Are medical schools teaching the basics?

There is deserved concern among medical educators that after four years of medical school, some graduates of American medical schools are not prepared to begin their first year of residency (known to most lay people as internship).

A respected voice of this concern comes from residency program directors who are the physicians responsible for selecting medical school graduates for training in their residency program. (Langdale et al. Preparing graduates for the first year of residency: are medical schools meeting the need? Acad Med 2003; 78: 39-44.).

As proof that medical schools are remiss in practical education are evidenced by the need for "intern boot camps" and The Association of American Medical Colleges (AAMC) recently described Core Entrustable Activities for Entering Residency.

Intern boot camps are organized to assure that their new residents are competent to begin their residency training. They may be sponsored and supported by teaching hospitals and are sometimes supported by industry funds. Their duration may last from 2 weeks to two months.

The Association of American Medical Colleges (AAMC) recently described Core Entrustable Activities for Entering Residency in an attempt to develop a standardized set of educational goals that students should achieve before graduating from medical school. There are 13 goals which include, for example:

  Gather a history and perform a physical examination
  Prioritize a differential diagnosis following a clinical encounter
  Provide an oral presentation of a clinical encounter

In a recent article in the New England Journal of Medicine, Aagaard and Abaza questioned the value of the fourth year of medical school. Rather than refining clinical skills, the year is too often spent working on research projects, visiting programs that they are interested in doing audition rotations, and spending large amounts of time and money applying to multiple programs (on the average 36) and interviewing at a dozen.

Clearly, many things need to change, not only in the fourth year but also in the entire medical school experience. The curriculum needs to focus on the "Entrustable Activities". Time should be dedicated to preparing to be a resident rather than embellishing a resume to obtain a desired residency. Embellishments include trivial "research" projects - usually chart reviews or case reports of patients they have never had contact with or trips to various parts of the world where they accomplish little. Students need to be accountable for their clinical knowledge base and embrace rather than disdain the Socratic method. Many schools have only a pass fail system, no class ranking, and uninformative dean's letters. Unfortunately, some residency programs have accepted that applicants are not prepared. Despite the lack of objective data regarding an applicant, interviewers for the residency are advised not to question the applicants on their clinical knowledge for concern of making them uncomfortable.

Aagaard and Abaza suggested, and I agree, that the 4th year should be the "boot camp" year, if necessary. Just as it is the car dealer's and not the buyer's responsibility to make sure that the new car is ready to drive, it should be the medical school's responsibility to make sure that their graduate is ready for internship.

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