The Fourth-year Medical Curriculum

From 1975 to 1979, an experienced medical educator who had retired as chair of a Department of Medicine audited the curriculum at his medical school and summarized his findings in an article in the New England Journal of Medicine. Among other recommendations aimed at improving the curriculum, the author concluded that the “fully elective fourth year” needed “total reorganization” because it was a “year of drift, lax evaluations, and passive absorption.” 1 The presence of a fourth year that was totally or mostly elective had become a common feature in U.S. medical schools by the end of the 1970s. 2 It was noted that students were “allowed great latitude in their choices with few constraints” and that the offerings among departments were not coordinated so as to provide a “meaningful range of elective courses.” 2 This situation was in marked contrast to the middle part of the twentieth century, where only a small number of schools offered sufficient elective time to allow the student to pursue areas of interest. 3 The perceived lack of structure of the fourth-year curriculum has continued to raise concerns. Mention has been made of a “pre-residency syndrome,” where fourth-year students take multiple “audition electives” in their chosen areas of specialty at locations where they plan to apply for training. 4,5 Such an approach to the fourth year could result from limited advice about what types of educational experiences are appropriate preparation to enter residency. In order to help students use their fourth year to advantage, there have been recommendations about what would constitute a useful elective program for students planning to enter residency training in obstetrics—gynecology, plastic surgery, ophthalmology, and surgery. 6–10 For example, a recommended fourth-year curriculum for students planning to enter obstetrics—gynecology included a medicine subinternship, critical care, and emergency medicine. 6 The perception of the fourth year as being unstructured and used for purposes not related to students' educational needs is, if accurate, potentially a matter of concern. There are data from the early 1980s showing that, in about two thirds of schools, 60% or more of the time in the fourth year was devoted to electives. 2 Information about whether the fourth year has changed since then, however, is not available. This study examined the fourth-year curricula in the academic years 1979–80 and 1999–00 to determine whether there had been changes in the relative amounts of time devoted to elective and required experiences and in the types of experiences required. The academic year 1979–80 was chosen as the baseline for this study because it fell at the end of a period where there was marked curricular change, including enhanced attention to making the educational program more flexible for students. 2 Method Data on the total numbers of scheduled weeks in the fourth year devoted to required courses or clerkships and to electives in U.S. medical schools during 1979–80 were obtained from schools' entries in the 1979–80 AAMC Curriculum Directory. 11 Similar data for schools during 1999–2000 came from the 2000 AAMC Curriculum Directory. 12 The Curriculum Directories are based on self-reported data provided by medical schools to the Association of American Medical Colleges (AAMC). Additional data were obtained from the 1999–2000 Liaison Committee on Medical Education (LCME) Annual Medical School Questionnaire—Part II. The LCME questionnaire was sent to the deans of all 125 LCME-accredited medical schools in February 2000 and had a 100% response rate. It asked for the number of total scheduled weeks and for the number of elective weeks in the fourth year. The LCME questionnaire data were used to supplement missing data, for example, weeks of elective time, in the 2000 AAMC Curriculum Directory. There was no such gap in the 1979–80 AAMC Curriculum Directory, and so supplemental data were not needed. The 1979–80 and 2000 AAMC Curriculum Directories also were used to identify what specific courses or clerkships were required in the fourth year. For each school in 1979–80 and 1999–2000, the total scheduled weeks in year four (required plus elective) and the total elective weeks in year four were recorded, if available. Vacation or other unscheduled time was not included. Schools where there was no separate fourth year (that is, where only the total number of weeks in the third and fourth years was given or where courses and clerkships were not specifically assigned to either year) were excluded from calculations of the length of fourth-year experiences. Required time was defined as weeks devoted to specific, named courses or clerkships. For the purposes of this study, selectives were categorized as required time because the schools set the specific parameters for what experiences were acceptable. Time was considered to be elective only if it was labeled as such by the school and had no specific content requirements associated with it. For example, the requirement of an “elective” in basic science was classified as selective time. If a range of available elective times was specified by a school, the minimum number of required weeks was recorded. There was no consistency among schools in when their fourth years began or ended. In general, the third year at most schools began between July and September, and the fourth year began about 12 months later. Based on the start date and the date of graduation, the potential total length of the fourth year could range from nine to 11 months. As noted previously, vacation time was not included in calculations of the length of the fourth years. Data were analyzed using a standard software package. The differences between 1979–80 and 1999–2000 in the numbers of total scheduled weeks, in required (structured) weeks, and in elective weeks in the fourth year in individual schools were tested with three paired t-tests. Results Distribution of time in the fourth year. Table 1 illustrates the amounts of total, elective, and required time for the 81 schools that had a separate fourth year in both 1979–80 and 1999–2000. The results of paired t-tests show significant changes in the number of total scheduled weeks in the fourth year (from an average of 36.0 to 34.2), in weeks of elective time (from 25.4 to 19.1), and in weeks of required time (from 10.6 to 15.1) at the schools. Comparing 1999–2000 with 1979–80, the average number of total scheduled weeks in the fourth year had