quantify. A recent guide from the Association for Medical Education in Europe reviews the subject and suggests that all electives should have clearly stated purposes, measurable outcomes, communication between host and home schools, adequate supervision, clear work expectations, and an element of reflective practice.50 Schools should establish portfolios with student feedback to guide future students on elective choices.
In this article, we provide a summary of fourth-year course offerings that clerkship directors and faculty can consider while counseling students. Although no national consensus yet exists, a core of experiences seems to be developing for several disciplines. Students’ fourth-year experiences may be defined as courses completed or as competencies gained. We have indicated how frequently courses appear in curricula nationally, goals of the courses, and evidence to support the achievement of the goals. This is a step in the process to align and standardize expectations among students, program directors, and clerkship directors in an effort to ease the stress of learners’ transition from undergraduate medical education to graduate medical education.
Acknowledgments: The authors would like to acknowledge the administrative and clerical support of Sainabou Jobe and Randi Andress in conducting this project.
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