- Email: [email protected]
Graduate medical education during the fourth year of medical school
SPECIAL ARTICLE
Graduate medical education during the fourth year of medical school Thomas K, Oliver, Jr., MD
A conference on Entry Into Graduate Medical Education During the Fourth Year of Medical School was held in Chapel Hill, North Carolina, on March 6-7,1991, under the auspices of the American Board of Pediatrics Foundation. Participating in the conference were members from a number of organizations (Table). The purpose was to discuss the pros and cons of beginning graduate medical education in the fourth year of medical school. This has begun this academic year at three universities: the University of Kentucky and the University of South Alabama in the departments of internal medicine and family practice and at Boston University in internal medicine. The policy of the American Board of Pediatrics (ABP) is that credit will not be given for training leading to certification that is completed before the medical degree is awarded. The Chairman of the Department of Pediatrics at the University of South Alabama has formally requested that the Board change this policy "so that we can compete in pediatrics for the best and the brightest students at the University of South Alabama with the departments of internal medicine and family practice." The other two university pediatric departments have not communicated with the ABP. At all three institutions, these are small programs with only a few students, who are in the upper third of their class and whose mentors believe that they also have the noncognitive qualities to begin graduate medical education after 3 years of medical school. For example, at the University of Kentucky two individuals, one each in internal medicine and family practice, are selected in the spring of their junior year. Although the American Board of Internal Medicine (ABIM) and American Board of Family Practice (ABFP) Conference supported in part by the Robert Wood Johnson Foundation (grant 17424). Reprint requests: Thomas K. Oliver, Jr., MD, Senior Vice-President, American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC 27514. 9/19/30119
have the same policy as the ABP, the two boards have agreed to waive the requirement for these three programs. During the first year of graduate medical education (while the individuals are still fourth-year students) they will continue to pay tuition and graduate with the M.D. degree with their class; they also will be paid a first-year resident stipend. The financial arrangements for doing this vary with each institution. Because they are students, all of their orders and prescriptions (and notes?) must be countersigned. This "experiment" is in fact not new. A number of medical schools entirely eliminated the fourth year in the early 1970s as part of a manpower initiative, a part of which included a capitation of $2000 per student, which was given to the medical school, which either graduated students after 3 years or increased the size of the class. Additional funds were awarded for program development. The awarding of the M.D. degree after 3 years of medical school expired after a few years, primarily when the capitation incentive was removed. A retrospective survey of medical school faculty and students revealed strong opposition to the 3-year program, although objective data (for example, scores on the National Board of Medical Examiners test, parts II and III) were no different between graduates of 3and 4-year programs. At Duke University, beginning in 1970, an early internship program was begun involving the departments of medicine, pathology, pediatrics, psychiatry, and surgery. It was discontinued after 4 years for two reasons: (1) The students who signed up had to remain at Duke throughout their training; the remaining students viewed this as having options for training at other institutions denied them and they lost interest in the program. (2) There developed severe interpersonal interactions between individuals who had been classmates when one was an intern and another was still a fourth-year student. The three new programs also deprive students of the ability to transfer to another program after they receive the M.D. degree; that is, no credit is given toward Board certification for training as a "student/resident" if he or she
175
176
Oliver
The Journal of Pediatrics August 1991
Table. Conference attendees, March 6-7, 1991: Entry Into Graduate Medical Education During the Fourth Year of Medical School Name of organization
Name of individual
Association of American Medical Colleges American Academy of Pediatrics American Board of Family Practice American Board of Internal Medicine
American Board of Medical Specialties American Board of Pediatrics
American Board of Pediatrics Foundation Accreditation Council for Graduate Medical Education Association of Medical School Pediatric Department Chairmen Association of Pediatric Program Directors Duke University School of Medicine Federation of State Medical Boards National Board of Medical Examiners Residency Review Committee for Internal Medicine Residency Review Committee for Pediatrics and American Pediatric Society Robert Wood Johnson Foundation University of Kentucky, Department of Medicine University of South Alabama, Department of Pediatrics
transfers. ABIM has developed guidelines for small demonstration programs that allow graduate medical education to begin in the fourth year. They would limit the number of programs to ten, including the present three; a maximum of 100 candidates per year would be admitted; and no more than 25% of the residency positions could be in the demonstration programs. In addition, there would be extensive evaluation of the program, by both program directors and ABIM. The ABFP has stated that they will probably formulate similar guidelines soon. In part, the purpose of these new programs is to reduce student indebtedness (although they will still have to pay tuition). It is also an initiative to attract bright students into the fields of internal medicine and family practice, because of the decreasing numbers of North American graduates entering these fields. It was agreed by the conference attendees that other disciplines could offer the same program (as happened at Duke). Thus the attraction for internal medicine or family practice might dwindle. Another and perhaps more important reason for these programs is the recognition that clinical education, particularly during the
