A panel of surgical educators discussed strategies for modifying the fourth year of medical school with the goal of enhancing its value in a Wednesday morning session titled The Fourth Year of Medical School: Redesign or Replace?

“Are our rising physicians competent, and are they financially solvent?” asked co-moderator Nancy L. Gantt, MD, FACS, professor of surgery, Northeast Ohio Medical University, and co-medical director, Joanie Abdu Comprehensive Breast Care Center, Youngstown, OH.

According to the Association of American Medical Colleges (AAMC), 75 percent of the class of 2017 graduated with educational debt, and nearly half (46 percent) were planning to enter a loan forgiveness or payment program. Dr. Gantt noted that the 2018 median cost of attendance for public medical school was $243,902 and $322,767 for private school. “Are we dissuading college students from even applying to medical school?” she asked, noting the potential shortage of an estimated 33,000 general surgeons and surgical specialists by 2025. “What can we do to make our medical schools reassess the fourth year to increase its value?”

Providing the medical student perspective, Sarah J. Armenia, MS, department of surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Rutgers University, Newark, NJ, conducted a small study specifically for this presentation to address how medical students perceive their fourth year. Most of the respondents—current fourth year medical students who had completed a surgery rotation—agreed that completing a surgery curriculum during the final months of medical school beyond an actual internship would be beneficial before residency (79 percent).

“As surgeons, we are very familiar with value-based care, we see it everywhere, and it’s no different with education. Value-based education is a deceptively simple concept. You want high quality with relatively low cost,” said Shimae C. Fitzgibbons, MD, Med, FACS, MedStar Georgetown University Hospital, Washington, DC, who provided the surgeon-educator’s perspective.

“I find it helpful to look back to where we got our existing [medical education] system when I think about what we should do with the fourth year,” said Dr. Fitzgibbons, referring to the Flexner Report, published in 1910, which encouraged American medical schools to enact higher admission and graduation standards, including a four-year medical education format. Flexner gave us a “massive report card focused on graduating physician-scientists,” she said, noting that Flexner’s review did not include key traits, such as professionalism, communication skills, and ethics. “Are we delivering value, or do the four years need to be redistributed?” she asked.

Dr. Fitzgibbons underscored the value of the Accreditation Council for Graduate Medical Education Milestones in Patient Care and the AAMC core entrustable professional activities for preparing medical students for the next stage in their education.

“All of us in the room and on the panel are patients, and we all want the brightest physicians so that they make wise decisions,” said David E. Lindsey, MD, FACS, department of surgery, division of critical care, trauma, and burn, The Ohio State University Medical Center (OSUMC), Columbus. In a presentation titled Integration of the M4 Year into a Longitudinal Curriculum, Dr. Lindsey described the LSI (lead, serve, inspire) curriculum at OSUMC, now in its seventh year, which allows students to gain hands-on experience early in the program through longitudinal, practice-based clinical service that offers opportunities to apply classroom knowledge to actual patient situations. Unlike other medical school programs where students spend two years in the classroom and two years in a clinical environment, the three-part, four-year curriculum at OSUMC enables students to get early clinical experience taking care of patients in the program in the first 10 weeks. Dr. Lindsey said the program design allows educators to “bring structure to the fourth year” and emphasized the importance of tracking students’ milestone performance and assessing achievement of core competencies.

The final presentation—Three’s Company, Four’s a Crowd: Condensing the Curriculum into Three Years—was delivered by Travis P. Webb, MD, MHPE, FACS, professor of surgery, associate dean of curriculum, Medical College of Wisconsin, Milwaukee. According to Dr. Webb, since 2007, nine U.S. medical schools have offered a three-year program. “The benefits include a decrease in debt (current average is $200,000); a focus on primary care of specific specialty; and student satisfaction,” said Dr. Webb. “You can train a medical student to go into surgery after three years and perform well,” he said, noting the important role competency-based education plays in accelerated learning programs.

“My big concerns—this is very time-intensive and there is potential for burnout. [Accelerated education] also requires careful selection of matriculates who have the right skills to excel in this fast-paced curriculum,” said Dr. Webb, who also emphasized the importance of educating the general public on the validity of three-year programs and achieving buy-in from administrators and other educators.

This Panel Session was sponsored by the Young Fellows Association and the Committee on Medical Student Education.