Medical students are asked to learn a vast amount of material in their preclinical years in anticipation of clinical rotations where they are expected to decide their area of practice for the next several decades. However, clinical and theoretical practice can often differ greatly. Medical students may enjoy studying the pathophysiology of a given process but not the day-to-day practice associated with it. Certainly, the opposite can be true as well; a subject that is not especially appealing to in undergraduate medical education may be very satisfying if considering the patient population with whom they would work or procedures they can perform. Thus, if there is no concomitant clinical exposure and the material is considered in a vacuum, the students may misunderstand the field.
Between the second and the fourth year of medical school, almost 60% of students change their mind regarding their intended field of practice, suggesting that students should have broader exposure to other clinical fields in their preclinical years and third year. Although the surveys cannot assess for this and there are no similar surveys of all residents for alignment of their chosen field with their prior expectations, this large shift in interests may persist into residency and future practice.
There may be several different means of accomplishing this integration of the clinical experience and the theoretical. Models of exposing students to the clinical environment in the first and second year exist and are becoming more frequent [8–11]. These can be in brief, weeklong burst weeks rotating through different specialties in the hospital or ambulatory settings.
It may be equally or even more important though to intersperse exposure to less common rotations among the core rotations during the third year. Certainly, the knowledge gained in core rotations cannot be supplanted but understanding the details of a given field may be as important to students, as they map out their career trajectory. Because the third year is particularly weighty with students getting the bulk of their clinical exposure then, it could be argued that there is no time to include other specialties into the schedule and that students often have a few weeks of electives that could be used to explore non-core fields. However, students do not know what they do not know. Many may have never considered pain medicine, anesthesiology, or vascular surgery and so it would not cross their minds to carve out elective time for these specialties. Mandatory participation in a broad range of elective experiences interspersed throughout the third year would accomplish this with the added benefit of building knowledge and understanding for colleagues in other fields of medicine.
The application demands of competitive fields put those students who do not decide on that specialty at a disadvantage. There are residencies that will place greater emphasis on research output and, if students decide in their third year to do a certain specialty, they may not have time to produce the scholarly output that would make them a competitive candidate. This may starve certain fields of needed personnel and direct students to other fields where they may not find as much professional fulfillment.
There may be other student-specific characteristics that predispose to a career change. (Table 3) Their future salary and the perceived competitiveness of the field may influence students. The duration of training and demands of the field may affect students considering family planning. They may find that their personality aligns more with one field of medicine than another does. Family pressures can also influence choice. Finding a mentor is also crucial to entering into a field of medicine as they can guide, provide feedback, and manage expectations.
To be sure, students that enter any of the various specialties can find personal and professional fulfillment as they interact with patients and pursue their intellectual curiosity. Professional satisfaction does not necessarily equate with one sole field and people could find joy in many areas of medicine. There are also physicians who have changed careers after initial residency or fellowship but this requires many more years of training and can lead to financial and emotional stress, as residents cannot start their careers and may have less flexible hours.
Another important consideration is that the US is currently facing a crisis in primary care and one could argue that a curriculum that emphasizes primary care responds to current needs more than one that accentuates further sub-specialization. An integrated curriculum can accomplish both ends though, exposing students to the many fields in medicine while simultaneously showing the benefits of a career in primary care.
Such restructuring of the clinical years requires and a thoughtful, individualized approach, leaning on the strengths of various medical schools and health systems. One-size-fits-all programmatic development will minimize nuance and not meet the needs of students and so adaptability must be the hallmark of clinical integration. Successful integration may expand the horizons of students and optimize career alignment for many. Future medical education research should continue into enhance and augment clinical experience throughout the undergraduate medical education continuum.