The educational value and objectives of the fourth year of medical school, defined as the time from the end of the clerkship year to graduation, have been debated for many years.1–8 In the early 1970s, approximately 25% of medical schools had eliminated the fourth year. However, within a decade almost all schools had reinstated the fourth-year curriculum, while placing few restrictions on what students did during the year.7 For the most part, students were encouraged to pursue potential career interests and/or to explore broad educational experiences.7,8
A central question still facing medical students and their career advisors is whether elective time in the fourth year should be dedicated to improving career-specific competencies, increasing the likelihood of matching in a residency program, or completing broad medical training. Residency program directors have given mixed responses when surveyed, with some advocating an increased number of career-specific electives and others recommending broader experiences to include electives in critical care, emergency medicine, and ambulatory medicine.8–10 Student guidebooks emphasize the importance of preparing for residency and virtually mandate away or “audition” electives for students applying to certain specialties.11,12 Even within a particular specialty, deciding which approach is the most valuable can be challenging. For example, pediatric educators advocate for both a broad educational experience and a high number of pediatric electives.9
Few data are available about what medical students consider to be important for the fourth year and what they choose to do with their elective time.13–15 In this study, we sought to learn what graduating fourth-year medical students considered to be the primary purposes of the fourth year of medical school, what their approach to the residency selection process was, and what challenges they faced in meeting their goals for the fourth year of medical school. In addition, we sought to determine whether students approached the fourth year differently depending on their chosen career specialty.
Method
To learn about graduating fourth-year medical students’ perspectives on the fourth year of medical school, we surveyed students from 20 U.S. MD-granting medical schools in spring 2014.
Survey development
We adapted survey questions from two previously validated electronic surveys9,15 and developed additional questions based on sequential feedback from a group of fourth-year medical students at the University of Vermont and site collaborators (see the Acknowledgments at the end of this article for a list of site collaborators). Our survey consisted of 52 questions that inquired about student demographics, experiences and expenses during the fourth year, career specialty choice, and attitudes toward fourth-year medical education and the residency application process (for a copy of the survey, see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A290). Questions about students’ perspectives on different aspects of the fourth year (e.g., the main purpose of the fourth year and the primary reason to do an away or audition elective) were structured as agreement statements measured on a five-point Likert scale, with responses ranging from 5 = strongly agree to 1 = strongly disagree. The survey had a single open-ended question that asked for students to share their thoughts about the fourth year. We administered the survey through LimeSurvey Version 2.00+ (Hamburg, Germany).
Sample
We selected 20 U.S. MD-granting medical schools (Table 1) to form a representative sample by ensuring geographic diversity and an equal number of public and private schools. Each medical school invited all graduating fourth-year students to participate in the study via an e-mail with a link to the survey, followed by a reminder e-mail one week later. The survey was accessible for seven weeks—from March 21, 2014 (Match Day), until May 9, 2014. As an incentive for participating, students could enter a drawing to win an iPad mini. Students’ data were included in the data analysis only if they had entered the National Resident Matching Program (NRMP) for 2014 and had at least completed the questions related to their primary specialty choice and their medical school. Participation in the survey was voluntary and anonymous, with assurances that all responses would be reported only in the aggregate.
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Table 1: Response Rates From 20 U.S. MD-Granting Medical Schools, Spring 2014 Survey of Fourth-Year Medical Students
The University of Vermont institutional review board and committees on human subjects granted exempt status for this study. All participating schools that required local institutional review board review obtained the appropriate approval.
Data analysis
We calculated the response rate for each medical school using the number of fourth-year students from that school who applied to the 2014 Match as the denominator. If that number was unavailable, we used that school’s number of graduating fourth-year medical students for the class of 2014 as a proxy.
From survey responses, we collated information about each student with respect to demographics; career specialty choice; the residency application process, including the number of applications, the number of interviews, and associated costs; the number, types, and cost of fourth-year away or audition electives; and attitudes about the purpose of the fourth year. In the data analysis, we included internal medicine subspecialties under internal medicine; pediatric subspecialties under pediatrics; and surgical subspecialties, radiation oncology, ophthalmology, and transitional year programs under surgery in order to ensure that we had a large enough sample in each category to make statistically valid comparisons. An “other” category was used for the specialties of neurology, physical medicine and rehabilitation, and pathology as well as combination residency programs or programs that could not otherwise be categorized.
