Drs. Gunderman and Tobben provide an important argument regarding the utility—or rather, disutility—of the so-called “clinical year” in radiology training. The authors argue that because the fourth year of medical school is predominantly elective, students may take courses to help them prepare for a radiology residency . It is on this specific point to which I disagree with the authors. Dr. Jackson provided a well-thought-out counterpoint to the authors’ perspective , including many points to which I am in agreement. It cursorily described the fourth year of medical school. Specifically, the fourth year of medical school warrants understanding in the context of the radiology “clinical year.”
Both articles realize that the fourth year of medical school is variable, but reach different conclusions. Medical school’s fourth year could be valuable in medical education. Unfortunately, the variability has resulted in a lack of purpose . Some students undoubtedly benefit from the elective time, using it to further their clinical acumen before residency. Others use it to pursue dedicated research or partake in global health experiences, all noble causes, but may not necessarily improve preparation for a radiology residency. Regrettably, for many students, the fourth year of medical school has been focused on residency applications, “away rotations” in their intended specialty, and residency interviews . This focus on residency applications has led to a “senioritis” effect, where, at one institution, only 40% of students are taking clinical electives during interview season and 50% are taking one after Match Day . In one study, approximately 58% of medical students believe that medical school should conclude once Match results are known . Human psychology being human psychology, many students choose the “easiest” electives to satisfy the (generally minimal) specific fourth-year requirements .
A related issue, and equally important, is the level of responsibility and autonomy during this year. There has been a progressive decrease in autonomy and responsibility for students and trainees over the past several decades . The reasons are multifactorial, but may ultimately relate to perceived risks and medicolegal aspects of medical education. In such an environment, removing the “clinical year” and relying on the fourth year of medical school for training would not be beneficial. The “clinical year” provides added ownership of patients, allowing the trainee to have primary responsibility to order imaging studies. Understanding the thought processes of referring physicians by being one—even in a time-limited capacity as an intern—is critical for radiologists. With the recent emphasis on appropriate imaging and stewardship of healthcare resources, such skills are increasingly critical. In addition, the soft skills gained by treating responsibilities in a “workplace” context rather than in a “school” context should not be understated.
Given the highly variable nature of the medical school fourth year, as well as the gradual erosion of student autonomy and responsibility, it would be safe to conclude that it would not qualify as an appropriate surrogate for the current “clinical year” as suggested by Gunderman and Tobben. Presumably, this could be corrected by creating a more focused fourth year for medical students and also increasing their responsibilities. However, such is not presently the case. Until that occurs, the “clinical year’s” added training, responsibilities, and perspective (“workplace” rather than “school”) are warranted before formal radiology training.
References
1. Gunderman R.B., Tobben J.P.: Is it time to jettison radiology’s clinical year requirement?. Acad Radiol 2016; 22: pp. 389-391.
2. Jackson V.P.: The clinical internship for radiology: is there value?. Acad Radiol 2016; 23: pp. 265-266.
3. Cosgrove E.M., Ryan M.J., Wenrich M.D.: Empowering fourth-year medical students: the value of the senior year. Acad Med 2014; 89: pp. 533-535.
4. Aagaard E.M., Abaza M.: The residency application process—burden and consequences. N Engl J Med 2016; 374: pp. 303-305.
5. Benson N.M., Stickle T.R., Raszka W.V.: Going “fourth” from medical school: fourth-year medical students’ perspectives on the fourth year of medical school. Acad Med 2015; 90: pp. 1386-1393.
6. Kanter S.L.: How to win an argument about the senior year of medical school. Acad Med 2009; 84: pp. 815-816.
7. Halpern S.D., Detsky A.S.: Graded autonomy in medical education—managing things that go bump in the night. N Engl J Med 2014; 370: pp. 1086-1089.