The concept of a 3-year doctor of medicine (3YMD) pathway is not new. Canadian schools have had them for 3 decades. These programs were common in the United States in the 1970s and 1980s, with their development fueled by governmental financial support and a predicted physician shortage. Their demise occurred when these factors decreased and faculty and student dissatisfaction grew.1 However, in the past decade, there has been a revival in the development of U.S. 3YMD programs, with varied goals. The Consortium of Accelerated Medical Pathway Programs, funded by the Josiah Macy Jr Foundation, has doubled in size since 2015 to 17 medical schools, and the number of 3YMD graduates from these schools is more than 150, compared with fewer than 10 in 2013.2
Motivation
The motivation to create an accelerated 3YMD program varies. At New York University Grossman School of Medicine (NYUSOM), the goals included reducing student debt, individualizing student education, and integrating undergraduate medical education (UME) and graduate medical education (GME) for students who know their career path. This motivation is supported by the Carnegie report,3 which challenged the conventional Flexnerian model of medical education4 to focus on competency, standardization of outcomes, and flexible and individualized learning pathways that allowed for shortened training. Other programs focus on training primary care physicians to serve in underserved or rural settings. The lengthening of residency and fellowship training delaying entry into practice and the debatable value of a fourth year of medical school focused on residency application further support accelerated programs.5,6
In 2010, curriculum reform at NYUSOM shortened the preclerkship curriculum from 2 years to 18 months. This reduction allowed the creation of individualized pathways, enabling students to graduate in 3, 4, or 5 years. Our 3YMD pathway commenced in 20135 and was the first program in the United States that included conditional acceptance to any of the NYU Langone Health (NYULH) residency programs through the National Resident Matching Program (NRMP). This continuum of UME and GME training allows integration of medical students in their departments, facilitates transition from UME and GME, and allows tracking of outcomes. We describe what has been of critical importance to successfully implement our innovative accelerated 3YMD pathway, including commitment by institutional leaders, curricular flexibility, robust mentoring, and moderate program size.7
Method
The structure and curriculum are described based on the authors’ involvement in designing and refining the 3YMD pathway over time. Student feedback was collected through informal debriefs as part of ongoing quality monitoring and improvement, and because these qualitative data are anonymous and were not collected for research, the summaries provided here were deemed not to require institutional review. Interviews were conducted with residency program directors (RPDs) involved in the 3YMD program in 2017 (May through June) under an NYUSOM IRB-approved research protocol. All 16 RPDs were recruited by email, and 15 provided consent and completed an in-depth, semistructured interview (conducted by one of the authors, C.G., who is not directly involved with the 3YMD program). The interview was based on a set of guiding questions that focused on program directors’ experience with and reflections on the 3YMD program. (The interview guide is available as Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A757.) Interview responses were recorded and transcribed, and a simple content analysis of the transcriptions was conducted to identify and describe major themes: After all the transcripts were read and responses to each core question across all RPDs were reread (to highlight areas of shared and divergent experiences and views by residency program), interview responses were then coded in ATLAS based on broad themes. (ATLAS.ti Scientific Software Development GmbH [2011]; ATLAS.ti Qualitative Data Analysis Version 7.0, Berlin, Germany.) Simple counts were used where relevant to describe similarities and differences in views and experiences.
Structure of the 3YMD Pathway
Admission to the 3YMD pathway and residency
Application to the accelerated 3YMD pathway is offered after acceptance into the traditional 4-year MD program. Interested students complete an additional application describing why they have chosen a specific career path and what experiences they have had to support their decision. Applications are sent to the RPD, who, with the department chair and several faculty members, decides whether to interview and admit the student. Criteria for admittance relate to the strengths of the students in knowing their career path and in being a good fit for the residency program. Admission to the accelerated 3YMD pathway offers conditional acceptance into the residency program through the NRMP on successful completion of medical school. At the outset, the dean of NYUSOM and CEO of NYULH set the expectation that each residency program opens approximately 20% of its slots for students to apply to the 3YMD pathway.
MD students can apply for the 3YMD pathway at 3 points: prematriculation, during the spring of their first year of medical school (opt-in 1), or during the spring of their second year (opt-in 2) (Figure 1). All students have an opportunity to shadow and explore specialty interests during their first year and become more familiar with NYUSOM and New York City. Opt-in 2 students have completed the first 4 months of clinical rotations and have interacted in their department. MD-PhD students apply after completion of their PhD, shortening the time to graduate by 1 year. Key to the success of the program is acceptance of students by the department. This acceptance allows early engagement and partnership.
