This document discusses the structure and purpose of the fourth year of medical school and opportunities for advanced training in emergency medicine. It reviews the literature on the lack of standardization of the fourth year and recommendations to improve preparation for residency. Examples are provided of innovative EM electives at different institutions, including advanced topics in EM, ultrasound training, and critical care rotations. The future of competency-based education and advanced competencies is discussed. Overall, the document argues that the fourth year should provide advanced clinical training opportunities to prepare students for intern level responsibilities in their chosen specialties.

1. Beyond the Clerkship: Advanced
Competencies and the Senior Year of
Medical School Training
Dr. David Wald, DO
Dr. Nicholas Kman, MD
@drnickkman

2. Objectives
 Review the literature on current and future structure
of the fourth year of medicine as it relates to EM.
 Describe the specialization of medical students
during 4th year.
 Describe curricula that can be implemented to
provide advanced opportunities for students in EM.
 Explain the concept of Advanced Competencies in
EM as they relate to Entrustable Professional
Activities (EPAs).

3. The Past

4. The Past

5. The Past

6. The Present
 Only 4th year constants across institutions:
 Expectation that students will take USMLE Step 2
 Select a specialty
 Interview for residency positions.
Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the
Senior Year". Academic medicine (1040-2446), p. 1.

7. The 4th Year: Purpose
 Preparing for residency through increased responsibility
for patient care
 Making wise and judicious career choices
 Creating defined time for guidance and preparation for
USMLE examinations and residency interviews
 Having the time to study/explore specialty in depth
 Developing an understanding of different practice settings
to prepare for later decisions
 Having time to foster and nurture socially responsible
activities and interests such as service learning
Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the
Senior Year". Academic medicine (1040-2446), p. 1.

8. 8
Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the
Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie
Foundation for the Advancement of Teaching, p. 346, OCLC 9795002.

9. The 4th Year of Medical
School
9

10. What do the Program Director’s think?
 Semi structured interviews
 30 PD’s, broad range of specialties
 3 EM PD’s
10

11. Common struggles of interns
Identify problems that could be better addressed in
the MS IV year
 Lack of self-reflection and improvement
 Poor organizational skills
 Underdeveloped professionalism
 Weak medical knowledge
11

12. Competencies
Competencies MS IV students should gain before
staring residency
 Advanced clinical reasoning
 Near intern level independence
 Responsibility and reliability
 Ownership of patient care
12

13. Recommended rotations
 Subinternship in field in which applying
 IM subinternship
 IM subspecialty
 Critical care
 Ambulatory care
 EM
13

14. Comments from the Author – M Harper
Additional insight or comments
 Curricular change is hard
 Currently involved in a curricular renewal
process
 Most of the focus is on the 3rd year
 Under consideration
 All 4th year students should develop an
individualized learning plan approved by a
career advisor
14

15. Expert recommendations for MS IV
curriculum
 English language literature review (1974-2009)
 66 publications
 40 – Aspects of MS IV education
 26 – Overview / general reviews
15

16. Three recurring themes
 Lack of clarity about the educational purpose
 Problems in curricular content and organization
 Concerns about the educational quality of
courses
16

17. Lack of clarity about the educational
purpose
 Preparation for residency
 “Preresidency syndrome”
 Culmination of medical school education
 Clear understanding of the objectives and
competencies to be mastered by graduation
 No publications on the role of the MS IV year
in the preparation of the medical graduate
17

18. Problems in curricular content and
organization
 Recommendations from specialty organizations
 College and pathway programs
 Accelerated programs
 Specific MS IV courses
18

19. Concerns about educational quality
 No publications specifically addressing
educational quality
 Unclear course objectives
 Lack of structured learning
 Grade inflation
19

20. Comments from the Author – A Walling
Additional insight or comments
 ACGME policies and practices will increasingly
influence medical student education
 Fourth year as capstone for medical school
versus preparation year for residency
 Turned in favor of the pre-residency viewpoint
 Other factors that increase the pressure towards
using the fourth year to prepare for residency are
student debt and the growing specter
of unmatched US graduates

20

21.  Description of the impact of an innovative
MS IV curriculum
 “College Program” UCLA – implemented
2001
 Improved career advising and mentoring
21

22. College structure
 Organized around a set of related specialties that
share similar traits
 College Chair and faculty
 Delivering specific curricular activities
 Advising students / mentoring
 Overseeing scholarly projects
22

