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Finding Greater Value in the Fourth Year of Medical School: Accelerating the Transition to Residency

Pellegrini, Vincent D. Jr MD; Franks, Adam M. MD; Englander, Robert MD, MPH

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doi: 10.1097/ACM.0000000000003049
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While some authors would offer that medical education has changed a great deal since the Flexner Report of 1910,1,2 others would argue that very little has changed. Recently, the Josiah Macy Jr Foundation called for major renovations to the traditional model of medical education in the United States, recommending a shift to a competency-based, time-variable model.3 Others have advocated shortening medical education to mitigate the effects of escalating student debt—or extending it to better prepare graduates for the unsupervised practice of medicine. A mandate for change has clearly emerged, but without consensus on specifics of the changes needed.

A new physician is the product of both undergraduate medical education (UME) and graduate medical education (GME), with the interface and redundancy occurring at the intersection of the fourth year of medical school and the first year of residency (internship). Critics of the fourth year of medical school have admonished the limited value of “audition” visiting rotations and the unfocused pursuit of a host of electives, while proponents have underscored the virtues of having time for personal maturation and focusing one’s professional interests.

The case for shorter training is punctuated by escalating medical student debt. In 2018, 75% of graduating physicians reported education debt; the median total was $200,000, with an average medical school component of $194,000.4 While Medical School Graduation Questionnaire results suggest that lifestyle considerations and specialty content predominantly influence career choice,5 the prevailing concern among educators and workforce experts is that the magnitude of education debt will drive medical school graduates away from primary care fields, where there is much need, toward higher paid subspecialties.6–9 Those who fear an impending physician shortage favor an earlier finish of formal education and entry into practice. While this strategy has been successful in primary care,10–12 it is equally relevant to surgical subspecialties where up to 90% of graduates pursue postresidency fellowship training.13–15 Proponents of longer medical training argue that current medical school graduates are less well prepared for residency and subsequently less ready for unsupervised practice after residency than in prior decades.16,17 The most common claim is that duty-hours restrictions limit trainee experience during residency. Clinical productivity pressures on faculty and “teaching physician” billing compliance issues have also whittled away at the resident autonomy that is traditionally credited with professional growth. Nasca suggests that education has been compromised by residents being effectively removed from a “pivotal role” in patient care.18

Over the past 2 decades, medical training has been shifting away from the Flexner model toward competency-based medical education (CBME), beginning with the Accreditation Council for Graduate Medical Education (ACGME)/American Board of Medical Specialties Outcome Project.19 This focus on competency-based advancement has heralded a true change in institutional direction in U.S. medical schools and residency programs. Yet, it is important to realize that opportunities for accelerated advancement may be realized by only a minority of trainees and that others may need longer time in training to achieve the necessary competencies. Shorter or longer training is the by-product of a primary emphasis on prespecified educational outcomes; the key is that our institutions must be capable of the flexibility needed to support this redirected focus on outcomes. The transition from time-dependent to outcome-dependent training must be purposeful and requires explicit identification and measurement of desired outcomes. Carraccio et al20 describe 4 steps in this paradigm shift:

  1. Delineation of competency outcomes that are required of physicians to meet societal needs. These outcomes are fixed while time to reach them is variable.21,22
  2. Delineation of performance levels determined by supervisor assessment of competency along a developmental continuum. Milestones in GME are a good example.19
  3. Development of curricula with assessment frameworks designed to optimize learners’ opportunities for advancement. Entrustable professional activities (EPAs), for example, provide such a framework.23,24
  4. Measurement of results using such surrogates as frequency of postresidency fellowship pursuit, board exam pass rates, and stability and longevity in first practice location.

Ultimately, any opportunity for CBME to repurpose and redeploy time from UME to the betterment of GME would provide benefits for learners, teachers, and patients. In this article, we consider redeployment strategies for the UME-to-GME transition. We begin by examining regulatory requirements for—and hurdles to—movement away from a fixed-time structure for UME and GME. We then describe 3 innovative programs, in pediatrics, family medicine, and orthopaedics, that are testing the boundaries of the UME-to-GME transition in ways that have potential to accelerate readiness for independent practice while enhancing learner experience and competence.

Regulatory Requirements for Effective Implementation

Oversight of medical education in the United States is provided by a complex constellation of regulatory bodies, whose guidelines are time tested and seemingly slow to change. When proposing an alternative pathway, therefore, it is prudent to seek avenues that work within existing guidelines rather than pursue an arduous process of guideline alteration. Relevant considerations include the need to satisfy requirements of

  • the Liaison Committee on Medical Education (LCME) for granting of an MD degree,
  • state medical boards for licensing,
  • the National Resident Matching Program (NRMP) for placing a resident off cycle,
  • the ACGME for fulfilling program requirements for graduation, and
  • professional specialty boards for sitting for certifying exams.