Robert G. Petersdorf, MD August G. Swanson, MD Errol R. Alden, MD Paul R. Young, MD John A. Benson, Jr., MD Richard J. Glassock, MD Harry R. Kimball, MD Peyton E. Weary, MD Robert C. Brownlee, MD Grant Morrow III, MD Thomas K. Oliver, Jr., MD Jimmy L. Simon, MD Fred G. Smith, Jr., MD Jon B. Tingelstad, MD William W. Cleveland, MD James R. Weinlader, PhD George W. Brumley, MD James A. Stockman lII, MD Lois A. Pounds, MD James R. Winn, MD Donald E. Melniek, MD Jordan J. Cohen, MD Catherine DeAngelis, MD Annie Lea Shuster John S. Thompson, MD Robert C. Boerth, MD
fourth year, which in most medical schools is largely elective with many "audition" electives, is educationally unsatisfactory. As one observer stated, if Abraham Flexner were to review medical schools in 1991, he would look at the clinical education aspects of medical school education, not the basic science aspects. Several curricular interventions are being made to improve clinical education, particularly in the fourth year. The Robert Wood Johnson Foundation is providing grant support to twelve medical schools to do this. (Sixty-seven medical schools applied for this grant, indicating widespread belief that the present curriculum needs to be changed.) Other universities and consortia also are addressing this issue. As a separate but related issue, there was considerable discussion of the planned single route to medical licensure and the examination called United States Medical Licensing Examination (USMLE), which will consist of three steps: steps I and II will be current NBME parts I and II, and step III would be an examination similar to part III NBME or the clinical Federation Licensing examination (FLEX). Step III of the examination would be taken after
Volume 119 Number 2
Graduate medical education during fourth year
completion of the first year of graduate medical education, after the M.D. degree was awarded, and could not be taken unless steps I and II are passed. Both the National Board examinations and the Foreign Medical Graduate Examination in Medical Sciences of Educational Commission on Foreign Medical Graduates (FMGEMS) (ECFMG), as they are currently constructed, would be eliminated. Because many medical schools require passing NBME as a graduation requirement, the question was asked (but not answered) of what credit for graduate medical educa-
tion would be given to a "student/resident" who failed NBME part II and therefore did not receive an M.D. degree. Although no votes were taken, there seemed to be a consensus that innovations in the medical school clinical education curriculum were preferred to the 3-plus-3 program. During 1991, the Board of Directors of the ABP will decide whether to change its existing policy of no graduate medical education credit before the award of the M.D. degree.
BOUND VOLUMES AVAILABLETO SUBSCRIBERS Bound volumes of the 1991 issues of THE JOURNALOF PEDIATRICSare available to subscribers (only) from the Publisher, at a cost of $52.00 for domestic, $71.64 for Canadian, and $68.00 for international subscribers, for Vol. 118 (January-June) and Vol. 119 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-325-4177, ext. 4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
17 7
Graduate medical education during the fourth year of medical school Thomas K, Oliver, Jr., MD
A conference on Entry Into Graduate Medical Education During the Fourth Year of Medical School was held in Chapel Hill, North Carolina, on March 6-7,1991, under the auspices of the American Board of Pediatrics Foundation. Participating in the conference were members from a number of organizations (Table). The purpose was to discuss the pros and cons of beginning graduate medical education in the fourth year of medical school. This has begun this academic year at three universities: the University of Kentucky and the University of South Alabama in the departments of internal medicine and family practice and at Boston University in internal medicine. The policy of the American Board of Pediatrics (ABP) is that credit will not be given for training leading to certification that is completed before the medical degree is awarded. The Chairman of the Department of Pediatrics at the University of South Alabama has formally requested that the Board change this policy "so that we can compete in pediatrics for the best and the brightest students at the University of South Alabama with the departments of internal medicine and family practice." The other two university pediatric departments have not communicated with the ABP. At all three institutions, these are small programs with only a few students, who are in the upper third of their class and whose mentors believe that they also have the noncognitive qualities to begin graduate medical education after 3 years of medical school. For example, at the University of Kentucky two individuals, one each in internal medicine and family practice, are selected in the spring of their junior year. Although the American Board of Internal Medicine (ABIM) and American Board of Family Practice (ABFP) Conference supported in part by the Robert Wood Johnson Foundation (grant 17424). Reprint requests: Thomas K. Oliver, Jr., MD, Senior Vice-President, American Board of Pediatrics, 111 Silver Cedar Court, Chapel Hill, NC 27514. 9/19/30119
have the same policy as the ABP, the two boards have agreed to waive the requirement for these three programs. During the first year of graduate medical education (while the individuals are still fourth-year students) they will continue to pay tuition and graduate with the M.D. degree with their class; they also will be paid a first-year resident stipend. The financial arrangements for doing this vary with each institution. Because they are students, all of their orders and prescriptions (and notes?) must be countersigned. This "experiment" is in fact not new. A number of medical schools entirely eliminated the fourth year in the early 1970s as part of a manpower initiative, a part of which included a capitation of $2000 per student, which was given to the medical school, which either graduated students after 3 years or increased the size of the class. Additional funds were awarded for program development. The awarding of the M.D. degree after 3 years of medical school expired after a few years, primarily when the capitation incentive was removed. A retrospective survey of medical school