23. 23
College structure – 6 UCLA colleges
Acute Care: time-based decision-making specialties
(Anesthesia, critical care EM)
Applied Anatomy: structure-oriented fields (Surgery, radiology,
pathology)
Medical Leadership: dual-degree programs in public health or
business administration
Medical Subspecialties: subspecialties focused on clinical reasoning
and advance fellowship training
Primary Care: longitudinal care specialties (FM, IM, pediatrics)
Urban Underserved: focuses on care of underserved communities

24. 24

25. 25

26. Comments from the Author – W Coates
 Variable college sizes year to year
 Yearly reallocation of resources
 Interdisciplinary faculty
 Mentoring junior faculty
 Residents as teachers
 Two tiered level of student advising / mentoring
 Group / peer
 Structural individual
26

27. Comments from the Author – L Wilkerson
 Senior scholarship day
 Facilitated poster and oral presentations
 Colleges sponsor the Special Interest Groups
and electives in the preclinical years
 Earlier college involvement
 Colleges shifting to an earlier start date
 Considering new senior year requirements
 More elective time
 Reviewing the role of the College Chairs in
preparing the MSPE
27

28. 28

29.  “Undergraduate Rotations” Listing from
www.saem.org
 Ultrasound, International, Disaster Medicine,
Geriatric EM, Toxicology, and Pediatric EM
29

30. What does VSAS say?
 353 Electives under “Emergency Medicine”
30

31. What does VSAS say?
 353 Electives under “Emergency Medicine”
31
Peds 21
Research 12
Toxicology 16
Ultrasound 24
Trauma Critical Care 5
EMS/Disaster 14
Wilderness Medicine 6
Global/International Health 4
Hyperbaric/Undersea 1
103

32.  Didactics
 Small group case-based discussions
 Small group labs
 Self-directed learning
 Critical care workbook
 Clinical shifts (12 x 9-hour shifts) at 2 clinical
sites
 Critical care experience/workbook (5 days)
 Exam

33.  Students identify a critical care patient in the
ED during their eve shift (2 pm – 11 pm)
 Students present the case on morning
teaching rounds in the ICU the next day
 Repeat the eve shift, then 4 days in the ICU
 Students follow their patients in ICU and
complete workbook

34.  Integrating critical care via a longitudinal
experience emphasizes the importance of
patient’s ED care on their hospital course
and highlights importance of
multidisciplinary approach

35. The Ohio State Experience
 Currently, we have 2 “Honors” longitudinal rotations
for students bound for EM
 Advanced Topics in Emergency Medicine (ATEM)
 Honors U/S

36. The Ohio State Experience
 Currently, we have 2 “Honors” longitudinal rotations
for students bound for EM
 Advanced Topics in Emergency Medicine (ATEM)
 Honors U/S
 Wilderness Medicine
 Global Health

37. Bahner, DP.; Royall, NA. “Advanced ultrasound training for fourth-year medical students: a novel training
program at The Ohio State University College of Medicine.” Academic Medicine, v. 88 issue 2, 2013, p.
206-13.

38. Honor’s Ultrasound Requirements

39. Honors Ultrasound
 @EDUltrasoundQA
 @EDUltrasound
 Facebook at OSU Ultrasound
 There's an App for that!

40. Kman, NE., et al. “Advanced topics in emergency medicine: curriculum development and initial
evaluation.” Western Journal of Emergency Medicine, v. 12 issue 4, 2011, p. 543-50.

41. ATEM Purpose
 9 month longitudinal honors elective with goal of
producing most capable and experienced residents
possible.

42. Course Components
 Teaching shifts
 Journal Club
 Small Group Didactic Sessions
 PALS and ATLS Training
 High Acuity Code Training
 EMS and Emergency
Preparedness Training
(MedFlight)
 Toxicology

43. Course Components
 Teaching shifts
 Journal Club
 Small Group Didactic Sessions
 PALS and ATLS Training
 High Acuity Code Training
 EMS and Emergency
Preparedness Training
(MedFlight)
 Toxicology

44. Course Components
 Teaching shifts
 Journal Club
 Small Group Didactic Sessions
 PALS and ATLS Training
 High Acuity Code Training
 EMS and Emergency
Preparedness Training
(MedFlight)
 Toxicology

