Med school on the five-year plan

Like most of his classmates, Julius Oatts is staying on at the School of Medicine for a fifth year of study. This option, available for more than 20 years, has become increasingly popular, with as many as two-thirds of each class adding a year to their medical studies, primarily to do research. For Oatts, an extra year gives him the chance to try on the lifestyle of a physician-scientist. “It’s easy to say you’re interested in patient care and research in the beginning of med school, but this is the first time that I have seen what the day-to-day of that is like, both the challenges and the benefits,” Oatts said, who’s doing research in ophthalmology. “You take a project and it’s yours for the year.”

At a time when some are calling to shorten medical training, more than half of Yale students are choosing to extend it. A March 21 article in The Journal of the American Medical Association called for a reduction in medical training by 30 percent by 2020, arguing that the lengthy and expensive training is a driver of high health care costs. Other articles call for accelerating medical education to address physician shortages, citing lack of evidence that longer training makes a better doctor. Dozens of schools are putting this theory to the test with six- to seven-year combined BS/M.D.programs. Some medical schools are offering students a three-year plan. Yale students are sticking around, however, to carry out research, bolster residency applications, explore career options—or maybe take one last year to focus on things other than medicine. While some other medical schools offer additional time for predefined research projects, Yale is unique in the absolute freedom it gives students.

The first students to take a fifth year to do research did so in the 1980s. For many years the number held steady at about half the class. In 2007, however, three-quarters of the class stayed on for a fifth year. About half the next year’s class took a fifth year; in subsequent years the number of students staying on has hovered between two-thirds and three-quarters of each class—65 students who started with the Class of 2011, and 57 who began their studies with the Class of 2012.

Originally devoted to a year of full-time research, the fifth year was born out of a recognized decline in physician-scientists, said John Forrest, M.D., HS ’67, professor of medicine and director of the Office of Student Research. Meanwhile, the months available for research in the four-year curriculum had slipped over the years from about 11 to five and a half as new requirements were added.

“Students who conduct 12 months of full-time research receive full fellowships of $24,000 to $28,000 per year. These fellowships are supported by grants from the Howard Hughes Medical Institute, our NIH CTSA-TL 1 grant, the Doris Duke Charitable Foundation, the American Society of Nephrology, the American Heart Association, and Yale-endowed one-year research fellowships,” Forrest said. “Many funding agencies supporting research are alarmed at the national decline in physician-scientists and have stepped up to the plate. They recognize that careers as physician-scientists often begin in medical school, particularly at research-intensive institutions such as ours.”

About half the students taking a fifth year spend only part of the time doing research in what’s called a partially funded or “flexible” fifth year. Their months of full-time research are funded at the NIH predoctoral rate. The year might include research and rotations abroad. Students also audit undergraduate classes and do elective rotations—two went to culinary school and wrote a nutrition curriculum for the medical school. Others take the year, or more, to earn a joint degree in public health, public policy, business administration, or theology.

“If there’s 70 people that do it, there’s 70 different things that they’ll get out of it and put into it,” said Michael Soule, M.D. ’12, who spent his fifth year researching substance abuse treatment in correctional facilities, serving on the admissions committee, and taking a class on his favorite poet, Wallace Stevens. “Literature and writing keep me afloat as a person,” said Soule, who began his residency in psychiatry at Massachusetts General Hospital last summer.

Zahir Kanjee, M.D. ’11, studied art history, Spanish, European literature, and kept up with The New England Journal of Medicine. He also squeezed in workouts, time with friends, and three months in South Africa researching drug-resistant TB. Kanjee, now an internal medicine resident at Brigham and Women’s Hospital in Boston, said students have dubbed the four-year route at Yale “the accelerated track.”

The fifth year at Yale is tuition-free, though some students may need additional loans to cover living expenses. The payoff, they said, is immeasurable. It’s been called the best year of medical school by many. “It’s a wonderful opportunity that most med students don’t get,” Kanjee said. “It made me a better person, a better doctor, a happier and more complete person.”

But with more than half the class adding a year to already lengthy training, is there simply too much to do in four years at Yale? For some students, the four-year track is too overscheduled to make a career decision, conduct in-depth research, and take advantage of what Yale offers outside the med school.

“One of the biggest things that I think drives our students to take a fifth year is that there isn’t enough time in the third year to make a career decision,” said Nancy Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean of student affairs. The third year, with its required clerkships in the core areas of medicine, has a tight schedule.

That’s one reason Mei Elansary, M.D. ’12, who started a residency in pediatrics at Children’s Hospital Boston after graduation, took a fifth year. “My third-year exposure wasn’t quite enough to decide if [pediatrics] was for me,” so an elective in pediatric emergency medicine during her fifth year helped finalize the decision.

Students who take a fifth year also tend to finish medical school with numerous publications and national meeting presentations on their résumés. “They’ve heard it will help their residency applications, especially in fields where there is a lot of pressure to do research in that area and publish,” Angoff said.

A framework for overhauling the curriculum is now under way and will likely give students additional time for research and electives. Opinions are mixed among faculty and students as to whether this change will affect the number of students who stay on for an extra year. Some insist that the fifth year, symbolic of the medical school’s culture of independent research and a thesis, isn’t going to change.

“Treating students with the understanding that we are going to be professionals who are all interested in different things, and putting the resources behind us to pursue our interests at the depth that we want—that trust and commitment to the students is reflected in the fifth year,” Soule said. “I think it’s really a reflection of the greater ethos of the school.”