A Capstone Course for Senior Medical Students: from Innovative Elective to Required Core Curriculum

Abstract

We describe our institution’s development and implementation of our Capstone course from a small elective course to the only required fourth-year course. The course’s structure evolved from mostly didactic to one including various workshops and simulation sessions. Course content has become increasingly specialty-specific. Implementation requires high faculty and resident involvement. Evaluations indicate a positive impact of the course on participants’ self-reported confidence and residency preparedness. Assessment remains pass/fail with more specialty-specific questions. As steadily increasing numbers of medical schools are developing transition to residency courses, we share our Capstone course’s evolution and lessons learned over the past nine years.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01880-2.

Introduction

A largely elective fourth year of medical school provides students with substantial flexibility but may not optimally prepare students for the transition to residency [1, 2]. Recently, the Coalition for Physician Accountability Undergraduate Medical Education (UME)-Graduate Medical Education (GME) Review Committee (UGRC) recommended specialty-specific training for all incoming first-year residents to improve patient care while transitioning from student to physician [3]. Some of this specialty-aligned training in knowledge and skills could occur during the fourth year of medical school, possibly through transition to residency courses, as residents who participated in a “boot camp” during medical school reported greater residency preparedness than those who did not participate with an observed dose effect of higher preparedness with longer courses [3].

Many medical schools have developed “boot camp” or capstone courses of varying length and content, some of which have published descriptions of their course development [1, 4, 5]. As noted in these reports, curricular development generally starts with needs assessments and medical student leadership input [1, 5–7]. This development includes discussions with medical students, program directors, and residents; review of Accreditation Council for Graduate Medical Education (ACGME) competencies; and feedback and surveys from recent medical school graduates in residency.

In 2012, we began a limited fourth-year Capstone internship preparation course that was fully integrated into the core required curriculum three years later. The development of a required Capstone course for an entire fourth-year class presents enormous logistical challenges and requires considerable financial and personnel resources, a strong medical education leadership commitment, and active engagement of students. Here, we describe the first longitudinal study of a Capstone course over nine years from a small innovative elective to a core component of the fourth-year curriculum with continued iterative development and modifications. We highlight the challenges that were overcome, the role of student feedback, and areas for ongoing improvement. Our experience with the course’s evolution may provide a template for schools in the process of developing or expanding their own residency preparation programs.

Methods

Course Inception

The fourth year at Washington University School of Medicine historically consisted entirely of elective rotations with flexibility to tailor clinical rotations and plan around residency interviews. Several studies have shown, however, that students are often underprepared for the transition to residency, and substantial variability in the structure of their elective year can negatively impact that preparation [8–10]. In 2011, the ACGME reduced intern shift length from 24 to 16 hours and introduced requirements around the transition from direct to indirect supervision of patient care activities. Thus, many medical schools, including ours, felt an urgency to help their future graduates become better prepared to succeed in this new environment as an intern.

Prior to 2011, our medical school had some experience with smaller department-level intern preparatory elective programs. In 2005, the Department of Medicine held a one-day session for students matching into internal medicine that covered electrocardiogram (ECG) interpretation, arrhythmia recognition, radiograph interpretation, and shortness of breath and chest pain evaluation and management. The Department of Pediatrics created a similar session that included pediatric topics. In 2006, the Department of Surgery initiated a weekly elective accelerated skills preparation course over seven afternoon sessions for fourth-year medical students matching into any surgical residency. This course improved student confidence and performance in procedural skills of suturing, knot tying, chest tube and central line insertion, airway management, use of surgical energy devices, laparoscopic skills, and on-call management [11].

Based on these successful educational interventions and following the new 2011 ACGME duty-hour directives, under the guidance of the Associate Dean for Medical Student Education, the directors of both the surgical and internal medicine preparatory courses (LMB and TMDF) along with a committee of multidisciplinary faculty agreed to pilot a new Capstone multidisciplinary two-week elective in the spring of 2012 prior to graduation. This development was substantially grounded in the course development at peer institutions. For practical reasons, initial enrollment was limited to 30 students. Over 60 students expressed interest, leading to a 30-student waitlist. In 2013, enrollment was expanded to 60 and the course length was increased to four weeks in order to expand the curricular content offered, to accommodate the larger number numbers of students, and to compensate for the additional time needed to schedule students in the simulation center. Even with the expansion to 60 students, another 30 students were waitlisted. Due to tremendous student demand, enrollment was increased to 90 in 2014. After clear signs of success (i.e., continued high demand and positive evaluation data), the Capstone course became required in 2015 after review by the medical school curriculum governance committees. To accommodate the entire class of approximately 125 students, the four-week course was offered twice during the second half of the year (Table 1). Since the Capstone course became part of the required curriculum, it has consistently been one of the most highly rated courses in the medical school curriculum.

