More Experiential Fourth-Year Med School Coursework May Breed Better Internal Medicine Interns

A new JGME study links intensive training during the final year of medical school with enhanced performance during the first year of residency.

This Q&A is excerpted from an article published on the Credentialing Resource Center, July 24, 2017.

The transition from medical school to residency is an aspect of physician training that has historically been overlooked in terms of research and modernization, according to Christopher J. Richards, MD, fellow in clinical instruction at Harvard Medical School in Boston. In fact, some have questioned the value of the fourth year of medical school and suggested outright eliminating it.

To assess how medical students’ fourth-year course loads affected their performance during their first year of residency, Richards and his colleagues examined the medical school transcripts of 78 first-year internal medicine residents at Beth Israel Deaconess Medical Center in Boston. The researchers compared the number of intensive courses the residents took during the fourth year—courses with greater-than-average demands of clinical responsibility and knowledge—with their first year of residency performance evaluations. 

The results of the study were published in the Journal of Graduate Medical Education, and Richards recently spoke to Residency Program Alert about the relationship between fourth-year course load and success during residency.

Q: First, can you explain why there has been less focus on the fourth year of medical school?

Richards: When the first four-year programs were developed, there was this period of time where medical students had a lot more clinical economy; this was historically before they transitioned into doctors and still had a lot of ward-based medicine delivery that they certainly do not get today. Now the situation is that medical students will differentiate into different types of physicians in the third to fourth year of medical school. So during the fourth year they’re applying for residency, be it internal medicine, surgery, pathology, radiology, etc. There is this idea of “make your own year” elective time based on the demands of what specialty they are going into. So the fourth year for some people is used to take elective coursework to differentiate themselves.

The other thing to know about the fourth year is that schools have increasingly put the scholarly component requirements on the MD, so students have to write a paper and do some sort of scholarly work. The fourth year can often be used for research as well.

There’s sort of this overarching feeling that not everyone needs to have the exact same experience, and some students are spending a lot more time doing research into residency programs. But the mainstay still has been, at almost every single school, to have at least one subinternship in internal medicine and a couple of required courses—but that only speaks to half of what the fourth year is. At Harvard Med, the fourth-year requirements are only a single subinternship in medicine and then three elective courses. That’s only potentially four months of clinical time over a 12+ month period.

Even with that kind of openness, there’s not a lot of requirement of how you fill the time or even fill it at all.

Q: Is that why there are those who argue for eliminating the fourth year of medical school?

Richards: Yes, and what we saw in the group of residents we looked at was that people took [as few as] one four-week course over a year and as high as 12 or more depending on the course load. But there were people who took a single course over a year.

Q: Can you explain how your study measured the relationship between the fourth year and internship success?

Richards: It’s a tricky thing to measure one’s clinical skillset. It’s not limited to testable knowledge on exams. It involves patient interaction skills, communication skills, and research skills. The ACGME has its six core competencies, so we have these evaluations for each resident and intern [that we] get at the end of a clinical rotation. These are sent to attendings and upper-level residents they worked with. Some surveys are even sent to nurses and other groups in the hospital to give a sense of those six domains on a 1–5 or 1–10 Likert scale of competency. Performance on these surveys was our basic unit of measure, which we thought would give us a sense of individual strengths across different domains as opposed to a single question: “Do you like the student or not?”

We took that outcomes data and linked it to a review of transcripts to get a sense what was the density of coursework each student took and what was the content of that coursework. We had a fair consensus of what made an intensive versus a nonintensive course—“intensive” in terms of patient interactions and clinical autonomy, rather than the difficulty of the subject matter. So we decided things like pathology were not clinically intensive because there’s no direct patient interaction; however, the subject matter of a pathology course could certainly be intense. Our interest was in internal medicine residents, so this doesn’t necessarily apply to a pathology resident. This is internal medicine residents who meet patients 11 months out of the year.

And we did the associations accounting for other measurements of success to hold other proxy measures of one’s capability constant, such as [United States Medical Licensing Examination] Step 1 scores, whether they graduated with honors or not, and the reputations of their schools—measures of how rigorous an individual might be in day-to-day academic pursuits. So correcting for that in multi-variable assessments, we came up with these associations and competencies around them for these domains and for a whole global assessment score we had.

Q: And what did you find?

Richards: The major findings were that the more intensive courses you took in a dose-dependent fashion, the better your scores improved. It was a small improvement, but what is interesting about it is that it was dose-dependent. It’s not as if you hit a threshold of intense coursework and all of a sudden this phenomenon disappears. It really is every single time you take an additional course, your scores seem to go up.

The other part of it that confirms that finding is that the inverse, but not the opposite, was true. The more time you spent taking less intensive coursework, there wasn’t an improvement, and there actually might have even been a negative change in performance.

So there was value to that intensive course, which is in excess of simply taking more courses, and that value is highlighted beyond comparing one intensive course to another; it’s there and is more pronounced compared to a nonintensive course. That was across all the competency domains except for professionalism. And the biggest correlation was with the global assessment when you ask at the end of the survey, “How do you rate this intern on a scale of 1–10?” That was actually where the correlation was the strongest.