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Figure 1: Accelerated 3-year MD pathway curriculum with entry points, as compared with 4-year curriculum, New York University Grossman School of Medicine. Abbreviations: USMLE, United States Medical Licensing Examination; CCSE, comprehensive clinical skills exam.
Curriculum
Another key to the program is the alignment of curriculum of the 3YMD pathway with that of the 4-year pathway. The curriculum for the first 2½ years is similar (Figure 1). The exception is that 3YMD students complete an 8-week experience between years 1 and 2. Prematriculation students also take a 2-week elective before the start of the first year. The alignment of the 3- and 4-year curricula facilitates delayed entry into the program, as well as a shift to the traditional 4-year pathway. The last 5 months are the most different, as students sit for the United States Medical Licensing Examination Step 1 and Step 2 Clinical Knowledge and Clinical Skills and complete requirements for graduation, including 130 weeks of medical education per the Liaison Committee on Medical Education.
Keys to Successful Implementation
Definition of success
Success of the 3YMD pathway is determined by its sustainability, satisfaction of students and RPDs, and professional development and competency measures that are comparable to those of 4-year students. Qualitative evidence presented in this article is derived from RPD interviews and from student reports. Quantitative information is being collected and will be published in the future.
Leadership and commitment to mission
Success of an educational program that is new and unprecedented requires strong leadership and engagement from the top. A clear mission and unwavering commitment from the dean and vice dean for education empowered UME leadership to create and sustain the 3YMD pathway. The pathway is a high institutional priority. The mission is not only to reduce student debt but also to advance student-centered education to enable students to enter their chosen fields 1 year earlier and begin post-MD training that will continue for 3 to 10 years. Leaders obtained the support of RPDs and department chairs for the success of the program.
Alignment of 3- and 4-year curricula and impact on program flexibility
The alignment of the 3- and 4-year pathway curriculum for the first 2½ years facilitates a shift to the 4-year pathway, if necessary, as a result of performance issues or a change in career path to a specialty unavailable in the 3-year pathway. It is also expected that some students will shift pathways to train in another location or to participate in a couple’s match.
Even though students were committed to a particular program at the time of admission to the 3YMD pathway, some students expressed uncertainty about their career choice. To date, 116 students have been accepted into the accelerated 3YMD pathway and 12 students (10%) have switched specialties, including 7 (6%) who remained in the 3YMD pathway, 4 (3%) who shifted to the 4-year pathway, and 1 (1%) who entered the MD-PhD program. These changes have occurred primarily because students have found another specialty that is more in line with their interests. This decision can be difficult for students, especially those who feel well connected in their department, with strong relationships with faculty mentors.
Though the program is structured so that 3YMD students do their residency at NYU, it is understood that they may change their minds, and they are supported in applying elsewhere through the NRMP. Graduation from the 3YMD pathway requires acceptance into a residency, so if one wants to go outside of NYULH for residency, one may need to shift into the 4-year pathway, as 2 students have done. To date, 4 of 5 students who applied elsewhere at the end of 3 years have been successful.
Promotion and remediation
The program is not time-variable competency based, but rather requires a student to achieve all required UME competencies in 3 years. Clear procedures are needed regarding promotion, remediation, and shifting to the 4-year pathway. Given that the first 1.5 years are pass/fail, students are required to pass all modules. They are expected to get honors or high pass in most, if not all, clinical rotations. Performance of all 3YMD students is reviewed monthly by an executive committee for the 3YMD pathway that is led by the vice dean for education.
Flexibility and understanding in the review and remediation process are needed. It has been possible for students to be successful despite failing a single exam. When issues related to professionalism arise, the same standards apply to 3- and 4-year students. Shifting to the 4-year pathway has been required for 4 students because of professionalism issues, including reliability, self-improvement, adherence to code of conduct, and relationships with other students and staff.
Mentorship: Advisors for professional development, student advocacy, and wellness
With any new educational program, one needs to offer extra support for students. In addition to mentoring programs in place for all medical students, the development of a unique faculty mentoring program has been crucial. Each 3YMD student has 3 faculty mentors: a career advisor, a departmental advisor, and a 3YMD pathway advisor. The career advisor is the same for 3- and 4-year students, facilitates integration within and among classes, and is an academic coach.