Table 1.

Outline of Capstone course structure and staffing by year

	2012	2013	2014	2015	2016	2017	2018	2019	2020
Number of weeks	2	4	4	4	4	4	4	4	4
Course type	Elective	Elective	Elective	Required	Required	Required	Required	Required	Required
Number of sessions	1	1	1	2	2	2	2	2	2
Grading scheme	Pass/fail	Pass/fail	Pass/fail	Pass/fail	Pass/fail	Pass/fail	Pass/fail	Pass/fail	Pass/fail
Students enrolled	31	60	80	125	94	134	117	128	122
Students on waitlist	30	30	0	–-	–-	–-	–-	–-	–-
Course director(s)	2	2	2	1	1	1	1	1	4
Course director specialty	IM, Surgery	IM, Surgery	IM, Surgery	Anesthesiology	Anesthesiology	IM	IM	IM	IM, Ob/Gyn, Peds, Surgery
Course director FTE	0.0	0.0	0.1	0.1	0.1	0.1	0.1	0.25	0.4
Course budgeta	$4547.84	$6800.91	$8269.19	$15,277.20	$28,934.08b	$18,093.84	$15,276.00	$12,889.33	$8681.41
Number of departments	8	7	11	8	11	11	11	11	11
Number of faculty teachers	32	29	79	42	60	71	66	63	45c
Number of resident/fellow teachers	11	11	58	48	46	57	65	49	39c
Number of other teachers	2	9	20	7	11	8	10	9	8
Lecture and large group discussion hours	29	41	40	40	42	43	40.5	41	41
Small group discussion hours	2	9	32	26.5	20.5	24.5	15.5	28.5	19.5
Workshop/Sim hours	17	17	26	26	30	35	35	30	42.5
Specialty session hours	–-	8	24	45	32	53	44	36	40
Overall course rating	–-	–-	–-	4.1	4.2	4.2	4.4	4.2	4.1

FTE full time equivalent (%), IM internal medicine, Ob/Gyn obstetrics and gynecology, Peds pediatrics

^aCourse budget does not include FTE salary support for course director(s)

^bCourse budget was higher in 2016 due to the animals for the surgery animate lab

^cThere were fewer faculty and residents involved in 2020 due to COVID

Initial Structure

An ad hoc Capstone Curriculum Committee, including fourth-year student representatives and physicians from multiple specialties, met numerous times beginning in 2011 and mapped the initial curriculum to the ACGME core competencies via consensus. As many elements of the department-specific sessions were rated highly by students and also mapped to core competencies, those sessions were included in the initial curriculum. Additional topics were chosen based on the likelihood of being high yield for the largest number of learners, willingness and expertise of available faculty, and local resources such as a simulation center. Given the background of the initial course directors (TMDF and LMB), much of the pilot course’s content fell broadly into the domains of general medicine and surgery; however, committee members from other specialties corroborated the general applicability of much of the content. From the outset, it was clear that the content would evolve over time, presuming the pilot was successful.

In 2012, enrolled students participated in all sessions. Didactic and small group sessions were in the morning, while workshops, simulations, and skill training sessions were in the afternoon. Morning session topics applied to all students (e.g., management of unstable arrhythmias, fatigue mitigation strategies, and ethical decision-making). Afternoon sessions included a mix of content that was generally applicable (e.g., airway management and on-call simulations) and specialty-specific (e.g., laparoscopic skills). Mid-level residents led specialty-specific on-call problem sessions on real-time patient management scenarios commonly experienced by interns.

Course Evolution

Table 1 and Appendix A show the evolution of the curriculum from 2012 to 2020. Since the course’s inception, pass/fail grading, timing in the spring of the fourth year, and the content of much of the core lecture series have been consistent. The initial course duration of two weeks was expanded to four weeks in 2013 to allow for increased course content and student contact hours and to facilitate simulation center scheduling.

Student and graduate feedback have guided substantive curricular changes, including more specialty-specific sessions, particularly for pediatrics, orthopedics, obstetrics/gynecology, emergency medicine, and psychiatry. Additionally, pre-skill session training lectures covering indications, contraindications, and procedural instructions were shortened and supplemented with procedural videos to provide more time for practice in simulated settings.

