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Adding Value to the Fourth Year The 4th Year Colleges Model


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Title: Adding Value to the Fourth Year The 4th Year Colleges Model

Adding Value to the Fourth YearThe 4th Year
Colleges Model
  • Ashley Christiani, MD
  • Chair Primary Care College
  • Assistant Clinical Professor
  • Department of Family Medicine
  • David Geffen School of Medicine at UCLA

  • Reflect on strengths and weaknesses of 4th Year
  • Consider challenges and benefits associated of
    building structure into the 4th year
  • Discuss the 4th Year Colleges model
  • Discuss how structure in 4th year can scaffold
    and support curricular innovation
  • Examine how UCLA experience with 4th year
    colleges might apply to curricular innovation at

  • The practice of medicine has changed
    dramatically over the last three decades. Medical
    education has struggled to keep up with these
    changes, with only limited success. The 4th year
    of medical school offers tremendous opportunity
    for curricular innovation, but little change has
    occurred in the past 30 years .
  • Curricular reform of the 4th year of medical
    school the colleges model. Slavin SJ, Wilkes MS,
    Usatine RP, Hoffman JR. Teach Learn Med. 2003

Curricular Innovation
  • Most educational innovations have occurred in the
    basic science years (PBL,organ/system-based
    courses, small group teaching, use of SPs,
    Doctoring courses)
  • Some extension to 3rd year (integrated ambulatory
    medicine w/FM, IM, Peds)
  • Little change occurring at 4th year level where
    so much potential lays.

Opportunities in 4th Year
  • Crucial juncture in transition to residency
  • 4th year students at ideal developmental level
    for educational purposes (solid grounding in
    sciences/year of clerkships/socialization)
  • Opportunity for individualized learning,
    exploration, career development, defining
  • Opportunity to bring it all together, focus on
    clinical skills, remediation of deficiencies,
    professionalism, information mastery, develop
    teaching, mentoring, research skills.

4th Year from Historical Perspective
  • The ignorance and general incompetency of the
    average graduate of American Medical Schools at
    the time when he receives the degree which turns
    him loose upon the community, is something
    horrible to contemplate.
  • -Annual Report of the President of Harvard
    College 1869-1870

Evolution in Medical Education
  • Flexner Report 2 years basic sciences followed
    by two years of required clerkships
  • In 50s-60s programs began to include elective
    time in 4th year
  • 1971 Health Manpower legislation incentives to
    increase physician supply some offer 3 year
  • 1985 Swanson pre-residency syndrome
  • 80s-present increasing elective time 4th year

The 4th Year
  • 2000 AAMC Curriculum Directory reveals structure
    of 4th year unchanged since 1970 for many
    schools. Primarily elective time. Average number
    required weeks 14 (0-28). Most require at least
    an inpatient sub internship.

Strengths of 4th Year
  • Flexibility allows personalized choices, allows
    for travel and away electives, research.
  • Sub-Internships- help prepare for residency,
    assume more responsibility for patient care.
  • Relatively relaxing period between the rigourous
    3rd year and demanding internship and residency.
    Opportunity for self reflection, time for friends
    and family.

Weaknesses of 4th Year
  • Without adequate guidance, may be unfocussed or
    lacking in intellectual rigor
  • Advising and mentoring is often inadequate
  • Opportunities to educate in important content
    areas are missed AAMC Graduation Survey 1999
    shows more than 50 felt time devoted to
    nutrition, pain management, occupational health,
    law and medicine, alternative medicine, cost
    effective care, quality assurance, practice
    management was inadequate.
  • Students widely dispersed may feel disconnected
    from peers, faculty and medical school

4th Year Colleges
  • Community of students and faculty sharing common
    interests who work together to maximize
    educational value of 4th year (Acute Care,
    Applied Anatomy, Medical Science, Primary Care,
    Urban Underserved, MD-MBA/MD-MPH)
  • Goal to maximize the potential of 4th year while
    preserving benefits of the old model-
    flexibility, opportunity to explore,
    self-reflection, research, etc.

4th Year Colleges
  • A curricular structure to...
  • Update new scientific and medical findings
    relevant to medical practice
  • Enhance clinical reasoning
  • Provide individual feedback
  • A society of faculty and students
  • Provide career advising and mentoring
  • Promote habits of inquiry

College Components
  • Career Mentoring and Advising
  • Core Foundation block
  • Electives
  • Longitudinal Experience/Community Service
  • Dinner Seminars
  • Research
  • CPX Feedback and Remediation

Primary Care College
  • To support students who are
  • considering a career in primary care.
  • seeking a solid foundation in general clinical

Typical Careers
  • Family Medicine
  • Geriatrics
  • Internal Medicine
  • Obstetrics Gynecology
  • Pediatrics
  • Psychiatry

Mentoring Advising
  • Organized structure of mentoring and support.
  • 4th year schedule and electives
  • Residency application and interviews
  • Special electives or away electives
  • Creative projects
  • Student Scholarship Day poster or presentation
  • Career planning
  • Senior Thesis
  • General advice and guidance

PCC Foundations Week
  • PCC Foundations Week Curriculum designed by
    incoming class with the help of suggestions from
    the prior class.
  • Goal to provide advance training in areas
    perceived to be under-taught in first 3 years
    of medical school or important in sub-internships
    and residency.

