Last March, Washington and Lee University's Law School dean told Inside Higher Ed that, "We wouldn't dream of training doctors only from a book," as a justification for his then newly unveiled plan to transform the third year of law school with experiential courses.
Well, medical schools may have taken the hint. In a study and corresponding editorial published Wednesday in the July issue of the Association of American Medical Colleges' Academic Medicine journal, experts are calling for a reform of the traditional senior year medical curriculum. The report -- which was co-authored by six medical school professors, five of whom are from the University of California at San Fransisco -- argues that medical curricula often fail to fully utilize the fourth year of medical school, succumbing instead to what some might call "senioritis." With students interviewing for residency programs throughout the year and senior grades usually not a factor in residency applications, many claim that students lose the self-motivation that makes their first three years successful. Moreover, medical students are often close to being done with their core requirements, leaving room for electives that are not related directly to their fields, and thus do not require as much attention.
During residency programs after medical school, "we will get paid almost no money for three to seven years," said Pamela Lyss-Lerman, a resident physician at San Fransisco and the principal author of the study. "In an economy like ours, if the fourth year isn't the best it can be, is it necessary to have students spend $50,000?"
While Lyss-Lerman does not advocate getting rid of the fourth year, she said that it needs to be revised to be more useful. The study suggests a curriculum wherein students "have more authentic roles in patient care," which, she said, will help them to develop their own identities as physicians and collaboratively practice the humanistic elements of medicine. Specific recommendations for fourth year curriculum additions include sub-internships in internal medicine, and rotations for critical care, ambulatory care, and emergency medicine. The idea is to make sure students are achieving competencies -- a movement in medicine to assess students based on critical skills rather than memorized facts -- even as they enter the home stretch of their education. The study suggestions were based on interviews with 30 residency program directors around the country.
Lyss-Lerman brings to light an issue that has long been a source of heated discussion for medical educators. In an editorial published along with the study, Academic Medicine's editor, Steven Kanter, writes that "some of us who engage in these academic dust-ups argue passionately for a predominantly elective senior year with maximal student input and minimal curricular requirements. Others enjoy preaching that students do not know enough to elect what to study, so faculty should simply prescribe it. A few contend that a largely elective year is an unnecessary expense for both students and schools."
This call for a discussion on how best to revise the senior year is a welcome change for many medical educators. Larry Gruppen, a professor of medical education at the University of Michigan saw the report as a worthwhile call to action.
"The problem of the fourth year is a pervasive one," Gruppen said. "When students are interviewing for a residency, it's important, but schools see it as taking away from students' educations. It has to be done, but it gets in the way of medical school. ... It all contributes to a widely-felt frustration."
He added that Michigan has recognized and worked on these issues for a long time, with one tangible result being the movement of more core requirements to the senior year. This has served to combat the "laissez faire pick-your-own elective," approach that can lead to student apathy, Gruppen noted.
Debra Litzelman, associate dean for medical education and curricular affairs at Indiana University, also found the report to be a step in the right direction for combating fourth year issues. Indiana, which does assessments based on core competencies, allows students to take electives but mandates that those courses focus on three upper-level competencies.
"I do think that maybe, based on the article, we are an exception in that we have thought a lot about the competencies, including the fourth year," Litzelman said. "It is something that our school has felt very strongly about."
However, some feel that putting too much emphasis on structure in the fourth year curriculum may limit students' creativity. John Mahoney, associate dean for medical education at the University of Pittsburgh Medical School, who works closely with Kanter, argues that "the majority of students make fabulous use" of their senior year by doing research and developing individual curricula. Furthermore, these students are adults and have the ability to make their own decisions, Mahoney said.
"I think increasing the number of requirements in any one school would rein in the ability to individualize the curriculum," Mahoney said. He added, "Making sure the student has a well-crafted senior year is important. That's different than what competencies all students should have when they arrive at residencies. One size fits all is easy to prescribe. It's more difficult to assure quality in dozens of different packages, but we're preparing these students for different things."
Lyss-Lerman responded that the idea is not to limit the scope of what students can do, it is simply to give students more of a sense of direction.
"If you think about what we do to [students] in their first three years of medical school and then their three years plus of residency when there's no creativity, if there's one year of providing more requirements, or even more structure, it is not going to inhibit them," she said. "We don't want to [impose] all requirements, just a better mesh."
Looking at the current role of the fourth year of medical school has highlighted another question: Why four years? In response to a similar conviction that the third year of law school is often not as useful as the first two, a few law schools have started programs for students to earn degrees in two years. At the moment, medical educators at Michigan are in the experimentation phases of designing a curriculum whose time frame is based on competency completion, rather than passing four years, Gruppen noted. This would mean that some students could finish their degrees in three years, while others may take five.
"Right now we are in the middle of a six-week target to look at what medical school would look like without a time frame at all," Gruppen said. "We identify competencies of what students are supposed to attain before they graduate. We give them feedback and measurement on how well they are doing and leave it up to them to decide how they want to attain competencies. So if you come in as a paramedic, you should be able to test out some things. Why put everyone through the same lockstep program?"
Litzelman and Lyss-Lerman agreed that this could be an instrumental way to reduce the debt burden for some students while giving others additional support. Litzelman, however, was wary of endorsing a curriculum that could truncate the current competencies as they are taught.
While competency-based time frames are a long way off, many see the focus on a more meaningful fourth year as the next step in improving medical education. As Lyss-Lerman noted, "part of [the fourth year apathy] is inevitable, and part of it is how the school defines the fourth year curriculum, but I do think we can get over this hurdle."