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      Students’ Perspectives on the Fourth Year of Medical School: A Mixed-Methods Analysis

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          Abstract

          Supplemental Digital Content is available in the text.

          Abstract

          Purpose

          Little is known about the purpose and value of the fourth year of medical school from the perspective of medical students. In this study, the authors systematically explored the year’s purpose and value as determined by students.

          Method

          In April 2011, the authors conducted semistructured focus groups with graduating fourth-year students at the University of Colorado School of Medicine to understand their perspectives on the purpose of the fourth year. Using results of a thematic analysis of the focus group data, the authors developed and administered a 10-item questionnaire to all graduating fourth-year medical students in May 2011. Questionnaire data were analyzed using descriptive statistics and exploratory factor analysis.

          Results

          A total of 17 students participated in two focus groups. Six themes related to the purpose of the fourth year emerged from the focus group data: career development and preparation, pursuing personal interests, career identification, exploration of diverse practice settings, influence of emotion, and flexibility and individualization. The questionnaire was completed by 134 of 148 students (91% response rate). Factor analysis of the questionnaire data identified five factors: strengthening one’s residency application, developing skills, pursuing personal interests, exploring diverse practice settings, and identifying a career.

          Conclusions

          Medical students uniformly identified the fourth year of medical school as having purpose and value, but their views on the fourth year’s purpose differed. This finding underscores the importance of the individualization of the fourth year. Students’ perspectives should inform any decisions made about modifying fourth-year curricula and structure.

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          Most cited references11

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          The role of emotion in the learning and transfer of clinical skills and knowledge.

          Medical school and residency are emotional experiences for trainees. Most research examining emotion in medicine has focused on negative moods associated with physician burnout and poor quality of life. However, positive emotional states also may have important influences on student learning and performance. The authors present a review of the literature on the influence of emotion on cognition, specifically how individuals learn complex skills and knowledge and how they transfer that information to new scenarios.
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            What training is needed in the fourth year of medical school? Views of residency program directors.

            To identify common struggles of interns, determine residency program directors' (PDs') views of the competencies to be gained in the fourth year of medical school, and apply this information to formulate goals of curricular reform and student advising. In 2007, semistructured interviews were conducted with 30 PDs in the 10 most common specialty choices of students at the University of California, San Francisco, School of Medicine to assess the PDs' priorities for knowledge, skills, and attitudes to be acquired in the fourth year. Interviews were coded to identify major themes. Common struggles of interns were lack of self-reflection and improvement, poor organizational skills, underdeveloped professionalism, and lack of medical knowledge. The Accreditation Council for Graduate Medical Education competencies of patient care, practice-based learning and improvement, interpersonal and communication skills, and professionalism were deemed fundamental to fourth-year students' development. Rotations recommended across specialties were a subinternship in a student's future field and in internal medicine (IM), rotations in an IM subspecialty, critical care, and emergency and ambulatory medicine. PDs encouraged minimizing additional time spent in the student's future field. Suggested coursework included an intensively coached transitional subinternship and courses to improve students' medical knowledge. PDs deemed the fourth year to have a critical role in the curriculum. There was consensus about expected fourth-year competencies and the common clinical experiences that best prepare students for residency training. These findings support using the fourth year to transition students to graduate medical training and highlight areas for curricular innovation.
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              Primary care specialty choices of United States medical graduates, 1997-2006.

              To describe trends in specialty choice and to identify predictors of primary care specialty choices among graduates of U.S. MD-granting medical schools. A longitudinal study evaluated 1997-2006 medical school graduates who completed the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire. Multivariate logistic regression identified significant predictors of graduates' choice of primary care specialty (general internal medicine, general pediatrics, internal medicine subspecialties, pediatrics subspecialties, family medicine, and obstetrics-gynecology) or "no-board-certification specialty," compared with all other specialties (reference). The sample included 102,673 graduates (64.9% of all 1997-2006 graduates). General internal medicine, family medicine, general pediatrics, and obstetrics-gynecology choice decreased, whereas internal medicine subspecialties, pediatrics subspecialties, and no-board-certification specialty choice increased over time (each: P < .001). Female graduates and those who planned to practice in underserved communities, espoused more-altruistic beliefs about health care, and ascribed greater importance to social responsibility in their choice of medicine at matriculation were more likely to choose general internal medicine, general pediatrics, family medicine, or obstetrics-gynecology, whereas graduates who had a physician parent and who planned full-time academic medicine careers were less likely to do so (each: P < .01). Graduates with higher debt were less likely to choose internal medicine and pediatrics specialties (each: P < .001) and more likely to choose obstetrics-gynecology (P = .001). Generalist-primary care specialty choices declined since 1997, whereas primary care subspecialty and no-board-certification specialty choices increased. Associations between primary care specialty choices and demographic, attitudinal, and career intention variables can inform the design of interventions to address expected primary care workforce shortages.
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                Author and article information

                Journal
                Acad Med
                Acad Med
                ACM
                Academic Medicine
                Published for the Association of American Medical Colleges by Lippincott Williams & Wilkins
                1040-2446
                1938-808X
                April 2014
                25 February 2014
                : 89
                : 4
                : 602-607
                Affiliations
                [1] Dr. Wolf is associate professor and director of medical education, Department of Emergency Medicine, and associate dean for curriculum, University of Colorado School of Medicine, Aurora, Colorado. He is also staff physician, Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado.
                [2] Dr. Lockspeiser is assistant professor, Department of Pediatrics, University of Colorado School of Medicine, and staff physician, Department of Pediatrics, Children’s Hospital Colorado, Aurora, Colorado.
                [3] Dr. Gong is assistant professor, Department of Family Medicine, and assistant director, Office of Evaluation, University of Colorado School of Medicine, Aurora, Colorado.
                [4] Dr. Guiton is associate professor, Department of Internal Medicine, and director, Office of Evaluation, University of Colorado School of Medicine, Aurora, Colorado.
                Author notes
                Correspondence should be addressed to Dr. Wolf, Department of Emergency Medicine, Denver Health Medical Center, 777 Bannock St., Mail Code 0108, Denver, CO 80204; telephone: (303) 602-5175; e-mail: Stephen.Wolf@ 123456dhha.org .
                Article
                00026
                10.1097/ACM.0000000000000183
                4885563
                24556778
                973dbbb3-5a57-43ab-9bca-0872748bb0e2
                Copyright © 2014 by the Association of American Medical Colleges
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