Background: The practice of medicine has changed dramatically over the last 3 decades. Medical education has struggled to keep up with these changes, with only limited success. The 4th year of medical school offers a tremendous opportunity for curricular innovation, but little change has occurred in the past 30 years. Description: This article traces the history of the 4th year, from the Flexnerian era in which the classic preclinical-clinical model for medical education was developed, through the 1970s, when virtually every medical school adopted a largely elective 4th year, to the present. Although the classic 4th-year curriculum has a number of strengths such as flexibility and relative autonomy of scheduling for students, it also has significant weaknesses. Evaluation: A major educational initiative for the 4th year - the "College Phase" - has been implemented at the David Geffen School of Medicine at UCLA. It is designed to remedy many of the weaknesses of the 4th-year curriculum while preserving the benefits. Conclusion: Five colleges have been created: acute care, applied anatomy, medical science, primary care, and urban underserved. Students participate in a number of different college-specific activities that are hoped to produce a more engaging, rigorous, and enriching experience for students and faculty alike.
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