“I haven’t seen a patient since my sub-I in October!”
– IUSM Student. Graduation Day, 2015.
As an MS1, I needed to learn anatomy and the basic science underlying medicine.
As an MS2, I needed to lean clinical medicine and pharmacology.
As an MS3, I needed to learn the management styles of different medical sub-specialties
As an MS4, I need to…get into a residency (?)
… The purpose of the MS4 year is not self-evident. Yes, I want to get good new on Match Day. Getting good news is not the goal itself; it is only the means to one. Further, there is little that I can do as an MS4 to influence the outcome of Match Day. My choice of Internal Medicine was set halfway through MS3 and by the start of MS4 my application was effectively complete. Since IUSM will not give grades and faculty comments from the final year to residency programs, I am unable to demonstrate improvement in my abilities. It can be difficult to not see myself as simply waiting to see where I’ll be invited for an interview.
By no means do I suggest that I know all I need prior to starting PGY1. Nor do I plan to be like my former classmate who proudly proclaimed on the Graduation Day to have not seen a patient for eight months. Although it is possible to avoid patient responsibilities in the final year, I plan to remain on the wards and continue absorbing nuances of healthcare. But the restrictions imposed on MS4s limit my learning. I cannot start or stop treatment plans. My notes are – mostly — unread and unsigned. How different it would feel to be the primary provider, charged with writing admission orders, coordinating treatment teams, and weighed with the responsibility of the MD degree!
What is the alternative? One option is to re-introduce a 3 year MD curriculum. 33 US medical schools had such a curriculum in the 1970s, but they fell out of favor. McMaster University in Hamilton, Ontario – perhaps the most innovative of all medical schools, having championed the OSCE Multiple Mini Interview[i] and the use of Evidence Based Medicine[ii] – continued to offer a 3year program. Recently, several US schools re-introduced 3 year programs. They argue that providing such an option will reduce tuition costs and allow students to enter underserved specialties and geographies[iii].
Another option is to provide MS4s with additional responsibilities. At IUSM, the ability to cancel orders in Cerner would be crucial. Writing admission orders would provide practical skills useful in residency. Further, having staff co-sign MS4 notes, rather than having inters or residents re-write those notes, would legitimize the role of MS4s on our teams and require us to more fully comprehend the management plans for our patients. Finally, having MS4s attend a continuity clinic would give us invaluable practice in outpatient management and teach us the complexities of preventative care.
Yet, while I will advocate for changes to the MS curriculum, I remain faced with my own MS4 year. How can I best take advantage of my final months prior to Internship? The answer, I think, lies in discovery. Rather than concern myself with others’ perceptions, I can focus on figuring out what type of medical practitioner I want to be. Are my interactions most comfortable when I am more formal or more casual in my demeanor? Which teaching style is most effective in educating my patients about their diabetes or their hypertension? How can I best establish a working relationship with RNs and pharmacists? I can also take advantage of the (relative) time freedom to revise my research interests and participate in clinical studies. I can seek out mentors in medical administration and learn about safety, informatics, or policy. And I can begin to set down my continuing education habits and figure out whether I’ll learn best from Board review books, Primary literature, or curated databases such as UpToDate.
It is important to challenge the status quo and question whether our current training practices are optimized to prepare students for PGY1. I, for one, think that our national medical training curriculum grossly mismanages the educational opportunity that is MS4. But I am comforted in knowing that I have significant freedom to set my own schedule this year. I, therefore, plan to take advantage of MS4 to hone my patient management styles and my research interests in preparation for the start of PGY1.
[i] PMID: 14996341
[ii] PMID: 7623571
[iii] PMID: 29117817