Current Course

The current required Capstone four-week course is offered twice per year (February and March), with 60–65 students per session. There are four specialty-specific tracks: internal medicine, surgery, pediatrics, and obstetrics and gynecology. In large measure, the content covered is well-aligned with national trends (Table 2). Morning sessions are primarily didactic, with some interactive formats and small groups geared toward practical medical management situations, and cover medical management expected of interns. Morning pediatric breakout sessions occur concurrently with adult sessions. Students who will care for adult and pediatric patients in residency (e.g., anesthesiology, emergency medicine, and internal medicine/pediatrics) can attend pediatric breakout sessions and watch the videotaped adult sessions later.

Table 2.

Required transition to residency courses in the fourth year at U.S. LCME-accredited medical schools

	2015-16	2016-17	2017-18	2018-19	2019-20
U.S. LCME-accredited schools participating in the survey	142	145	147	151	153
Number (%) of schools with required residency transition course for all studentsa	43 (30%)	88 (61%)	89 (61%)	101 (67%)	108 (71%)
Number (%) of schools with required specialty-specific residency transition course(s)a	39 (27%)	51 (35%)	58 (39%)	63 (42%)	63 (41%)
Total number (%) of schools with required residency transition course(s) (course for all students and/or specialty-specific courses)a,b	82 (58%)	98 (68%)	96 (65%)	106 (70%)	115 (75%)
Of schools with required transition courses, number (%) with topics of…	# (% of 82)	# (% of 98)	# (% of 96)	# (% of 106)	# (% of 115)
Training in clinical procedures	72 (88%)	71 (72%)	76 (79%)	84 (79%)	97 (84%)
Disease management	69 (84%)	65 (66%)	68 (71%)	76 (72%)	86 (75%)
Working with EHR/health records	44 (54%)	44 (45%)	43 (45%)	53 (50%)	65 (57%)
Health system content	75 (91%)	69 (70%)	62 (65%)	76 (72%)	81 (70%)
Medical regulatory content	45 (55%)	48 (49%)	50 (52%)	60 (57%)	68 (59%)
Stress, wellness, and burnout in residency trainingc	60 (73%)	71 (72%)	74 (77%)	87 (82%)	101 (88%)
Handoff procedures	58 (71%)	66 (67%)	73 (76%)	85 (80%)	94 (82%)
ACLS/ATLS training and certification	38 (46%)	43 (44%)	49 (51%)	55 (52%)	52 (45%)
Experiencing the life of a resident	57 (70%)	N/A	N/A	N/A	N/A
Patient safety/reporting and medical errors	N/A	67 (68%)	72 (75%)	85 (80%)	91 (79%)
Advanced communication skills	N/A	N/A	67 (70%)	80 (75%)	93 (81%)
Working in teams	N/A	N/A	73 (76%)	92 (87%)	93 (81%)
On-call emergencies	N/A	N/A	N/A	76 (72%)	86 (75%)

Source of data: Unless otherwise noted, LCME Part II Annual Medical School Questionnaire provided by Andrew Nees, Senior Research & Data Analyst Data Operations and Services, Association of American Medical Colleges

LCME Liaison Committee on Medical Education, EHR electronic health record, ACLS advanced cardiac life support, ATLS advanced trauma life support, N/A not applicable (item was not included on questionnaire)

^aSource of data: https://www.aamc.org/data-reports/curriculum-reports/interactive-data/medical-schools-transition-residency-course

^bA school was counted as having a course if the school reported a required fourth-year transition to residency course that included at least one of the listed topic areas

^cWording in 2016 was “Stress and Burnout in Residency Training” while in 2017–2020 was “Stress, wellness and burnout in residency training”

Afternoon sessions are hands-on workshops and simulations. All students participate in procedural workshops that cover vascular access (peripheral intravenous line, central venous catheter, intraosseous access), diagnostics (ultrasound, paracentesis, thoracentesis, lumbar puncture, arterial blood gas), and common technical skills (suturing, chest tubes, Foley catheters, nasogastric tubes, local anesthesia, arterial lines). Simulations cover airway and acute care management scenarios, and small groups discuss on-call problems and mock pages from nurses.

Specialty-specific workshops include emergency simulations, case-based discussions, laparoscopic labs, energy sources and stapling labs, casting and splinting simulations, and a Trauma Evaluation and Management (TEAM) session in preparation for Advanced Trauma Life Support (ATLS) training, which students entering surgery, emergency medicine, and anesthesiology take to prepare for internship requirements in many institutions. Based on student rosters, specialty-specific sessions for students entering psychiatry and pathology are incorporated annually when applicable and available by respective departments.