3YMD students are assigned a departmental advisor at the time of acceptance into the program, in contrast to 4-year students who are assigned a departmental advisor in their third year. The departmental advisor facilitates early involvement in departmental activities and helps plan the summer program between the first and second years. This advisor introduces students to faculty and residents, encourages them to attend conferences, includes them in celebrations, and provides opportunities to explore clinical and research topics of interest. These activities help to integrate students into the department and solidify their career choice. The departmental advisor, along with the RPD, supports the student in the completing of the residency application. The amount of involvement in the department varies among students and by departments, but students who are more involved describe greater satisfaction with medical school. The departmental advisor may continue to mentor students as they transition into the residency program.
The 3YMD pathway advisor is a faculty member who understands the curriculum and logistical needs of an accelerated student and is a facilitator of the dynamic relationship between the students and the program. This advisor provides guidance on student schedules, summer experience after the first year, selection of clerkship order and electives, and meeting the requirements for graduation. Our 3YMD pathway advisor meets individually at least quarterly with each student, and is in contact, as needed, between meetings. Close communication is necessary to clarify the program requirements, encourage shadowing within and outside students’ chosen field to confirm their decision, and seek answers to both student-specific and program-related questions. Monthly lunches enhance connections among 3YMD students in different years of the program. The 3YMD advisor also provides important support for changes in specialty, both those within the 3YMD pathway and those that require shifting to the 4-year pathway. Students also discuss issues with the 3YMD pathway advisor that need to be addressed to enhance the program and medical school experience. This advisor also monitors students’ well-being; is supportive in academic, professional, and personal issues; and refers students for additional help when needed.
The coordination of multiple advisor roles occurs through discussions with the student. For example, the departmental advisor helps the student identify a mentor with expertise aligned with the student’s interests and works with the student to design the summer research and clinical experience after the first year; the 3YMD pathway advisor ensures that the student’s needs for this experience are met and that the experience fulfills requirements.
In 2014, peer mentoring was added by pairing students with other students ahead of them in the 3YMD pathway in the same or similar specialty. After several years with graduates of the pathway in NYU residencies, peer mentoring includes residents in the same specialty. Students appreciate advice from those ahead of them, and senior students and residents are happy to be helpful.
Size of program
The moderate size of the program has helped it be successful because students do not feel isolated and they interact with residents who are graduates of the program on clinical rotations. With growth every year (Figure 2), 19% of the Class of 2019 graduated through the accelerated 3YMD pathway. These 28 students entered the pathway in approximately equally divided numbers between prematriculation (n = 11, 39%), opt-in 1 (n = 9, 32%), and opt-in 2 (n = 8, 29%), providing evidence of the appeal of multiple entry points to students. As of 2019, there are 81 graduates of the program, including 77 in 21 NYU residencies. With the growth and success of the program, the 3YMD pathway has become an integral part of NYUSOM.
Figure 2: Number of graduating students and available residency positions, New York University Grossman School of Medicine 3YMD pathway, 2016–2019.
Findings Thus Far
In informal debriefs and discussions during the initial year of the program, many students noted that in clinical rotations they were reluctant to admit that they were 3YMD students, concerned that attending physicians and residents would take less interest in them because they had already decided on their specialty. Some students thought they were expected to know more than other students when their preclinical training was the same as 4-year students. In the initial year of the program, during a town hall meeting with students, senior 4-year pathway students vocalized a concern that accelerated 3YMD students took “their” residency positions. This concern has dissipated as opportunities to opt-in to the 3YMD pathway have been implemented. Occasionally, a student would note that when 3- and 4-year students were first-year residents at the same time or first-year residents who were 3YMD graduates were supervising their 4-year classmates, 4-year students questioned the abilities of 3YMD students. These biases have lessened greatly now that there are many 3YMD pathway undergraduate students and graduates in our residencies. Students are generally proud to say that they are part of the accelerated 3YMD pathway, and during webinars to recruit students to the program, 3YMD students report feeling less stressed than do 4-year students, thanks to their conditional acceptance into residency.
