The third and fourth years of medical school are the clinical years. This is when medical students are exposed to the job in hospitals and clinics affiliated with the medical school. The transition out of the classroom is always a challenge. There are many steps to take before graduation.
Clinical Rotations in the Third Year
The medical student is exposed to the major clinical fields for weeks at a time. In general, the third year covers fields like internal medicine, pediatrics, family medicine, surgery, obstetrics, gynecology, and psychiatry. Each rotation, or clerkship, has a similar structure plus characteristics unique to it.
The medical student is usually under the supervision of a resident, or doctor in training. There are often two residents to work with: a first-year resident, also known as an intern, and a resident in the second year or beyond. The entire team is managed by an attending physician whose role involves guidance and teaching. More time is spent with the resident than the attending physician for the day-to-day clinical work, but the attending physician is there for difficult clinical situations.
From day one, the student performs the basic duties of a physician. For each new patient admitted into the hospital or visiting the clinic, the student interviews the patient and performs a physical exam. He or she presents the patient case to the resident and/or attending physician. The student should also attempt to make a diagnosis and develop a plan for further testing and treatment. For hospitalized patients, the student also checks in on the patient each day (pre-rounding) before the team goes around and discusses each patient (rounding). Since the rotation is intended to expose the student to a real work environment, this means starting the day early if necessary. Working on call, which can be overnight or several extra hours beyond the usual day, and weekends may be required for the same reason.
Other tasks include learning hands-on procedures, keeping track of clinical information on hospitalized patients, and checking results of tests. Although the student is working, he or she is also studying. One of the most important tasks as a doctor is to learn independently. Because of this, the attending physician often tells the student to look up information related to the patients. There are also medical school lectures and conferences within a hospital, including morning report and noon conference. A student must balance patient care and medical education.
The student is expected to bring a stethoscope, a reflex hammer, and other necessary medical instruments for any clinical setting. He or she should also carry pocket medical references for quick referral, such as pocketbooks for drugs (e.g., Tarascon Pharmacopoeia) and medical conditions (e.g., Massachusetts General Hospital Pocket Medicine). Personal digital assistants (PDAs) with medical software also serve this purpose and are preferred by many medical students.
The grade for each rotation is based on two components. The first involves attending physicians filling out evaluations of the student's overall performance, which includes knowledge, attitude, professionalism, and work ethic. The second involves a standardized test to assess the student's knowledge of the clinical specialty.
Clinical Rotations in the Fourth Year
Regarding the fourth year of medical school, it is the student's year to explore and customize his or her education. Often, the student is required to do a sub-internship, a rotation that involves more workload than a third-year rotation. This is usually in either internal medicine or pediatrics and serves to transition the student to residency. A few other rotations may be required. Otherwise, there is a minimum number of elective rotations that the student chooses to do based on the specialty of interest or personal curiosity. These can be done within the medical school or at an outside institution.
Standardized Testing
For graduation, students in the United States must take Step 2 of the United States Medical Licensing Examination. Since 2004, Step 2 has been divided further into two separate tests. USMLE Step 2 Clinical Knowledge (CK) is the multiple-choice exam testing knowledge of the third year of medical school. USMLE Step 2 Clinical Skills (CS) is a new test that focuses on communication skills. It involves actors playing the role of patients for students to interview and examine, just like in a real clinical setting. Passing the test is based on doing the appropriate things in the patient encounter, writing a chart note with a reasonable assessment and plan, and communicating clearly and professionally.
Residency Matching
Most students graduate from medical school intending to participate in patient care. During the fall months of the fourth year, students apply for residency. They complete a single application to be sent to residency programs of interest in their specialty of choice. They go to interviews after being invited, just like applying for medical school.
After interviews, students take part in the National Resident Matching Program. Out of the programs that interview them, students submit a list of the ones they want, ranked in order of preference and leaving out programs they do not wish to be considered for. Each residency program submits their own list ranking the candidates in order of preference. A computer then attempts to match the applicant preferences against the institution preferences. If the student's #1 program also ranked him or her in the list, the student is placed among the program's open slots. Otherwise, the computer goes to the #2 program and repeats the process. At times, a student is in a slot but is bumped out by a higher-ranking candidate, after which the computer rematches the student based on the remaining choices in the list. This goes on until the computer matches everyone somewhere to the best of its ability.
The results are announced on Match Day, which is usually every March. This along with graduation day are the most important days for any new medical doctor.
References
- Liaison Committee on Medical Education (LCME) - Functions and Structure of a Medical School
- United States Medical Licensing Examination (USMLE), Step 2
- National Resident Matching Program (NRMP)
