For many medical students, the fourth year of school represents a transition of sorts. After a rapid succession of licensing exams, residency applications, acting internships, and away rotations, most students find themselves essentially done with medical school and looking ahead to the next phase of their training. The fall and winter are dominated by interviews, while the spring is preoccupied by the Match in late March before graduation in the early summer.
Schools not only tolerate but encourage this shift; the number of required rotations is limited to a mere few, with some students finishing as early as October. Students are often encouraged by the school to take “flex” or research months during interview season, in which no classes or formal responsibilities exist. The general consensus among students, teachers, and schools alike is that the fourth year represents a chance to travel, relax, and reset before entering the crucible of residency. Why, then, does it tend to be the most expensive?
Some of these costs can be attributed to the sheer cost of applying to residency; despite schools largely continuing to embrace the post-pandemic shift to virtual interviews, fees can easily range from $300 to more than $1000, depending on how many schools an applicant chooses to apply to. This is to say nothing of the additional costs associated with participating in required away rotations for specialties such as orthopaedic surgery and EM, or registering for the NRMP. A 2023 cross-sectional study of orthopaedic surgery applications, for example, found that away rotation costs ranged from $25–$4,000 for both allopathic and osteopathic students.
While the aforementioned costs certainly warrant discussion, a large driver of the fourth-year cost is undoubtedly that many schools charge the same full tuition price as previous years (an average of nearly $50,000 a year), despite students taking far fewer classes or rotations. A counterpoint could be that fourth-year schedules vary wildly; a student might opt to front-load their schedule with an empty second half, or vice versa. And while research/flex months are encouraged, students are not mandated to take them; theoretically, one could do electives every month of the year. But such a stance is impractical and ultimately does not reflect the reality of the year, where students understandably take a light course load after applying in order to recharge before residency. Nor does it account for the turbulence of interview season, in which invitations are extended at unpredictable times and desirable dates fill within a matter of minutes.
A potential solution to alleviating this financial burden could be to prorate a student’s tuition based on how many classes and electives they actually take. Many colleges already have systems in place to charge additional tuition for every credit hour taken above a pre-specified amount. Could the same work at the opposite end of the spectrum, in which students taking few classes in their final semester are charged a reduced sum? Alternatively, graduation eligibility should be determined by the completion of requirements and not strictly by fulfilling a sometimes arbitrary number of credit hours. During the pandemic, several medical schools, including NYU, allowed their students to graduate one to two months early to serve as front-line personnel; clearly, the structure already exists to facilitate an early graduation. It is a matter, then, of incentivizing all parties to do so.
In practicality, it could work like this: at my medical school, fourth-year students are required to complete, at the minimum, an internship, an EM rotation, two outpatient rotations, and three electives (seven blocks). The fourth year begins in May and consists of 12 four-week “blocks” through the year; blocks one through eight finish before the end of the calendar year, with the remaining four occurring between January and April. Our school also offers the opportunity through medical school to complete “longitudinal” electives throughout the previous three years. If completed correctly, these fulfill one or more of the elective requirements. A student who assumes the responsibility of balancing a heavier courseload upon scheduling could use the eight blocks to complete Step 2 and their seven required rotations. In the case of someone who previously completed a longitudinal elective, they would even have an additional month to spare for an away rotation or additional elective. These students, having finished all of their requirements in the first semester, could be given the option to graduate or finish a semester early, saving them more than $30,000. Some students will understandably elect not to pursue this route, but many would — it offers them both the financial and time flexibility to rest or pursue other interests before the beginning of residency.
In a field in which the average debt of medical school graduates is $264,000, renewed effort should be given to lowering costs of training. While some schools have introduced free tuition to all students, such programs are currently only made possible through large endowments and are currently infeasible for the vast majority of schools. Prorating the cost of fourth-year tuition based on classes would allow for financial relief while simultaneously honoring the flexibility that the final year of medical school provides.
What are your thoughts on the cost of each year of medical school? Share in the comments.
Ayush Peddireddi is a fourth-year medical student at the Ohio State University College of Medicine. His professional interests include hematologic malignancies, health care delivery, and public policy. He plans to pursue a residency in internal medicine following graduation.
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