Positive experiences with 3YMD graduates, who often have a smoother-than-average transition to residency because of involvement during medical school, have made RPDs more enthusiastic about the program. Six graduates have been selected to be chief residents, from among 15 eligible in the first 2 classes, evidence that their performance is at least comparable to other residents. Several department chairs and RPDs have opened additional slots for talented 3YMD applicants, indicating satisfaction with the program. Interviews with RPDs who have 3YMD students (most of whom were interns at the time of the interviews) indicate that there was initial skepticism about the introduction of this pathway because of concerns about being able to select students at admission, the importance of time, and unease with students selecting residency programs so early. However, over time, RPDs generally found the pathway to be a great benefit in attracting students who were very focused from the start and fit well with the program “phenotype.” RPDs quickly realized this pathway was a great way to recruit stellar students into their programs. One RPD noted, “The whole secret is picking the right student from the beginning.” In addition, developing these students early enabled RPDs to ensure the right fit between the student and residency program and to learn what they should look for in a 3YMD student. Initial challenges in rolling out the 3YMD program led some RPDs to note that better communication would have helped them be more aware of changes in the design and implementation of the program. A few RPDs also noted that students occasionally received mixed messages or conflicting advice from their multiple advisors but reported that those conflicts were relatively easy to resolve when they arose. More than half of the RPDs shared their belief that the 3YMD students should focus on being a student—that is, focus on being in medical school—and not to try to be a resident too early. That focus, they felt, was important for students to be sure about their residency choice and to have the foundation that would fully prepare them for day 1 of residency. All 12 of the 15 RPDs who had a 3YMD graduate in their program reported that the intern was indistinguishable from the other interns, except in having greater knowledge of the health care systems and in some specific skill sets (e.g., research, prior clinical experience) where the 3YMD intern was superior.
Summary
Although the initial creation of our accelerated 3YMD pathway was met with some external skepticism,8 a recent survey showed that 35% of U.S. medical schools have, or are developing, accelerated 3YMD pathways.9 Schools have developed widely different approaches depending on their mission and local environment. The accelerated 3YMD pathway at NYUSOM is now in its seventh year with 123 students, of which 81 are graduates in residency programs. The program is designed for students who know their career path to allow them to enter practice 1 year early. We initially estimated that 25% of students would pursue different careers, but only 10% have changed specialties to date, and more than half of those individuals have been able to remain within the 3YMD pathway. Even with NYU’s tuition-free initiative, earlier entry into practice leads to financial gains from reduced cost of living during medical school and 1 additional year of earnings. Conditional acceptance into residency permits smoother transition across the UME-to-GME continuum with substantial benefits to both students and residency programs.
Noted in List 1 are obstacles and requirements for building an effective accelerated program. Designing a successful accelerated program requires strong support on many levels, including from the dean of the medical school, the dean for education and student affairs, department chairs, RPDs, and multiple advisors. High expectations and determination to overcome challenges are critical for success. Flexibility is key because adjustments will be needed to ensure that the program thrives and benefits both students and residency programs. Additional mentoring and student support are necessary. While many of the accelerated 3YMD pathways elsewhere are small, our experience is that a larger cohort is beneficial because students have other 3YMD students and residents to turn to for advice and support.
List 1
Expected Obstacles and Requirements for Building a Successful Accelerated 3-Year MD Pathway
Obstacles
- Initial biases from faculty and residency program directors
- Feelings among accelerated students of being judged differently by faculty and other students
- Feelings among fourth-year students of having lost out on residency slots
- Changes in career paths by some students in the program
Requirements
- Strong level of leadership and commitment from the dean and undergraduate medical education leaders
- Involvement and buy-in from department chairs, residency program directors, and faculty
- Alignment of curriculum to allow students to opt in and out of the pathway
- Development of a unique mentoring program with a program-specific advisor and early assignment of departmental advisor
- Program sized for sustainability
- Flexibility, when possible, in allowing students to stay in the accelerated 3-year MD pathway even if they change specialty
A limitation to the generalizability of our experience to other 3YMD programs is that it may not always be possible or desired to align the curriculum between 3- and 4-year programs. Other approaches to achieve flexibility to serve the best interests of individual students are then needed.10 We think offering all residencies is important for student-centered education but recognize that the mission of other programs may be different. In our experience, however, support by top leadership and robust mentorship are both indispensable.
Regarding future directions, in July 2019, the NYU Long Island School of Medicine opened as a 3-year tuition-free medical school associated with primary care residencies.
Enthusiasm for our accelerated 3YMD pathway among students, residency programs, and faculty has risen over time, as evidenced by the increased number of students and residency positions (Figure 2). Students tell us they feel ready to graduate and start residency, and the RPDs say they are pleased to welcome familiar students. Lastly, it is our observation that on graduation day, our 3YMD students seem very happy, appreciating the time and expense they have saved.
References
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