decreased by 5%, the average number of elective weeks had decreased by 33%, and the average number of required weeks had increased by 30%.TABLE 1: Average Total Amounts of Time in the Fourth-year Medical Curriculum in 1979–1980 and 1999–2000 and Time Devoted to Required and Elective Experiences*These results were mirrored by all schools for which data were available. In the 94 schools that had a separate fourth year in 1979–80, there were averages of 36.0 total scheduled weeks (SD = 6.7), 25.6 elective weeks (SD = 9.7), and 10.4 required weeks (SD = 10.0). In the 101 MD-granting medical schools in 1999–2000 with a separate fourth year, there were averages of 34.0 total scheduled weeks (SD = 4.6), 19.4 weeks of electives (SD = 6.6), and 14.7 weeks of required experiences (SD = 6.5). In 1979–80, 72% of total time in the fourth year was devoted to electives; in 1999–2000, 57% of total time was elective. The fourth year was completely elective in 36 of the 94 schools with a separate fourth year in 1979–80. In 1999–2000, two of the 101 schools had an all-elective fourth year. Required experiences in the fourth year. The increase in the amount of required time in the fourth year is reflected in an increased breadth of required experiences. Table 2 compares the specific courses and clerkships that were required by five or more schools in the 94 schools with a separate fourth year in 1979–80 and in the 101 schools with a separate fourth year in 1999–2000. The cutoff of five was chosen to eliminate idiosyncratic offerings. To be included in the list, five or more schools in either year had to have required the subject. In a comparison of 1999–2000 with 1979–80, the number of schools requiring an advanced clerkship in surgery or a surgery subinternship, which could include surgical subspecialties, had increased 85%, and the number requiring advanced medicine had increased 44%. The number of schools requiring a clerkship in neurology had increased 181%, from 16 to 45. There was a large increase (from seven schools to 50 schools) in schools requiring a choice of subinternship from among several disciplines: medicine, pediatrics, family practice, and, in some cases, surgery. This requirement was often in addition to one or more other required subinternships in medicine or surgery. Courses that were required by fewer than five schools in 1979–80, such as critical care, radiology, and a rural preceptorship, were more common in 1999–2000. Only two clerkships that were required by five or more schools during the fourth year in 1979–80 were required by fewer schools in 1999–2000. These were family medicine and pediatrics. Family medicine clerkships had moved to the third year, among the other required basic clerkships. Fourth-year pediatrics experiences in 1999–2000 tended to be offered as one of several options for subinternships, not as an independent requirement.TABLE 2: Courses or Clerkships in the Fourth Year That Were Required by Five or More Medical Schools in Either 1979–1980 or 1999–2000*Conclusions and Implications Compared with 20 years ago, the amount of elective time in the fourth year has decreased and the amount of required time has increased. Students now are more commonly expected to participate in advanced clinical experiences, such as subinternships in medicine or surgery, as well as other clinical clerkships, such as neurology and critical care. Total scheduled time in the fourth year decreased from an average of about nine months to about eight and a half months. The reason for this decrease is unknown. What reasons exist for the increased requirements in the fourth year? One possibility is the redistribution of required clerkship time across the clinical years. For example, in both 1979–80 and 1999–2000, the average total amount of required clerkship time in internal medicine in the third and fourth years was 12 weeks. 13,14 However, in 1979–80, 63% of third-year internal medicine clerkships were 12 weeks in length or longer, while in 1999–2000, only 48% of third-year clerkships were 12 weeks long or longer. 11,12 In many schools, the additional required clerkship time in internal medicine (typically four weeks) occurs in the fourth year. The spreading out of core clerkship time into both the third and the fourth years, which also has occurred in many schools in surgery, has been done in part to accommodate the presence of a required family practice clerkship. In 1979–80, only 49 schools required family practice, 13 and this clerkship often was placed in the fourth year. In 1999–2000, a required family practice clerkship was found in 107 schools, 14 most often in the third year. 12 The dividing of core clerkships into third- and fourth-year components does not totally explain the increased time devoted to required subjects in the fourth year in many schools. New subject areas also have appeared, for example, neurology and critical care, which were not previously present as separate entities either in the third or the fourth year. Does the increased time devoted to required courses and clerkships in the fourth year address the concerns about laxity and aimlessness that have been raised? The increased structure does have the potential to provide students with a broader clinical base prior to entry into residency training. However, there still is an average of about five months of elective time. This time could be of great benefit to students, if used wisely. Electives can enhance and expand a student's education. To make maximum use of this opportunity, a range of elective opportunities should be available, and students should have access to good advice to help them select unique programs to complement their career goals. Advice is needed especially on the relationship between choice of electives and residency program selection. There are no comprehensive current data on the prevalence of students' use of “audition” electives. The limited available information indicates that audition electives have variable utility in helping students gain entry into a residency program, depending on the specialty and the individual program. 4,7,15,16 In summary, the increased structure in the fourth year over the past 20 years can be considered to be an improvement. While some flexibility has been lost, considerable opportunity still exists for students to pursue areas of interest. More consideration is needed, however, as to what the goals of the fourth year should be and how the curriculum should be organized to ensure that the goals are met.