Implementation Challenges and Responses

One of the most resource-intensive curricular components in the entire medical school, the Capstone course requires more than 100 residents, fellows, nurses, attending physicians, and other health professionals annually as instructors.

To meet this challenge, the course leadership meets with education staff to provide oversight on course administration. In 2020, leadership expanded to four course directors, representing major specialties (internal medicine, obstetrics/gynecology, pediatrics, and surgery), after having one to two course directors prior to this. A 0.1 full-time equivalent (FTE) faculty support for a single course director was created in 2014 and has expanded to 0.1 FTE per course director currently. Residents and nurses receive small financial stipends for teaching hands-on sessions. The Office of Medical Student Education expanded the course budget to accommodate these changes.

Faculty and trainees in most clinical departments now help teach the course, with several benefits from multi-departmental involvement. Course ownership by many departments broadly distributes instructional hour workload. Residents and faculty interface with future members of their fields and training programs through hands-on sessions and small group discussions. Finally, faculty collaborate across departments in curricular development and course implementation.

Data Collection and Analysis

Over the nine-year course administration period of 2012–2020, four different sets of Capstone course data were collected. First, a pre-course questionnaire was collected from 2012 to 2017 and included intended specialty, preparation for intern year, course-specific factors that varied year-to-year, procedural skill experience, and confidence in patient management scenarios and procedures (Appendix C). Due to year-to-year consistency of responses, the pre-course questionnaire was eliminated in 2018. Second, a post-course questionnaire was collected from 2012 to present and included overall course and session ratings with narrative feedback, course-specific questions, and confidence in patient management scenarios and procedures (Appendix D). All students who participate in Capstone were required to take the pre-course questionnaire (through 2017) and post-course questionnaires, and their responses were de-identified prior to analysis. The repetition of confidence questions between the pre-course and post-course questionnaires allowed for pre/post analyses of impact of the Capstone course on preparation for intern year skills.

Third, a standardized course evaluation was collected from 2015 to present and included overall ratings for aspects of the course and year-to-year variations in course-specific questions (Appendix E). This evaluation form is standardized across all required courses at Washington University School of Medicine (WUSM), which is why data collection began in 2015 when the Capstone course became a required part of the curriculum. Overall course rating was from poor (1) to excellent (5). Course-specific questions allowed for continued evolution of the course based on annual student feedback.

Fourth, an early post-graduate year 1 (PGY-1) survey was collected 2012 to 2018 and included a 5-point Likert rating of the course (Appendix F). This survey was administered 3 months into intern year to all medical school graduates who took the course: a subset from 2012 to 2014 when elective and all graduates from 2015 to 2018 when the course was required. Graduates rated whether the course was useful in preparing for PGY-1 from strongly disagree (1) to strongly agree (5). This question was eliminated from the PGY-1 survey in 2019 due to year-to-year consistency in responses and to reduce survey burden.

Descriptive statistics are presented by year. Paired Student’s t-test compared pre- and post-course responses by year. Statistical significance was defined as two-sided p < 0.05.

Results

As shown in Table 1, from 2012 to 2020, a total of 891 fourth-year students completed the Capstone course. The course was elective with a single session annually from 2012 to 2014 and became required in 2015 with two sessions annually. The number of course directors fluctuated from two (2012–2014) to one (2015–2019) to four (2020) with course directors from various specialties. Course director support has increased from a total of 0.0 (2012) to 0.4 FTE (2020). Not including course director FTE, the course’s budget increased annually from roughly $4500 in 2012 to almost $29,000 in 2016 due to animal costs for the surgery animate lab. Since then, the course budget has since decreased annually to roughly $8700 in 2020. The number of involved departments, faculty, trainees, and other staff involved increased as the course grew to a total of 11 departments and as many as 140 teachers but decreased in 2020 with changes in the course due to COVID. Specialty sessions increased to a peak of 53 h in 2017 and have stabilized to roughly 40 h annually since then. Workshop and simulation hours have increased to over 40 h in 2020. The course has maintained pass/fail grading throughout its history.