45. Course Components
 Chest Tubes
 Adult and Pediatric Airway
 Procedural Teaching in
Clinical Skills Lab
 Ultrasound
 EMS Lecture/Experience
 Mentorship
 Research or Q/A Project

46. Course Components
 Chest Tubes
 Adult and Pediatric Airway
 Procedural Teaching in
Clinical Skills Lab
 Ultrasound
 EMS Lecture/Experience
 Mentorship
 Research or Q/A Project

47. Course Components
 Chest Tubes
 Adult and Pediatric Airway
 Procedural Teaching in
Clinical Skills Lab
 Ultrasound
 EMS Lecture/Experience
 Mentorship
 Research or Q/A Project

48. The Future

49. The Future: Competency Based Education

50. Advanced Competencies and Electives
 16 weeks for advanced competencies and advanced
electives (4 total elective blocks).
 Students can choose a variety of advanced
competencies and advanced clinical electives.
 Advanced electives are a place for students to
become proficient at level 1 milestones for their
chosen residency specialty.
 This 16 week period will include time for
assessments.
50

51. Advanced Competencies
 Medical Administration
 Inter-professional Collaboration
 Social Media in Medicine
 Ultrasound
 Procedures
 Patient Experience
 Research (will require preapproval with preceptor)
 Teaching in Medicine
 Clinical Practice Guidelines & Evidence-based Medicine
51

52. Advanced Competencies
 Professionalism
 Bioinformatics
 Health Coaching
 Health Literacy & Healthcare Disparities
 Genetics
 Quality Improvement/Patient Safety
 Emergency Preparedness and Disaster Response
 Global Health
 Latino Health
52

53. Advanced Competencies
 Professionalism
 Bioinformatics
 Health Coaching
 Health Literacy & Healthcare Disparities
 Genetics
 Quality Improvement/Patient Safety
 Emergency Preparedness and Disaster Response
 Global Health
 Latino Health
53

55. Advanced Clinical Electives
 The Ohio State University has 30 clinical
departments. 21 specialties are presented to
students for Career Exploration week.
 The Advanced Clinical Tracks will offer a variety of
experiences and electives to prepare students for
Milestone 1 (intern level for that specialty).
 Example EM Advanced Clinical Track: Selectives in
EM, ICU, Diabetes, Pain & Palliative, or CHF;
Advanced Competency in Ultrasound, Advanced
Topics in EM, elective in Wilderness Medicine.
55

56. The Future
 Fit Advanced Topics in Emergency Medicine
Objectives to Level 1 Emergency Medicine
Milestones
 Develop this into an Advanced Clinical Track from
students going into Emergency Medicine
 Graduate the finest EM interns our colleagues could
hope to match!
56

57. Advanced Competencies Pearls
 The link is of EM to EPA’s is undeniable! Emergency
Medicine will have an integral part in the clinical
years of medical school.
 Fourth year of medical school is a necessary
component of medical student clinical development.
 Opportunities such as Ultrasound, International,
Disaster Medicine, Geriatric EM, Toxicology,
Wilderness, EMS, and Pediatric EM exist for our
graduates.
57

58. References
 Wolf, S J (02/19/2014). "Students' Perspectives on the Fourth Year of Medical School: A Mixed-
Methods Analysis". Academic medicine (1040-2446), p. 1.
 Cosgrove, E M (02/19/2014). "Empowering Fourth-Year Medical Students: The Value of the Senior
Year". Academic medicine (1040-2446), p. 1.
 Bahner, DP.; Royall, NA. “Advanced ultrasound training for fourth-year medical students: a novel
training program at The Ohio State University College of Medicine.” Academic Medicine, v. 88
issue 2, 2013, p. 206-13.
 Kman, NE., et al. “Advanced topics in emergency medicine: curriculum development and initial
evaluation.” Western Journal of Emergency Medicine, v. 12 issue 4, 2011, p. 543-50.
 Alliance for Clinical Education Perspective Paper: Recommendations for Redesigning the “Final
Year" of Medial School. Accepted for publication in Teach Learn Med.
 Pacella CB. Advanced opportunities for student education in emergency medicine. Acad Emerg
Med 2004; 11(10): 1028e9-1028e11.
 Flexner, Abraham (1910), Medical Education in the United States and Canada: A Report to the
Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The
Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002.

59. Questions and Discussion?
59

60. Questions and Discussion?
60