Foundations Week 2004
  • Success in the 4th Year - Resident panel
  • Diagnostic Imaging
  • Practical Dermatology
  • In-House Emergencies
  • Geriatric/Pediatric Emergencies
  • Ventilator Management
  • EKG Interpretation
  • Pain Management
  • Simulator Sessions
  • CPX Review Step 2 CS Preparation

Procedural Labs
  • One Inpatient Sub-Internship, One Ambulatory
    Sub-Internship. Advisors provided list of
    recommended electives that can be tailored to the
    students individual needs or interest.
  • Students encouraged to participate in
    international or away electives during their
    4th year. A special elective in cross cultural
    medicine in rural Jamaica has been designed for
    PCC students.

Community Service
  • Clinical or academic experience that serves
    community. May include teaching activities,
    research or direct patient care. Minimum
    equivalent of 6 half-day sessions over course of
  • Clinical experiences with underserved populations
  • UMMA Free Clinic
  • Union Rescue Mission
  • Salvation Army Clinic
  • Venice Family Clinic
  • Nursing Home Clinic
  • Prenatal Clinic
  • Teaching Assistantship (Doctoring 4), PBL
  • Mentored research or special project

Dinner Seminars
  • Behavioral Medicine and Psychiatry
  • Career Residency Planning
  • Complementary Medicine and Nutrition
  • Geriatrics
  • International Health
  • Pediatrics
  • Public Health Care for Underserved Populations
  • Sports Medicine
  • Womens Health

Creative Project
  • Required creative or scholarly project may
  • Presentation at Senior Scholarship Day
  • Scholarly Paper or Abstract
  • Presentation to colleagues in the Dinner Seminar
    Series or other venues
  • Curricular innovation
  • Community outreach

Senior Scholarship Day
  • Forum for presentation of original research or
    projects done in the 4th year. Attendance and /
    or submission of presentation is required for
    2004-5 academic year.

  • Evaluation Data

Mentoring Survey
  • Telephone Format 25 Questions
  • Post-Match, Pre-Graduation
  • Random Sample with Replacements
  • 100 response rate annually
  • Control Group UCLA Class of 2001 (n30)
  • Intervention Groups
  • UCLA Class of 2002 (n60)
  • UCLA Class of 2003 (n70)

  • Faculty Advisor - Clinicians that provided
    information during years 3 and 4 on 4th year
    schedule and application to residency.
  • Role Model - Someone you model your career upon.
  • Career Mentor Someone who takes an active role
    in your career development.

Pre-Colleges Post-Colleges
  • faculty advisors
  • None 33.3
  • One 33.3
  • Two 30.0
  • Three 3.3
  • faculty advisors
  • Post 1 Post 2
  • None 0 2.9
  • One 6.7 28.6
  • Two 31.7 48.6
  • Three 16.7 15.7
  • Four 5.0 2.9
  • Five 3.3 1.4

Finding (Post Colleges) Increase in of
advisors students identified, sharp decrease in
those identifying no advisor.
Role Models at UCLA
  • Pre Post 1 Post 2
  • Identified a Role Model 47 68 91
  • Adequate opportunity 70 65 76
  • to find role models
  • Adequate Accessibility 63 73 89
  • to role models
  • Post Colleges Nearly doubled the of students
    identifying a role model. Increases noted in
    opportunity and accessibility to role models.

Career Mentors at UCLA
  • Pre Post 1 Post 2
  • Identified a career mentor 37 35 73
  • Adequate opportunity 70 45 70
  • to find career mentors
  • Adequate Accessibility 47 74 70
  • to career mentors
  • Post Colleges 36 increase among students
    identifying career mentors. Opportunities to find
    mentors remained stable, while accessibility to
    mentors increased 23.

4th Year Opinions
  • Pre Post 1 Post 2
  • Connected w/ faculty 47 57 70
  • Connected w/ my classmates 37 80 43
  • Connected w/ medical school/ 93 52 80
  • student affairs office
  • Greater percentage of the class now reports
    feeling connected with the faculty and their
    classmates. Slight decrease in connectedness
    with the medical school noted.