Fluency with these requirements, as detailed below, is essential to gain approval of an innovative time-variable or accelerated program and to implement it successfully without a protracted process of guideline revision.

LCME requirements

LCME accreditation standards must be followed in designing an accelerated medical school track. An initial consideration is the minimum standard that the “medical education program includes at least 130 weeks of instruction.”25 Some programs have created accelerated tracks that are abbreviated and time fixed; it is essential that such accelerated programs preserve requisite curricular elements needed to meet core program objectives while concurrently providing opportunities for students to pursue individual career interests. Others have incorporated competency-based, time-variable curricula that provide for graduation upon attainment of a final judgment of competency.26 Under both models, the programs are required to meet the LCME standards of providing 130 weeks of formal education and a centralized assessment system that ensures “all medical students achieve the same medical education program objectives” and a “single set of core standards for the advancement and graduation” from the program.25

Students who attain competency in a time-variable curriculum or meet degree requirements in a time-fixed accelerated track may complete their degree “off cycle” at some time during the traditional fourth academic year and before the NRMP’s Main Residency Match (the Match) in the spring. When qualified students are assured a position in a residency program affiliated with their medical school or home institution before the Match, the several months they would have spent traveling to interviews and audition rotations during their fourth year can be devoted to completing clinical rotation requirements. As accelerated programs mature, medical school curriculum scheduling changes can often be coordinated with the academic calendar and implemented to satisfy the 130-week milestone in 3 conventional academic years. This calendar alignment obviates a host of special considerations related to off-cycle timing. It is important to note that major curriculum modifications and the establishment of a parallel educational track must be endorsed by both the relevant institutional oversight committees and the LCME.25

State medical board requirements

State medical boards have their own rules for granting “training” licenses for house officers in accredited residency programs. Commonly a diploma signifying successful completion of the medical curriculum is all that is required. Issues related to curriculum duration and timing of granting the medical degree are typically of secondary interest to state licensing boards. However, some states do have time requirements that must be addressed, and below we provide an example of a legislative solution orchestrated by the pediatrics initiative in California. Even in the absence of state time mandates, early communication is wise to ensure timely receipt of off-cycle medical licenses.

NRMP requirements

The NRMP’s all-in policy requires participating GME programs to fill all positions through the Match, and formal exemptions are limited to extraordinary circumstances. However, according to the NRMP, an exemption is typically not necessary for implementation of innovative accelerated programs, irrespective of the location of the program. Rather, the NRMP’s off-cycle policy extends a functional exception provided that the trainee is eligible for postgraduate training before February 1 of the anticipated Match year.27 Importantly, equitable treatment of the student who elects to opt out of the accelerated program during the fourth year must be ensured with a “hold harmless” option that allows the student to register for the spring Match before the late registration deadline. At the Medical University of South Carolina (MUSC), for example, December 31 has been set as the last day for withdrawal from the accelerated orthopaedics program, as described below. While entry into the Match at a late date is a relative disadvantage to the applicant, it carries no more risk than that incurred by making a late specialty decision.

ACGME requirements

ACGME considerations are also important, but these apply directly to the residency program and indirectly to the learner. If a program admits an off-cycle resident, it must reduce its number of NRMP-eligible positions in the next Match so it does not exceed the approved permanent complement. In some instances, the program may need to seek a temporary complement increase to remain compliant because the number of residents in the program after matriculation of the off-cycle resident will exceed the approved permanent complement until completion of the next cycle of graduation and the Match. This excess number of residents may be a concern to the Residency Review Committee (RRC), even though it is only a transient issue. Consultation with the specific RRC is advised to determine whether a temporary complement increase is required and the extent of supporting data needed to justify the request.

Professional specialty boards

Professional board certification requirements for residency program graduates vary by medical specialty. Satisfying specialty-specific minimum requirements for time in residency must be ensured.

Examples of Innovative Programs in 3 Disciplines

Education in Pediatrics Across the Continuum (EPAC)

Medical education programs participating in the EPAC pilot—an innovative same-institution accelerated transition to residency program in pediatrics—were the first to move from a fixed-time, variable-outcome model to a fixed-outcome, variable-time model for select students.28 EPAC was conceived by Deborah Powell, MD, dean emerita of the University of Minnesota, who envisioned students selecting their specialty early in medical school and then entering residency with an agreement to stay at their home institution. Including the commitment to remain at the home institution for residency was viewed as critical to provide the continuity necessary to assess longitudinal progression from UME to GME to practice based on competency rather than time.

