The Fourth Year

The Fourth Year

Rian M. Hasson

Andrea B. Wolffing

Sandra L. Wong


The vital importance of diversity in the surgical workforce has been covered in other chapters of this book, so the focus here will not be on the inherent business case for diversity, but rather on the needed work around the fourth clinical year of the medical school curriculum to attract and recruit talented students to careers in surgery. While many of the illustrative examples included in this chapter are focused on women and underrepresented in medicine students, the principles may be extrapolated to broader issues of diversity and inclusion in surgery.


Many statistics portray the changing demographics of medical schools. Data from the American Association of Medical Colleges1 show that, in 2018, numbers of female, black or African-American students, and American Indian or Alaska Native applicants and enrollees increased. In fact, more women than men enrolled overall.
The number of black or African-American men who enrolled increased by 4.6% after many years of decline or minimal growth. Medical schools are becoming more diverse.

While women now represent the majority of students enrolling in US medical schools, there are still a gap with those underrepresented in medicine (defined as those racial and ethnic populations underrepresented in the medical profession relative to their numbers in the general population2) and in the pipeline for surgical careers. There is more of a paucity of data around the LGBTQ + population (encompassing all members of the sexual behavior minority and gender identity minority communities) because so many choose not to disclose sexual or gender identity status.

There is underrepresentation of diverse populations in the ranks of practicing surgeons, and this perpetuates barriers to careers in surgery. Women make up less than 21% of practicing general surgeons, but a far lower proportion in subspecialties such as orthopedic surgery (5.3%) and thoracic surgery (7.0%).3 While the overall number of women in surgery has steadily increased, their numbers in academic surgery positions and high-ranking leadership positions remain low,4 and women constitute only 25% of assistant professors, 17% of associate professors, and 9% of full professors in the United States. As such, medical student exposure to women in surgery is sparse, and the profession is still strongly influenced by surgical stereotypes5:

The “iron surgeon” powerful, invulnerable, untiring. Those trained by him pass on the mystique, transmitting from one surgical generation to the next an embodied professional ethos. The iron surgeon does battle with death, exterminates disease, declares war on softness, sloth, and error. He is technically brilliant, clinically astute, technologically sophisticated. His feelings, if he has any, are private; his inner life, if he has time for one, is unengaged by his work. The feelings of his patients are also private. Their personalities, problems, hopes, aspirations, are irrelevant. The iron surgeon’s task is to excise disease. The rest is for nurses or social workers.

This picture portrays surgeons as an example of decisive, masculine perfection; it is implied that surgeons do not display weakness or emotion, nor give excess thought to communication or family issues which, if raised, are thought to be contradictory to their role. This view has discouraged those whose values or personal characteristics do not align with such an antiquated (and untrue) portrayal of a rewarding career in surgery.6

Applications from US medical students to general surgery programs decreased 13% in the 2 decades between 1994 and 2014,7 though these numbers appear to have stabilized more recently. Of course, many factors impact career decisions, and not all students should consider a surgical career.8 This is a decision that may have been solidified even before the start of the clinical curriculum.9 When there is possible interest in the field, multiple factors contribute to perceived barriers to careers in surgery, notably including a lack of exposure to and participation in surgical procedures10,11 and decreased access to surgical role models, gender concerns, and perceived inability to achieve work-life balance.12 Suggestions for improvement include improved attending surgeon awareness of such stereotypes, participatory encouragement in surgery, and the sharing of “real-life” narratives to dispel the negative stereotypes influencing surgical recruitment.6


While medical student exposure to interest groups typically takes place far earlier in the medical school curriculum than the senior year, the impact of exposure to and engagement in surgical experiences should be emphasized during the third- and fourth-year clerkships and elective/subintern rotations. During the fourth year, students select their rotation schedules based on specialties of interest to them as possible career choices. Electives or subinternships are unique opportunities to engage those students who have identified a potential interest in a surgical career or who have demonstrated talents or skills that would be desirable in a future surgeon.

Surgical activities such as use of surgical simulation tools (e.g., suture kits, laparoscopic box trainers) or participation in wet labs (e.g., skull base labs or bone labs), either as a component of a rotation or as a supplemental resource, may increase a student’s desire to pursue a surgical residency. Many medical schools now offer “boot camp” opportunities for students who have matched into a surgical specialty in preparation for internship (typically toward the end of medical school), but consideration of such electives earlier in the senior year may influence decision-making prior to specialty selection. These popular practicum electives have an interactive focus on developing clinical and procedural skills in a structured setting. Many curricula are designed to include surgical anatomy and surgical skills (with highly sought-after opportunities to use simulation tools or work with animal or cadaver models) as well as scenario-based instruction around perioperative floor or ICU management (i.e., mock paging).

Outside of classic curriculum-based learning, unique opportunities for medical student engagement include short but high-impact activities such as the Student Surgery Leadership Weekend hosted by Michigan Medicine ( and the Society of Thoracic Surgeons Looking to the Future Scholarship Program ( Engagement of students and exposure to the field (including time with attending surgeons) appear to be key elements of these local and national programs, especially since such exposure goes beyond the walls of a familiar “home institution” and demonstrates the reach of a surgical career outside of a clinic or operating room.

Data suggest that both surgical residents and faculty members greatly underestimate their outsized influence on a student’s ultimate decision-making around a career in surgery. A cross-sectional survey showed that over 62% of residency applicants “strongly agreed” that residents and faculty played an important role in shaping their decisions, but only 10.7% and 4.5% of residents and faculty, respectively, felt similarly about the degree of their influence.13 For those faculty who may take an opportunity to reminisce about their own days as medical students, they may in fact recall how instrumental their resident team was to their education on any given rotation or the special sense of engagement when a faculty member made an extra effort to notice the student during a complicated case or during a busy clinic to go over a teaching point. Even simply demonstrating “joy in your work” in the form of patient care or an operative procedure can have an impact on a student otherwise inundated with patient lists and daily tasks. What many surgeons may also recall is the moment when someone indicated to them that surgery should be a career they consider. These points of contact, which can actually be quite brief, have high impact. Taking advantage of these informal opportunities matters to students and can make the difference between a student who feels like they could be a surgeon (or not).


Diversity and Inclusion

Medical schools and healthcare institutions continue to promulgate a more diverse workforce, but parallel efforts to ensure inclusion seem to lag. A key factor needs to be accounted for: creating a work environment that does not undermine efforts to achieve diversity.

A common scenario: A student has finally made it… Made it through the first 2 years of medical training and they have completed their third-year rotations. Career paths have narrowed, life decisions are being finalized, and the students are well on their way to securing their fate in surgery. They appear “bright-eyed, bushy tailed,” and ready to conquer the world. Despite the notion that surgery is a homogenous “old boys club” with grueling hours, thankless sacrifice, and minimal efforts to improve diversity and inclusion, things appear to have changed. Work hours have been reduced, there is greater emphasis on teaching and simulation, and the field is ready to welcome them with open arms. It is a new day… or is it?

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

May 5, 2022 | Posted by in GENERAL SURGERY | Comments Off on The Fourth Year

Full access? Get Clinical Tree

Get Clinical Tree app for offline access