“Renovate this old house!” That is the only logical conclusion if we truly want to overhaul the fourth year of medical school. We currently have a system that forces medical students into hundreds of thousands of dollars of debt, only to let them spend nearly half of their final year in limbo. Whether traveling across the country or burning out over Zoom, paying for travel and lodging to interview for residency slots like contestants on a reality dating show is unsustainable. The senior year of medical school is no longer an educational endeavor; it is a multi-million-dollar, anxiety-fueled marketing campaign masquerading as a curriculum. It is time to stop tweaking the margins and completely dismantle it.

Imagine a streamlined medical education that cuts out the bloated fat of our current timeline. It’s been done before (1). Since World War II, three-year programs were common, often combined with baccalaureate degrees (2). Today, the University of Missouri-Kansas City stands as the most prominent survivor of this model—and it is thriving. Other recent innovations have allowed students to complete their final year of medical school in conjunction with their intern year of training (3). As more of these models emerge, the Consortium of Accelerated Medical Pathway Programs (CAMPP) has grown to include approximately 32 programs as of 2024 (4).

Currently, these pathway programs rely on direct links to affiliated residency placements (4). But what if that wasn’t a requirement? What if we completely eliminated the fourth year for everyone by the end of year three?

How do we handle the residency bottleneck without the grueling, months-long interview circus that currently paralyzes senior year? If we recognize (and accept) that the current rank processes on the part of the residency program is not a predictor of performance in the residency (5), then we can consider one radical solution: replacing the current Match system with a regionalized lottery. No more performative interviews, no more algorithmic gamesmanship, and no more signaling tokens. Applicants would simply submit their regional and specialty preferences, medical schools would certify their clinical competency, and a computer program would finalize placements instantly, taking into account couples placements. This would erase the four-to-five-month black hole of the senior year, saving students tens of thousands of dollars and granting them an entire year of their lives back.

Of course, defenders of the status quo will panic, warning of catastrophic, unintended consequences. To be fair, they aren’t entirely wrong; the short-term structural shockwaves would be massive.

First, a pure lottery system completely strips programs and applicants of “culture fit”—though one has to question how genuine “fit” really is in the era of virtual interviews, or ever really was. Under a Match lottery, an urban trauma center might end up with a resident who thrives in quiet, rural research settings, potentially increasing attrition and mismatch-induced burnout. Furthermore, without a traditional application process, residency programs would have to trust that medical schools are being completely transparent about a student’s true readiness.

Within the compressed curriculum itself, we would also lose the vital “decompression chamber” that some of the fourth year occasionally provides. That final year, for all its flaws, gives students time to mature or recover from the exhaustion of core clerkships. Without it, we risk launching younger, structurally fragile physicians straight into the meat grinder of the PGY-1  year.

Yet, we must ask ourselves: are the risks of the unknown truly worse than the established problems of the system we run today? We are actively wasting human capital and financial resources to maintain a tradition that serves institutions far better than it serves students or patients. If we truly believe that medical education should be efficient, equitable, and focused on producing capable clinicians, we must be willing to tear down the fourth year, the Match, and the interview process, and finally begin the renovation.

What do you think? 

1. How much of an impact would undergraduate medical education institutions experience if they lost an entire year of tuition revenue, and where would that financial burden ultimately shift?
2. If the fourth year of medical school is truly salvageable, what concrete educational value does it provide that cannot be replicated in either a compressed three-year model or the first few months of residency?
3. If we transition to a competency-based lottery, how would this impact medical students’ motivation?
4. What other possible unintended consequences might arise from the ashes of such an extreme make-over?

References

1. Drees BM, Omurtag K. Accelerated Medical Education: Past, Present and Future. Missouri Med 2012; 109(5):352–356.
2. Schwartz CC, Ajjarapu AS, Stamy CD, Schwinn DA. Comprehensive history of 3-year and accelerated US medical school programs: a century in review. Med Educ Online 2018; 23(1). https://doi.org/10.1080/10872981.2018.1530557
3. Chang LL, Grayson MS, Patrick AA, Sivak SL. Incorporating the Fourth Year of Medical School into an Internal Medicine Residency: Effect of an Accelerated Program on Performance Outcomes and Career Choice. Teach Learn Med 2004; 16(4):361–364.
4. Coe CL, Santen SA, Reboli AC, Boscamp JR, Stoltz AM, Latif E, et al. (2024). Accelerated 3YMD programs: the last decade of growth of the Consortium of Accelerated Medical Pathway Programs (CAMPP). Med Educ Online 2024; 29(1):2400394.
5. Ezeh UC, Svirsky MA, April MM. Relationship Between National Residency Matching Program (NRMP) Rank Order and Otolaryngology Residency Performance. OTO Open. 2024 Apr 3;8(2):e127. doi: 10.1002/oto2.127.

Author: Gary L. Beck Dallaghan, Ph.D., Alliance for Clinical Education (Credit for this idea goes to Jason Rosenstock, M.D., Association of Directors of Medical Student Education in Psychiatry)