A set of interrelated questions addressing away or audition electives for residency was assessed for internal consistency by Cronbach alpha (0.70). As a consequence of nonresponse to some items, there was 6.5% missing data. Missing data were handled using multiple imputation, with missing information estimated across 20 imputations and reported results reflecting pooled estimates.16,17
One-way analysis of variance was conducted to analyze the effects of specialty on continuous outcome variables of interest. Chi-square analysis was used to compare categorical variables, and paired t tests were used to compare average scores on Likert-scaled items. All group comparisons were conducted controlling for demographic covariates of age, gender, and medical school, with Sidak–Bonferroni correction for multiple comparisons. As expected, some outcome variables were skewed. Consequently, all group comparisons were conducted with bias-corrected bootstrapping (1,000 samples).18 For all analyses, P < .05 was considered statistically significant.
Responses to the open-ended question were coded into themes by one of the authors (N.M.B.) and confirmed by a second (W.V.R.). Initial coder agreement was good (r = 0.88). Differences in coding were resolved by consensus. Responses were assessed for differences between primary care (internal medicine, family medicine, obstetrics–gynecology, and pediatrics) and nonprimary care specialties (all other specialties).
Results
A total of 1,367/2,884 students responded to the survey for an overall response rate of 47.4% (Table 1). Response rates at individual medical schools ranged from 23/136 (16.9%) to 91/106 (85.8%). Five schools had response rates of less than 40%. The demographics of respondents from these five schools did not differ from those of the entire response population (P > .05 for all comparisons). All of the schools required at least one elective with advanced patient care responsibilities, such as a subinternship, whereas 40% required two.
Internal medicine, surgery, and pediatrics were the primary specialties applied to in the Match for over half (740; 54.1%) of the respondents (Table 2). Among respondents, 71 (5.2%) did not match successfully into their chosen specialty.
Table 2: Demographic Characteristics of Fourth-Year Medical Studentsa
On average, students applied to a mean of 36.4 (standard deviation [SD] = 22.6) residency programs and interviewed at approximately one-third of the programs to which they applied (mean = 12.3, SD = 5.6) (Table 2). Surgery applicants applied to significantly more residency programs than applicants to all other specialties (mean = 58.2, SD = 22.3; P < .001 for all comparisons) (Table 3). Pediatrics, family medicine, and psychiatry applicants applied to a comparable number of programs and to fewer programs than those applying to emergency medicine, internal medicine, or obstetrics–gynecology (P < .001 for all comparisons). The overall number of interviews for all specialties was similar except that radiology applicants interviewed at significantly more programs than applicants to any other specialty (mean = 16.9, SD = 8.5; P < .001 for all comparisons).
Table 3: Fourth-Year Medical Students’ Approach to the Residency Interview Process by Specialtya
The majority of students reported spending between $1,000 and $5,000 to interview (899; 65.7%) (Table 2). Only 117 (8.6%) spent more than $7,000. However, almost 20% of surgery applicants spent more than $7,000 (50/257; 19.5%), and surgery applicants spent more than those applying to other specialties (P ≤ .01 for all specialties except radiology and obstetrics–gynecology) (Table 3). Family medicine applicants spent significantly less than those applying to other primary care specialties (P < .001 for all comparisons). For those who couples matched, the cost to interview was significantly higher than for those who did not couples match (P = .001). Among respondents, 187 (13.7%) reported needing additional funds in the form of a residency relocation loan (Table 2).
Slightly more than half of the respondents began their fourth year of medical school in July 2013 or later. More than half of the students completed at least one (mean = 1.8, SD = 0.8) monthlong away or audition elective in their career specialty of choice (765; 56.0%) (Table 2). The number of students taking away electives varied by career specialty, ranging from approximately 42% for internal medicine to approximately 89% for emergency medicine. Overall, surgery and emergency medicine applicants were significantly more likely to complete an away elective than students applying to all other specialties (P < .001).
The majority of students who completed away or audition electives spent between $1,000 and $4,000 to complete these electives (388/765; 50.7%) (Table 2). For approximately 35% of the respondents, financial constraints limited the number of away electives they could take. Among students who completed an away elective, 680/765 (88.9%) reported that the elective affected their ranking of a program, and 261/765 (34.1%) matched to the programs where they had done an away elective. This did not vary significantly across specialties (P = .248). Overall, students felt that the main purposes of completing an away elective were to evaluate a residency program, to obtain an interview, and/or to increase the likelihood of matching at that program (Table 4).