faculty and students revealed strong opposition to the 3-year program, although objective data (for example, scores on the National Board of Medical Examiners test, parts II and III) were no different between graduates of 3and 4-year programs. At Duke University, beginning in 1970, an early internship program was begun involving the departments of medicine, pathology, pediatrics, psychiatry, and surgery. It was discontinued after 4 years for two reasons: (1) The students who signed up had to remain at Duke throughout their training; the remaining students viewed this as having options for training at other institutions denied them and they lost interest in the program. (2) There developed severe interpersonal interactions between individuals who had been classmates when one was an intern and another was still a fourth-year student. The three new programs also deprive students of the ability to transfer to another program after they receive the M.D. degree; that is, no credit is given toward Board certification for training as a "student/resident" if he or she
175
176
Oliver
The Journal of Pediatrics August 1991
Table. Conference attendees, March 6-7, 1991: Entry Into Graduate Medical Education During the Fourth Year of Medical School Name of organization
Name of individual
Association of American Medical Colleges American Academy of Pediatrics American Board of Family Practice American Board of Internal Medicine
American Board of Medical Specialties American Board of Pediatrics
American Board of Pediatrics Foundation Accreditation Council for Graduate Medical Education Association of Medical School Pediatric Department Chairmen Association of Pediatric Program Directors Duke University School of Medicine Federation of State Medical Boards National Board of Medical Examiners Residency Review Committee for Internal Medicine Residency Review Committee for Pediatrics and American Pediatric Society Robert Wood Johnson Foundation University of Kentucky, Department of Medicine University of South Alabama, Department of Pediatrics
transfers. ABIM has developed guidelines for small demonstration programs that allow graduate medical education to begin in the fourth year. They would limit the number of programs to ten, including the present three; a maximum of 100 candidates per year would be admitted; and no more than 25% of the residency positions could be in the demonstration programs. In addition, there would be extensive evaluation of the program, by both program directors and ABIM. The ABFP has stated that they will probably formulate similar guidelines soon. In part, the purpose of these new programs is to reduce student indebtedness (although they will still have to pay tuition). It is also an initiative to attract bright students into the fields of internal medicine and family practice, because of the decreasing numbers of North American graduates entering these fields. It was agreed by the conference attendees that other disciplines could offer the same program (as happened at Duke). Thus the attraction for internal medicine or family practice might dwindle. Another and perhaps more important reason for these programs is the recognition that clinical education, particularly during the
Robert G. Petersdorf, MD August G. Swanson, MD Errol R. Alden, MD Paul R. Young, MD John A. Benson, Jr., MD Richard J. Glassock, MD Harry R. Kimball, MD Peyton E. Weary, MD Robert C. Brownlee, MD Grant Morrow III, MD Thomas K. Oliver, Jr., MD Jimmy L. Simon, MD Fred G. Smith, Jr., MD Jon B. Tingelstad, MD William W. Cleveland, MD James R. Weinlader, PhD George W. Brumley, MD James A. Stockman lII, MD Lois A. Pounds, MD James R. Winn, MD Donald E. Melniek, MD Jordan J. Cohen, MD Catherine DeAngelis, MD Annie Lea Shuster John S. Thompson, MD Robert C. Boerth, MD
fourth year, which in most medical schools is largely elective with many "audition" electives, is educationally unsatisfactory. As one observer stated, if Abraham Flexner were to review medical schools in 1991, he would look at the clinical education aspects of medical school education, not the basic science aspects. Several curricular interventions are being made to improve clinical education, particularly in the fourth year. The Robert Wood Johnson Foundation is providing grant support to twelve medical schools to do this. (Sixty-seven medical schools applied for this grant, indicating widespread belief that the present curriculum needs to be changed.) Other universities and consortia also are addressing this issue. As a separate but related issue, there was considerable discussion of the planned single route to medical licensure and the examination called United States Medical Licensing Examination (USMLE), which will consist of three steps: steps I and II will be current NBME parts I and II, and step III would be an examination similar to part III NBME or the clinical Federation Licensing examination (FLEX). Step III of the examination would be taken after
Volume 119 Number 2
Graduate medical education during fourth year
completion of the first year of graduate medical education, after the M.D. degree was awarded, and could not be taken unless steps I and II are passed. Both the National Board examinations and the Foreign Medical Graduate Examination in Medical Sciences of Educational Commission on Foreign Medical Graduates (FMGEMS) (ECFMG), as they are currently constructed, would be eliminated. Because many medical schools require passing NBME as a graduation requirement, the question was asked (but not answered) of what credit for graduate medical educa-
tion would be given to a "student/resident" who failed NBME part II and therefore did not receive an M.D. degree. Although no votes were taken, there seemed to be a consensus that innovations in the medical school clinical education curriculum were preferred to the 3-plus-3 program. During 1991, the Board of Directors of the ABP will decide whether to change its existing policy of no graduate medical education credit before the award of the M.D. degree.
BOUND VOLUMES AVAILABLETO SUBSCRIBERS Bound volumes of the 1991 issues of THE JOURNALOF PEDIATRICSare available to subscribers (only) from the Publisher, at a cost of $52.00 for domestic, $71.64 for Canadian, and $68.00 for international subscribers, for Vol. 118 (January-June) and Vol. 119 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA/800-325-4177, ext. 4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
17 7