Do We Really Need a Fourth Year of Med School?
As a newly minted physician, I recently decided to reflect on my past year of medical school training, and consider some of the challenges and problematic trends in healthcare that I've already encountered -- from increasing healthcare costs to rising medical school debt to worsening healthcare inequities. I thought back to the rippling effects of the private equity-driven closure of Philadelphia's historic safety-net Hahnemann Hospital; the redistribution of patients stretched the broader Philly healthcare system just as COVID-19 catalyzed an urgent need for more beds. I remember trying to track down paper records for underserved ex-Hahnemann patients and being in disbelief that a developed nation in the 21st century allowed healthcare to be practiced this way. I also considered how my fourth-year of medical school was altered by the pandemic. Participating in a virtual musculoskeletal anatomy elective without a cadaver was certainly a unique experience, and to be frank, I felt like my clinical knowledge deteriorated during some virtual rotations. I also found it challenging to evaluate residency programs without visiting the facilities or meeting current residents. From reflecting on my experience, I came to the following conclusion: it's time to re-evaluate the current structure of medical education in order to better prepare students for the broad challenges in healthcare. Certain schools have already started making reforms. In the past 10 years, medical schools have been changing medical curriculum to better prepare students for clinical practice. Beyond curriculum redesign, 22 schools have created tracks that eliminate the fourth year of medical school altogether. In a 2016 survey, one-third of medical schools were considering accelerated tracks to incentivize students into primary care specialties and reduce overall debt burden. Reducing the length of training is one approach that struck my interest. To learn more, I ventured out to understand the perspectives of fellow medical students. This spring, I conducted a survey of 39 fourth-year medical students from Georgia and the Philadelphia area. The sample size is small and isolated to narrow geographic regions; however, the survey was intended to be personally informative and directional, rather than statistically robust. I aggregated their responses and summarized their commentary into three proposals to improve the value of the fourth year of medical training: reduce the cost, alter current rotations, and modify the structure. The survey offers initial insight into medical student perceptions and may vary from the results of larger studies. Survey Results  Among the 39 respondents, 59% believed the pandemic negatively impacted their medical training, and only 53.8% found the fourth year of medical school valuable. Respondents also found the third year to be significantly more valuable than the fourth year for clinical training, with a mean "value" of 8.8 vs 6.3 on a 0-10 scale Additionally, 26.3% of respondents would prefer to attend a 3-year medical program if it was an option at their institution. From free-text answers, respondents indicated that clinical training was impacted in the following ways during the pandemic: shortened duration of rotations, fewer electives, seeing fewer patients, more students on rotations together, lack of away rotations, more virtual rotations, and less in-person training. Additionally, 23.1% of respondents spent 50% or more of their fourth year in virtual rotations rather than in-person rotations. Value of third- and fourth-year of medical school descriptive statistics on 0 to 10 scale. From free-form responses (n=33), most medical students thought the virtual interview format led to substantial cost-savings. However, two-thirds of respondents commented negatively on the virtual interview format and would have preferred an in-person interview season or a hybrid model with an in-person second look. Proposals for Improving the Fourth Year, Derived From Free-Form Survey Responses  Reduce the cost  The average medical student owes $241,600 in total student debt at graduation, which only compounds with interest. A few ways to combat the rising costs of medical education include: eliminating tuition for research or vacation blocks, providing stipends for research, and compensating extracurricular work. Another option is to prorate the total cost of the fourth year to the amount of time physically on the wards, where medical students provide labor and participate in experiential learning. While cost was a common problem among respondents, it's an especially challenging area of reform given the financial incentives of academic institutions. However, medical schools often have endowments, which should be used to offset the increasing cost of medical tuition. New York University's $600 million endowment completely offset the tuition of all medical students, but even a more modest endowment can reduce the cost of the fourth year. For example, a $100 million fund at University of California Los Angeles offsets the total tuition and living cost for 20% of the student body (approximately 120 students). Alter electives  Several free-form responses proposed increasing autonomy to better prepare fourth-year students for intern year. One option is to redesign medical student sub-internships in a manner that offers them more responsibility -- closer to the level of responsibility at the resident intern level. Students could pend orders and write notes co-signed by precepting residents and attending physicians. Another option is to provide rotations toward the end of the fourth year where students are only paired with interns. This way, fourth-year students can be better prepared for the intern role. Several students wanted more specialty-directed education. Students could participate in specialty-specific tracks or schools can increase flexibility of required rotations to fit declared specialties. Finally, a common thread in the responses was a desire for more hands-on learning. Schools should offer simulation courses so medical students can practice procedures or prepare for high-intensity responsibilities like running a code. Modify the structure  While some schools offer 3-year tracks, more schools should consider a 3- or 3.5-year curriculum with an optional fourth year. But reducing the length of training is only one option -- there are several ways to make the fourth year more meaningful. One option is to allow longer fourth-year blocks dedicated to meaningful research projects. Students could also be involved in longer multi-month community engagement or public health opportunities. Additionally, novel elective rotations could allow students to intern/co-op at policy think tanks or research organizations. Counting these experiences toward graduation requirements would produce more well-rounded physicians. Finally, schools could provide opportunities to take course work outside of the medical school or earn another degree integrated into the fourth year such as an MPH, MBA, or MS. While not all of the challenges the class of 2021 faced will continue with adapted social distancing guidelines, there is still value in restructuring the fourth year of medical school. As the role of the physician evolves and the complexity of the healthcare system deepens, we need well-trained physician scientists and physician leaders to advocate for affordable high-quality care and excellent patient safety. A more meaningful fourth year of medical training could produce a generation of physicians who can tackle the structural issues of the healthcare system and help address healthcare inequities. Aaron Bhol, MD, MBA, is an emergency medicine resident physician at Oregon Health & Science University in Portland.