The fourth year of medical education: a literature review

To identify expert recommendations and examples of programs that could be incorporated into curricular renewal of the fourth year of medical school.

In 2009, the authors searched the relevant literature published from 1974 to 2009 using PubMed; they then searched bibliographies and related articles. They consulted clerkship and residency program directors at their institution and accessed recommendations from national organizations.

Of the 66 publications reviewed, 40 focused on aspects of fourth-year education and 26 included the fourth year in general reviews. Long-standing concerns included clarifying the purpose of the year, the optimal type and organization of courses, and academic quality of courses. Specific concerns included excessive focus on securing residency positions ("preresidency syndrome"), uncertainty about the optimal ratio of required and elective courses, and grade inflation.

Despite representing a substantial proportion of the student experience, the fourth year has received significantly less attention than other phases of the curriculum. The authors conclude that goals for the year should be clarified, reflect the mission of the school, and be designed to both complete the medical school experience and facilitate the transition to residency. Schools should decide the types of courses and organization of the year based on these goals. Organizational strategies for the fourth year should incorporate the requirements of the United States Medical Licensing Examination examinations and the residency application process. Fourth-year curricula and their constituent courses should be well designed and stringently evaluated to ensure educational goals are met and appropriate grades awarded.