The goal of medical education is to transform the student from practitioner to healer. Medical education reform has produced significant movement from a process-driven approach, with a focus on defining requirements by time, to an outcomes-driven model, with a focus on defining relevant competencies and selecting the experiences that help learners achieve them. As part of this reform, a topic of rich discussion has been the time allocated to medical school, particularly the fourth year. There is growing recognition by students and faculty of the limited value of a senior year focused on the National Resident Matching Program (“the Match”) as the predominant driver of content, with its random collection of “audition rotations.” That said, we acknowledge that each year, the Match grows more stressful as medical schools expand.
A number of studies have contributed to the growing consensus around the value of the fourth year in the professional development of medical students.1 As David Sklar eloquently expressed, “The current limitations are of our making, and we owe it to our students to create a better final year of medical school.”2 The design of that “better final year” must accommodate the residency selection process by providing students the emotional and logistical support they need. Equally important, the fourth year must prepare students for the rigors of internship, and provide opportunities for growth through community service and scholarly activity. These latter activities are critical for learners' professional development, and may ameliorate burnout and set the stage for a fulfilling career in medicine.3
As we move closer to standardizing outcomes through describing educational milestones for each of the competencies, we move closer to developing specific expectations for incoming residents. The international movement to define and assess a set of core entrustable professional activities (EPAs) has reinforced the importance of situated workplace learning and assessment, with learners and teachers engaging together over time in caring for patients.4 This contrasts sharply with the practice of multiple 1- or 2-week clerkships, in multiple specialties, in which students function as observers, or with block clerkship experiences with a different attending physician every week or every 2 weeks. As Goldfarb and Morrison noted, “More intensive experiences in both inpatient and outpatient settings are needed . . . The limited opportunity for students to participate meaningfully in patient care during their undergraduate careers is the problem that needs correction.”5
In order for each medical student to achieve competency, demonstrate it, and earn entrustment, medical educators must develop a more individualized approach. A decade of studies has demonstrated that physicians are poor at self-assessment. As Eva et al6 found, ironically, the lowest achievers have both the highest confidence and are most resistant to external feedback. Medical students need the support of more effective advising and mentoring that focuses on developing their skills as self-directed learners. The Individualized Learning Plan—as a method of supporting growth—demonstrates promise, with trained faculty mentors guiding students to combine self-evaluation with feedback from faculty and residents in setting their SMART (specific, measurable, achievable, realistic, time-limited) goals. Shepard and colleagues7 describe the importance of faculty helping students set goals that are sufficiently challenging as they develop their individualized learning plans. Ideally, medical students will already have, or will develop, a mindset that supports growth from challenge, and medical schools will provide an environment of appropriate challenges.8 As a means to create the most efficient and long-lasting learning, the curriculum design at the new University of Las Vegas School of Medicine includes the “challenge-point framework,” with faculty mentors working with students to discern the point at which individuals are optimally challenged.9
What are the intensive clinical experiences where students can be challenged and achieve real growth? Lyss-Lerman et al10 surveyed residency program directors on the most important rotations for preparing for internship. There was near universal agreement (93%) on the value of a subinternship in their chosen career field, closely followed (63%) by subinternships in medicine and medicine subspecialty rotations. A substantial minority (43%) recommended critical care rotations.10
In this issue, Richards et al11 provide further support for the value of optimally challenging student learners. Their study assessed the relationship between fourth-year medical school course load and success during internship. They compared the number of intensive clinical experience courses learners took in medical school, which they defined as subinternships, as well as intensive care, surgical, and emergency medicine rotations, with multi-source performance evaluations of 2 classes of internal medicine interns. They found a dose-dependent relationship between the number of higher-order clinical experiences in a student's senior year and the likelihood of that student achieving excellent performance evaluations as an intern: “The positive influence of intensive coursework was seen in all of the ACGME competencies except professionalism as well as in our measurement of global assessment independent of any of the ACGME milestones.”11
These findings have important implications for medical educators in the design of the fourth year. They support strengthening the clinical intensity of the final year through multiple rotations where students would have meaningful participation in patient care. Requiring multiple subinternships, intensive care, and other hands-on patient care rotations where students have real responsibility under supervision, may produce more “ward-ready graduates”11 and allay student fears about competence. Individualized learning plans could form the basis for each student to structure the senior year curriculum to meet his or her areas in need of improvement or enrichment. This would empower students to choose experiences that will allow them to achieve the multiple goals of identifying careers, achieving confidence in their competence, exploring diverse practice settings, and pursuing personal interests.1