Table 4: Fourth-Year Medical Students’ Perspectives on the Fourth Year of Medical Schoola
Approximately 25% of the respondents agreed (agree or strongly agree) that more time was needed in the fourth year to decide on specialty choice (364 [26.6%]) (Table 4). More students agreed than disagreed (disagree or strongly disagree) that more time should be allotted for interviewing (agree: 688 [50.3%]; disagree: 396 [29.0%]) and that medical school should end once the Match results are known (agree: 792 [57.9%]; disagree: 285 [20.9%]) (Table 4). These responses did not vary significantly by specialty (P > .05). Students agreed that the fourth year of medical school has multiple valuable purposes, including maximizing the likelihood of matching into their residency of choice, gaining a broad educational experience, and preparing for residency (Tables 4 and 5). Overall, the quantitative data analysis showed that students more strongly agreed that the purpose of the fourth year of medical school was to prepare to be a good resident than to maximize the likelihood of matching into a chosen residency (P < .01) or to gain broad educational experiences (P = .01). Responses were similar across most specialties. However, applicants to surgery were more likely to agree that the purpose of the fourth year was to maximize the likelihood of matching into their residency of choice than applicants to family medicine (P = .002), internal medicine (P < .001), pediatrics (P = .016), or psychiatry (P < .001).
Table 5: Fourth-Year Medical Students’ Open-Ended Responses About the Fourth Year of Medical Schoola
In the analysis of the written responses to the open-ended question, students applying to a primary care specialty were more likely to report that the fourth year of medical school is valuable compared with those applying to a nonprimary care specialty (primary care: 223/399 [55.9%]; nonprimary care: 176/372 [47.3%]; P = .018) and more likely to report that the fourth year’s main purpose is for a broad educational experience (primary care: 137/399 [34.3%]; nonprimary care: 75/372 [20.2%]; P < .001) (Table 5). Those students applying to nonprimary care specialties were more likely to report that the fourth year’s purpose was to obtain a residency position (138/372 [37.1%]; P = .039). A minority of students reported that the fourth year was “useless” or a “waste of time” (140/771 [18.2%]) or that the fourth year could be “shortened” or “eliminated” (127/771 [16.5%]).
Discussion
The purpose of the fourth year of medical school remains controversial and depends on the perspective of the stakeholder. Health care policy experts concerned about the shortage of primary care physicians suggest that the fourth year could be shortened or even eliminated.2,19 Residency program directors increasingly desire students to gain advanced career-specific clinical skills during this time so as to be better prepared for residency.8,20–23 Others view the fourth year as part of the developmental continuum in medical education that includes residency training and practice with specific milestones or integrated activities that should be accomplished by the conclusion of the year.24,25 Medical schools vary in their approach. Many only require students to complete one or two electives with advanced patient care responsibilities.7,8 However, few studies have addressed how fourth-year medical students and junior residents view the fourth year of medical school.13,26
Graduating fourth-year medical students from one institution reported that the fourth year was valuable and important for a variety of reasons ranging from strengthening one’s residency application to identifying a career.13 Junior residents participating in a focus group suggested that the most valued aspects of the fourth year had been preparing for residency; assuming additional clinical responsibilities; expanding knowledge, skills, and perspective; clarifying career choices; and decompressing from the clerkship year.26 In both studies, externally driven goals, such as residency selection and preparation, outweighed internally driven goals, such as personal growth, reflection, and development. With respect to elective time, a survey of fourth-year students in the Midwest showed that students completed a mean of 1.6 away or audition electives specifically to improve their chances of matching at a particular residency program.15
Our study is the first national, representative sample of fourth-year medical students from U.S. MD-granting medical schools. The sample size of 1,367 students from 20 schools allowed us to determine the influence of career specialty choice and other factors on both the attitudes and activities of fourth-year medical students.
Our data are consistent with previous reports in that the majority of students stated that the fourth year had value. Our finding that fourth-year students viewed the main purposes of the fourth year as strengthening their residency application, developing skills for residency, and gaining a broad educational experience confirms the results of investigators exploring students’ views on the fourth year at a single medical school.13 Another of our findings is the extent to which the externally driven goals of obtaining a residency and preparing to be a good resident are viewed by students as the primary purposes of the fourth year. Even among students valuing a broad educational experience, being prepared for residency was important. These goals are, in part, specialty driven. Those applying for residencies perceived to be hard to obtain, such as surgical specialties, were more likely to view the fourth year as a time to maximize the likelihood of matching in their residency of choice. In fact, surgery applicants applied to more residency programs, completed more away or audition electives, and spent more money on the interview process than applicants in almost every other specialty. Interestingly, unlike in previous studies, we found that few students independently suggested that the fourth year was a valuable time to develop nonclinical skills such as personal reflection, thought by many educators to be essential for a career in medicine.1,8,13,26
One possible explanation for why fourth-year medical student respondents in our survey seemed more driven by residency selection and preparation than respondents to prior surveys is that for students graduating in 2014, matching at a residency program was more challenging than it was when previous surveys and focus groups were conducted.27,28 By 2014, there were as many as nine applicants for each residency position, and failure to match in the NRMP was associated with dire consequences including failure to obtain any residency at all.28–30
Other observations can be gleaned from our study. First, as only approximately one-third of students matched at a program where they had done an away or audition elective, it is unclear whether these electives enhance the likelihood of matching. It may be that so many students in certain specialties complete away electives that any potential benefit to a single student is diluted. Second, the majority of students favored ending medical school once the Match results are known. From our data, we could not determine whether students primarily felt this way because (1) they needed time to relax or relocate, (2) the noncompulsory or required electives after Match results were known were not perceived to be of a high quality, (3) the noncompulsory or required electives after Match results were known were not perceived to be relevant to their future career or residency, or (4) they had a desire to begin the next phase of their education. Third, approximately 18% of respondents found the fourth year valueless. This was not affected by specialty choice. Previously, only junior residents sure of their future career choice at the beginning of the fourth year had reported this.26
Medical school is an extremely costly endeavor. Rarely mentioned, though, are the added costs of applying for residency, including taking away or audition electives and traveling for interviews, particularly for those entering nonprimary care residencies. Although these costs pale beside the total cost of medical school, it remains a sizable investment for students already heavily in debt. Approximately one-third of the fourth-year medical student respondents in our survey reported that financial constraints interfered with their taking away electives, and approximately 15% required a residency relocation loan to finish the fourth year. Our study is unique in that we describe the number of interviews and the costs associated with the interviews or with completing an away elective and compare those costs by specialty choice.