Several critical factors led to successful implementation of the EPAC pilot in 2013, commencing with receipt of a grant from the Macy Foundation. Early partnerships with the Association of American Medical Colleges (AAMC) and Carol Carraccio, a respected expert in CBME,29 were crucial to broad stakeholder buy-in and creation of a national consortium of schools engaged in this novel pathway. The decision to pilot this program in pediatrics was based on the suggestion from the Careers in Medicine program at the AAMC that students who enter medical school with the intention to pursue pediatrics have a higher likelihood of persisting in their initial specialty choice.30 This was an important consideration because the pilot would generate only a small number of initial participants: Each of the participating schools—the University of California, San Francisco; the University of Colorado; the University of Minnesota; and the University of Utah—agreed to 4 students for a minimum of 4 cohorts.

Alignment of the EPAC pilot with requirements of accreditation and certification bodies—including the LCME, ACGME, American Board of Pediatrics, and the Federation of State Medical Boards, as well as the state medical boards representing the pilot schools—was critical. For example, in California, existing law stipulated a minimum number of weeks to attain the MD degree. The University of California, San Francisco, EPAC group worked with other CBME-pilot schools in the state and successfully lobbied the state legislature to eliminate this time requirement and instead emphasize competency as represented by degree completion. Local alignment of internal institutional leadership (both individuals and committees) with the project was also essential and required continuity of project champions. One school dropped out of the pilot after a vice dean who had championed the project left the institution; the new dean did not prioritize the project.

Arguably, the most important factor was alignment of outcomes with the ACGME competencies and milestones as modified for pediatrics. As all residency programs are required to submit data to the ACGME every 6 months on the progress of residents relative to milestones, EPAC’s measurable outcomes had to be (1) acceptable across a variety of settings, (2) assessable, and (3) have direct connection to the ACGME competencies. The EPAC group therefore adopted EPAs as the framework for competency assessment. This required a leap of faith because the AAMC Core Entrustable Professional Activities for Entering Residency24 (Core EPAs) were still being developed and their performance without direct supervision would be relied upon as the basis for the UME-to-GME transition. The national consortium of schools agreed that clinical competency committees (CCCs), as used in residency programs, would determine entrustment. These CCCs would compile data through individual assessments and direct observations of student performance; in aggregate, these data would support decisions about the required level of supervision for any Core EPA. One requirement for the UME-to-GME transition would be reaching the level of indirect supervision, confirmable by a second assessment, on all the Core EPAs. Similarly, progression beyond GME would depend upon entrustment of unsupervised performance of the 17 Pediatric EPAs31 as determined by aggregate observations of resident performance by residency program CCCs.

The EPAC project is now in its fifth year since matriculation of the first EPAC students in 2014. The first 2 cohorts and some members of the third cohort have transitioned to residency. At 2 schools, those transitions were time variable. At the other 2 schools, students were all judged to be prepared to make an early transition to GME, but institutional barriers precluded a change in their graduation date. One of those schools was recently able to overcome that barrier and will allow future competency-based advancement. Additionally, all students who have advanced in a time-variable fashion to date have experienced a decrease in their total time in medical school of 6–10 months. The financial implications are twofold: (1) all of these students have earned a resident’s salary earlier than their colleagues in the traditional fixed-time model, and (2) most have been able to avoid one semester of medical school tuition.

The EPAC project has provided some important lessons:

  1. Time-variable, competency-based advancement in medical education and training is possible, but barriers within a fixed-time system must be anticipated and overcome.
  2. Changing the system requires a deliberate and intentional plan to satisfy existing regulatory requirements.
  3. Defining outcomes and selecting a framework for assessment are essential to adopting a time-variable, competency-based model.

Accelerated transition in a medical (family medicine) residency program

The traditional medical school curriculum is characterized by standardization of the first 3 years of medical school to ensure that all students receive a similar foundation of medical education.32 This uniformity contrasts with the flexibility needed in the final year, which must provide multiple electives in support of the exploration of various specialties, with few requirements.32,33 Because of the broad knowledge base required for family and internal medicine, there is a strong correlation between these residency programs’ internship requirements and medical schools’ fourth-year requirements such as a medical subinternship and critical care, emergency medicine, and outpatient electives.32,33 Students entering family and internal medicine fields therefore might be expected to be well prepared entering their medical internships, but their performances in the fourth year and subsequent internship have not been well correlated.34,35

