Nope mostly not funny, sorry.
Making the rounds over the last few days are a series of articles questioning the need for the fourth year of medical school. Traditionally, that year is when students emerging from their rotations (when they get to see what practice in many fields of medicine looks like) decide what they want to choose as a specialty and send out residency applications post-haste. The remainder of the year is spent flying around the country interviewing for residency programs, burnishing their applications with related electives and sub-internships, and taking time to relax after a grueling twelve months as the low man on the totem pole in the hospital.
Some medical schools, like NYU and UC-Davis, have begun offering 3-year tracks. These schools slice out the fourth year by shortening the two preclinical years to 18 months, then chopping off the last six months of the traditional fourth year. UC Davis’ program is restricted to those students committed to primary care, while NYU’s program makes all specialties available but requires students to do their residencies at NYU itself.
These are interesting experiments. But the larger question, really, is do we need the fourth year at all? Why do these accelerated programs require a focus on primary care, or make you to stay at home for residency?
Take my school, which I keep nameless here for fear of an overzealous liability lawyer squashing me with a cease-and-desist letter for using the school’s name on a website that talks in-depth about poop, vomit, and why the TSA is just a phenomenally expensive off-Broadway play.
Anyway. My school completes all two-year preclinical coursework in one year. This is the first year we’ve done this kind of curriculum; Duke is really the only other program nationally that does anything similar. So we are the guinea pigs. The administration is fond of saying we aren’t “compressing;” that is, we aren’t trying to jam two full years into one. Instead, we cherry pick the important stuff, teach it all at the same time, and leave the more specialized material for later. We also (nominally) chop out fluff: lectures taught primarily by research PhD’s who, predictably, focus on their research are discouraged in favor of clinically focused, succinct information. So by cutting out lectures where the professor talks for an hour about his mouse models, you can more intentionally dedicate time to what students need to know for boards or to succeed when rotating in the hospital, etc.
That’s the theory, anyway. To be honest, we had mixed success with the new model this pioneer year (my struggles with anatomy, for instance, are well-documented here). If you can get it right, which I suspect my school eventually will, you’ve successfully saved a full year of classroom schooling.
But my school is still a four-year program. Once you finish your rotations in the hospital, you come out on the other side with almost a full two years to complete an “immersion phase,” where we complement more focused clinical rotations in potential career paths and fill in some basic science knowledge gaps in our preferred fields. The idea is that you don’t have to know all the basic science inherent to stomach physiology if you have zero intention of becoming a gastroenterologist. But if you are considering a career in emergency medicine, maybe you do need to take a basic science course on the molecular underpinnings of septic shock.
Anyway. The immersion phase sounds nice, and I’m sure it will be a blast. It’s why I came here. But for students who emerge from the hospital rotations this coming year with a deep commitment to a particular field (this will certainly not be me), why should they have to wait to apply for residencies? Their board scores are in. They’ve completed the necessary classroom work. They finished their rotations. Why do the academic equivalent of “dabbling” for two years – all the while, hemorrhaging time, energy, and most importantly money – when they could shave a year off their tuition and student loan bills?
(actually my dog)
The answer probably lies in a special word. When the medical education community hears this word, they collectively roll over and make pleased moaning noises like my dog when you rub his belly. That word is “competency.”
Competency-based assessment is the buzzword du jour in most professional education circles these days. The idea is that you can measure a potential physician by much more than their test scores: you evaluate their professionalism, their ability to work on teams, their clinical skills, and of course their “medical knowledge” (which is mostly test scores). Underlying the competency-based assessment idea is the concept that we’re producing doctors that are fabulous at taking tests but maybe are not the most patient-centric physicians we can make. If you produce doctors that are better at the harder-to-evaluate competencies like teamwork, professionalism, and empathy, then the implication is that your quality of care should increase. (Whether or not the quality of care would increase with a nominally competent new physician over a nominal “high testing” physician is an open question, of course).
In a perfect world, a medical student would graduate not when a certain four years has elapsed, but when a student reaches competency in all necessary domains. If a particularly advanced student (not me) checks basically all the boxes after second year, why not go ahead and apply to residency programs during the third? “Internship-ready” students could be allowed to jump ship if they are willing.
On the flip side, if I struggle to demonstrate all required competencies, even after four years of medical school, I should be able to take additional years (of course, as is financially workable) and bring myself up to par. This model would prevent graduation of doctors who pass knowledge-based tests but are flagged as unprofessional – a problem strongly correlated with doctors who are punished for wrongdoing later, and may generally be a marker for someone suited for a less people-focused area like research – until they either grow up, receive some kind of remediation, or figure out a different path.
Oh… oh god. I just linked to PubMed from my blog. I’m so sorry. Excuse me while I go pour myself a large neat bourbon and go play fetch with large sticks with man’s best friend while wearing Levi’s and flannel.