Flexibility remains an important issue for medical students. More than half of the respondents needed more time to interview, and approximately a quarter needed more time to decide on a career specialty.
There are limitations to the study. Student response rates varied by medical school; however, in the data analyses, we controlled for the different medical schools and found little variability in the results. Although the overall survey response rate was slightly less than 50%, the demographics of the sample and career specialty choices selected closely matched the NRMP data from 2014,28 supporting the sample’s representativeness. We categorized subspecialties under their respective specialties rather than analyzing them individually. Therefore, we could not draw conclusions about differences among subspecialties in the same specialty or determine the influence of highly competitive subspecialties on the data reported. Because we did not ask respondents specifically which courses they had taken and if they were required, we could not compare schools’ use of the fourth year for residency preparation versus students’ attitudes about the purpose of the fourth year.
Our qualitative data analysis was based on a single open-ended question. However, the themes that emerged were similar to those reported elsewhere,13,26 and the qualitative results closely matched the quantitative data. Our survey did not directly address nonclinical skills, personal growth, and reflection, but this may be because our preliminary discussions with medical students did not identify this as a key issue to be addressed in the survey instrument. Our study did not assess the roles of mentors or the importance of research. Finally, we could not discern whether students’ perceived need for residency preparation matched with what was expected by residency program directors.
Many medical education experts agree that the fourth year should facilitate transition to residency.7,8,19 Results from our study demonstrate that medical students also view the fourth year as a time for residency selection and preparation. How best to accomplish this and enhance personal, internally driven goals has been a challenge. Viewing the fourth year as part of an educational continuum, which includes residency, with specific developmental milestones along the way may assist curricular development. However, to address the specific needs of students, the fourth year should retain sufficient flexibility to allow students adequate time to identify a career, complete away electives, and interview at residency programs. It is clear that medical students desire to be well prepared for residency. A focus should be placed on developing individualized, student-driven educational and career goals and providing the resources to help students meet these goals.
Acknowledgments: The authors wish to thank Sherilyn Smith, MD (University of Washington), and Kathryn Huggett, PhD (Creighton University), for their help designing the survey instrument and project implementation; Susan Bannister, MD (University of Calgary), and Carol B. Benson, MD (Harvard Medical School), for assistance with manuscript preparation; and the following for their efforts: Latha Chandran, MD (Stony Brook University), Charles Christianson, MD (University of North Dakota School of Medicine and Health Sciences), Robin English, MD (Louisiana State University Health Sciences Center New Orleans), Amie Jones, MD (Mayo Medical School), Soo Kim, MD (Loma Linda University), Jennifer Koestler, MD (New York Medical College), Lisa Leggio, MD (Medical College of Georgia at Georgia Regents University), David Levine, MD (Morehouse School of Medicine), Starla Glick Martinez, MD (Northeast Ohio Medical University), Alex Mechaber, MD (University of Miami Miller School of Medicine), Glen Medellin, MD (University of Texas Health Science Center at San Antonio), Pradip Patel, MD (University of Louisville School of Medicine), Sandra M. Sanguino, MD (Northwestern University Feinberg School of Medicine), James Stallworth, MD (University of South Carolina School of Medicine), Linda Tewksbury, MD (New York University School of Medicine), and Stephen Tinguely, MD (University of North Dakota School of Medicine and Health Sciences).
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