Indeed, some differences exist between the priorities and expectations of predoctoral medical educators and residency directors. Both rate outpatient general medicine rotations highly, but residency directors value a medical subinternship just as strongly.36 A greater valuation differential exists around skill mastery. Predoctoral educators, focused on delivering a broad medical education, prioritize history taking, physical data collection, and treatment plan development. Residency directors, more focused on patient interactions, place greater value on the practical skills of physical examination and patient management.36

Past attempts at improving the fourth-year learning experience through increasing responsibility and ownership have enjoyed success by combining the fourth year of medical school with the first year of residency and eliminating redundancies.37 In 1991, the American Academy of Family Physicians allowed the University of Kentucky to create an accelerated family medicine residency in this manner. Two years later, 11 other schools followed suit, and since then more than 25 accelerated family and internal medicine programs have emerged.10–12,38 Marshall University, the University of Nebraska, and the University of Tennessee have published excellent academic outcomes from their accelerated programs, including board exam pass rates, USMLE Step 3 exam scores, and pediatrics in-training exam scores.10–12,32,38 These programs have also demonstrated higher graduate retention in-state, higher service to rural and underserved populations, and reduced education debt.10–12,39,40 Similar outcomes have been reported by accelerated programs in internal medicine, obstetrics, pediatrics, and psychiatry.12

While accelerated programs admittedly select a cohort of exceptional students, examples of heterogeneous groups of students thriving with an augmented fourth-year experience also exist. One example is a purposeful retooling of the fourth year at the Marshall University Joan C. Edwards School of Medicine that has demonstrated significant benefits for all participating students. The Rural Family Medicine Scholars (RFMS) program is a customized fourth-year subinternship curriculum that began at Marshall University in academic year 2015–2016 and incorporates mentoring, service, didactics, and required rotations. The RFMS program accepts all applicants, resulting in an academically heterogeneous cohort of students interested in family medicine. As Table 1 shows, mean GPA before the fourth year and mean USMLE Step 1 exam scores are lower for RFMS students than for their classmates. However, RFMS students’ mean GPA at the end of the fourth year and their USMLE Step 2 exam scores compare favorably with those of their non-RFMS peers pursuing a match in family medicine and the medical school class overall (Table 1). Furthermore, the overall Match rate of 100% for RFMS students before the Supplemental Offer and Acceptance Program (SOAP)—inclusive of matches to both Marshall University and external family medicine residency programs—is statistically better than the rates for non-RFMS students attempting to match to family medicine programs (42.9%) and for the class overall (89.5%). Compared with their peers, RFMS students perceive better alignment of predoctoral and residency education priorities and expectations, and they demonstrate greater ownership for their education.

Table 1:
Comparison of Academic Performance and Match Outcomes of Medical Students Participating in the Rural Family Medicine Scholars (RFMS) Program and Their Peers, Marshall University Joan C. Edwards School of Medicine, Academic Years 2015–2016 Through 2017–2018

Accelerated transition in a surgical (orthopaedic) residency program

Orthopaedic residents seek fellowship training more frequently than residency graduates in any other medical specialty, a trend that increased from 76% in 2003 to more than 90% in 2014, with nearly 5% pursing a second fellowship experience.13–15 Recent evidence suggests that such behavior reflects a desire to further refine technical skills rather than to address areas of deficiency.41 Yet, general surgical faculty believe more than one-third of graduating residents are not prepared to enter clinical practice, and fellowship directors believe two-thirds of entering trainees are unable to operate unsupervised for 30 minutes in a major surgical case.16,17,42 The American College of Surgeons responded to these concerns with the Transition to Practice program in 2013,43 an elective one-year apprenticeship for residency graduates before entering independent surgical practice. These observations question the adequacy of contemporary surgical residency education in the context of an 80-hour workweek that reduces surgical experience.44,45 These considerations led the MUSC orthopaedic residency program to collaborate with the undergraduate curriculum committee to restructure the fourth year of medical school for the principal purpose of providing additional operative experience for residents in the surgical specialties.

In 2013, the orthopaedic faculty envisioned repurposing the fourth year of medical school by achieving an “early” graduation. A conservative approach to restructuring the curriculum has resulted in the Accelerated Curriculum for Orthopaedic Residency (ACFOR) program’s October graduation with 134 weeks of formal medical education; this increases to 137 weeks with an optional 3-week orthopaedic elective that can be pursued during the summer at the beginning of the third year (Figure 1). Redeploying the time “gained” from the balance of the fourth year of medical school allows 8 months for internship rotations before the traditional July start date, which provides a later opportunity to customize 8 months of the final year of residency into a fellowship-comparable experience. Graduates of the ACFOR program end up with 68 months of orthopaedic residency education, compared with the required 60 months. The first ACFOR student started in the MUSC orthopaedic residency in fall 2017; 0, 1, or 2 candidates are selected each year, with the balance of the 4 residency positions filled in the traditional Match that occurs the following spring.