4th Year-Beneficial Components
  • Pre Post 1 Post 2
  • Access to career mentors 50 45 87
  • Advising on elective choice 37 48 74
  • Longitudinal Experiences
  • Clinical experience 43 42 60
  • Research experience 17 43 49
  • 1 wk foundations course 13 63 64
  • Connect w/ faculty/classmates 68 63 69
  • Post Colleges Students reported increases in
    all components of this new curricular
    organization for 4th year and its approach to
    mentoring and advising.

4th Year Rated Good-Excellent
  • Pre Post 1 Post 2
  • Educational Value 83 92 91
  • Flexibility 97 97 98
  • Quality of Elective Advising 32 55 76
  • Quality of Res App Advising 63 73 91
  • Overall Satisfaction 100 97 99
  • 4 pt Likert scale (1-poor, 2 fair, 3good, 4
  • Post Colleges Gains reported in overall
    ratings of the 4th year modified curricular
    components. Overall satisfaction remained

  • Students fear of losing flexibility and comfort
    of the 4th year. Concern that they will come out
    the losers. Involve students early, look for
    areas to add value for them (management skills,
    preparing for residency), preserve flexibility.
    One versus two week Foundations block.
  • Financial Resources Support for Chairs,
    programming supplies. Grants, Deans Office
  • Students want prep for Sub-Is, hands on
    workshops less interested in soft subjects
    like nutrition, alternative medicine, other
    under-taught areas of medicine identified in

Unanticipated Benefits
  • Multidisciplinary community of College faculty
    allows leveraging of strengths, transcend
    departments (or turf battles), create
    multidisciplinary curriculum
  • College Chairs meet monthly- responsible for QA
    and development of 4th year electives, provide
    support for the Deans
  • College Chairs write MSPEs close relationship
    with students
  • Colleges reach down to years 1-3 to support and
    develop students i.e. PCC Pathway program
  • Responsive to student/MEC needs (i.e. Radiology
    enhancement for 2005, Healers Art, Step 2 CS

PCC Pathway Program International Health
Poverty Medicine
  • Multidisciplinary program with curriculum to
    enhance cultural competency, community health,
    and care for underserved populations encompassing
    areas of
  • Health Care
  • Public Health
  • Research
  • Advocacy

Pathway Components
  • Program Director
  • Dinner Seminar Series
  • Longitudinal Experiences Years 1-3 (clinical or
    research based)
  • Scholarly Project/Research Health disparities,
    community health, care for underserved. Link to
  • Workshops and Panel discussions
  • Film Series
  • Faculty Advisors Public Health, SOM, School of
  • Syllabus Recommended readings
  • PDA tools (clinical resources, calendar of events
    and seminars, evaluations, specialized 'procedure
    cards' and other materials)
  • ANGEL support with "chat room"
  • Highlighted as special area of focus on MSPE.

Seminar Topics
  • Healthcare Policy
  • Border Health
  • Effects of War, Globalization, Sanctions on
  • A look at the Cuban, Haitian and the Dominican
    Republican Healthcare System
  • Socialized Medicine
  • Community Based Primary Healthcare
  • Gangs and Violence
  • Infectious Diseases and the Poor (Malaria, TB,
  • International Health Experiences a look at
    Doctors Without Borders, Doctors for Global
  • Homelessness and Healthcare
  • Poverty Medicine
  • Torture Medicine
  • Travel Medicine The Ten Commandments
  • Alternative Medicine from other Cultures
  • Cultural Sensitivity

  • 4th Year Colleges preserve flexibility while
    providing enhanced opportunities for
  • Advanced training in clinical skills
  • Mentoring and Advising
  • Research
  • Community involvement
  • Teamwork skills and communication
  • Developing habits of life-long learning
  • Integration and synthesis of basic sciences into
    clinical framework
  • Professionalism

Additional Considerations
  • 4th Year Colleges integrate well into a
    progressive stepwise remodeling of curriculum.
  • Provide an automatic mechanism for continued
    innovation so schools arent stuck in a static
    model for another 3 decades allowing outreach
    and insertion of novel curriculum in years 1-3
  • Colleges assist in creating community -bring
    faculty together as well as students
  • Allows more flexibility than Colleges that divide
    in first year students are supported without
    being prematurely tracked.

Curricular Innovation at UMDNJ
  • Goal 1 Mastery of Clinical Knowledge with
    Integration of Basic Sciences
  • Goal 2 Excellence in Clinical Skills
  • Goal 3 Excellence in Professionalism and
  • Goal 4 Commitment to the Health of the
    Community and Appreciation of Social and Cultural
  • Goal 5 Dedication to Life-Long Learning
  • Goal 6 Development of Effective Skills in
    Education and Communication

  • Ashley Christiani, MD
  • Primary Care College Chair
  • 50-071 Center for Health Sciences
  • David Geffen School of Medicine at UCLA
  • Los Angeles, CA 90095
  • (310) 825-5469