The ACFOR candidate typically pursues an orthopaedic summer research elective after the first year of medical school, declares interest in ACFOR at the end of the second year, and pursues a modified third-year clerkship schedule that prioritizes early rotations through medicine and surgery in addition to 2 other core clerkships. A final MUSC orthopaedic residency acceptance decision is rendered in February of the third year, after the candidate has completed 4 core clerkships and additional elective rotations in orthopaedics and rehabilitation. All candidates complete all remaining core clerkships during the remainder of the third year; those not selected for an MUSC orthopaedic residency through the ACFOR program pursue a traditional fourth-year curriculum. Those entering the accelerated program spend June of the fourth year preparing for the USMLE Step 2 Clinical Knowledge and Clinical Skills exams and then pursue 4 customized student rotations (ambulatory office orthopaedics as an advanced surgery elective, an advanced inpatient medicine subinternship, an advanced inpatient surgery subinternship, and musculoskeletal radiology) at the beginning of the fourth year, before starting their internship.

Figure 1:
Block diagram of the Accelerated Curriculum for Orthopaedic Residency (ACFOR) at the Medical University of South Carolina, implemented in 2017. The first 2 (preclinical) years of the medical school curriculum are unchanged. During the third and fourth years, students complete all elements of the longitudinal Fundamentals of Patient Care course (not shown). The third year is modified to include early clerkships in medicine and surgery as well as a required selective in orthopaedics to support the residency selection process, which occurs in February of the third year (see arrow). All remaining required clerkships are completed before the granting in October of the MD degree, which is awarded after 134 weeks (or 142 weeks, including an optional summer research fellowship). Internship begins on November 1. The student retains the ability to withdraw from the accelerated program through December 31 of the fourth year and return to the traditional program in time to reenter the NRMP Match. Abbreviations: USMLE, United States Medical Licensing Examination; OB/GYN, obstetrics–gynecology; Ortho, orthopaedics; neuro rehab, neurology and rehabilitation; pysch, psychiatry; fam med, family medicine; CK, Clinical Knowledge; CS, Clinical Skills; MSK, Musculoskeletal; NRMP Match, National Resident Matching Program Main Residency Match. aInternship 101 is a clinical skills course that is approved to replace one 3-week selective. bStudents have the option to complete the advanced surgery elective rotation at another medical school accredited by the Liaison Committee on Medical Education.

The MD degree and state medical license are concurrently awarded at the end of October, allowing commencement of the internship on November 1. Tuition is prorated for the final term, and paid employment as a first-year resident begins at this time. The financial benefit of this accelerated transition is threefold: (1) relief from tuition payments after early graduation, (2) cost savings from avoiding interview travel, and (3) generation of a paycheck. Ultimately, MUSC anticipates the graduating ACFOR program residents will be better equipped to commence the unsupervised practice of orthopaedics than their peers, perhaps without an additional fellowship year, thereby reducing overall surgical training time by one year. The concept underlying the ACFOR program became so popular at MUSC that nearly every clinical department launched an accelerated option to enter their residency program starting with the 2019–2020 academic year.


Completion of a competency-based UME program in 3 years affords opportunities for research and other advanced experiences in the traditional fourth year as well as early advancement to residency training. Three-year curricula in both the United Kingdom and Canada have demonstrated no decrease in physician quality at any level of training.37–39 Some students find value in the traditional fourth year, but many desire it to be more than a year completing audition rotations and graduation requirements unrelated to their chosen specialty.11,36,38 The option of an accelerated transition to residency predicated on a competency-based experience, with the centerpiece being a customized fourth year, provides numerous benefits and facilitates the transition from UME to GME.37,39,40 Learning is enhanced by increased ownership, and earlier credit is earned for the patient encounters and procedure counts required by specialty programs, mitigating losses of experience in residency secondary to duty-hours restrictions and better preparing learners for residency and independent practice upon completion of residency. Students ready for such an early transition derive considerable benefits, including reduced educational debt, as does the U.S. health care system as it awaits the addition of competent new physicians to add to the health care workforce.


The authors acknowledge Donna H. Kern, MD, senior associate dean for medical education and associate professor, Department of Family Medicine, Medical University of South Carolina College of Medicine, for her support of the program, participation in the panel session at the AAMC’s Learn Serve Lead 2017, and assistance in technical editing of the manuscript.


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