Pre- and Post-Capstone Course Questionnaires

Pre- and post-course questionnaire annual survey results are shown in Table 3. As expected for required questionnaires, response rates were very high (96–100%). The Capstone course was highly recommended while elective (4.6–4.8 out of 5 in 2012–2014), and it continued meeting expectations for knowledge and procedural skills after transitioning from elective (4.3–4.5 out of 5 in 2012–2014) to required (4.1–4.5 out of 5 in 2015–2019). From 2012 to 2017, students’ post-course ratings were significantly higher than pre-course ratings for their preparedness for residency and confidence with the clinical skills required to begin a residency program. As stated in the “Methods,” the pre-course questionnaire was eliminated in 2018 to reduce survey burden. The Capstone course consistently met students’ expectations of increasing knowledge and improving procedural skills, but procedures were rated lower in 2020. When the course was offered on an elective basis, students almost universally agreed they would recommend the course to other fourth-year students.

Table 3.

Mean responses (standard deviations) to Capstone pre- and post-questionnaires by year

Graduating class	2012		2013		2014		2015		2016		2017		2018		2019		2020
Elective vs. required	Elective		Elective		Elective		Required		Required		Required		Required		Required		Required
Survey completion ratea	100%		97%		96%		98%		96%		98%		100%		100%		100%
Survey item	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post	Pre	Post
Overall, I am well prepared to begin a residency programb	3.6 (0.8)	4.0 (0.4)	3.6 (0.8)	4.0 (0.8)	3.8 (0.7)	4.1 (0.6)	3.6 (0.7)	4.0 (0.7)	3.6 (0.7)	4.1 (0.7)	3.5 (0.9)	4.0 (0.7)	–-	4.2 (0.7)	–-	4.1 (0.6)	–-	4.1 (0.7)
I am confident that I have acquired the clinical skills required to begin a residency programc	3.6 (0.7)	3.9 (0.4)	3.6 (0.9)	4.1 (0.7)	3.8 (0.7)	4.2 (0.6)	3.6 (0.8)	4.0 (0.7)	3.6 (0.8)	4.1 (0.7)	3.6 (0.8)	4.1 (0.6)	–-	4.1 (0.7)	–-	4.1 (0.6)	–-	4.1 (0.7)
The Capstone course met my expectations in increasing my level of knowledge on topics included in Capstone curriculum	–-	4.4 (0.5)	–-	4.3 (0.8)	–-	4.5 (0.6)	–-	4.1 (0.8)	–-	4.3 (0.8)	–-	4.4 (0.7)	–-	4.4 (0.7)	–-	4.4 (0.7)	–-	4.2 (0.7)
The Capstone course met my expectations in increasing my level of skill in performing procedures included in Capstone curriculum	–-	4.4 (0.5)	–-	4.4 (0.5)	–-	4.5 (0.6)	–-	4.2 (0.7)	–-	4.4 (0.6)	–-	4.3 (0.8)	–-	4.5 (0.6)	–-	4.4 (0.7)	–-	4.0 (1.0)
I would recommend the Capstone course to other 4th-year studentsd	–-	4.6 (0.5)	–-	4.6 (0.8)	–-	4.8 (0.5)	–-	–-	–-	–-	–-	–-	–-	–-	–-	–-	–-	–-

^aSurvey completion rate is for students who completed both the pre- and post-questionnaires for 2012–2017 and for those who completed the post-questionnaire in 2018–2020

^bPre vs post paired t-test; 2012: p = .016; 2013: p = .003; 2014–2017, p < .001

^cPre vs post paired t-test; 2012: p = .009; 2013–2017, p < .001

^dThis item was asked on the post-Capstone survey only for the years in which the Capstone course was offered on an elective basis (2012–2014)

Student Course Evaluations

As shown in Table 1, course quality ratings on student course evaluations consistently remained high in 2015–2020 after becoming required (overall course rating 4.1–4.4 out of 5). Similar to other required courses, student feedback was collected in a standardized fashion starting in 2015, and it has remained a very highly rated course in our 4-year curriculum. Within the Capstone course, the highest rated course elements were procedural skills workshops, case-based scenario discussions, responding to mock page scenarios, and emergent care simulations. Course challenges included the operational complexity, recruitment of resident and fellow instructors, and funding for some of the skills labs, primarily the animate surgical procedure lab. Students consistently indicated preferences for more specialty-specific content and interactive sessions, which were progressively integrated over the course of the Capstone evolution.

Post-Graduate Surveys

The results of PGY-1 surveys three months into residency for students who took the Capstone course are shown in Table 4. In 2012–2018, surveys were completed annually by 51–81% of graduates who took Capstone, with lower response rates after the Capstone became a required course. The Capstone question was eliminated from the PGY-1 survey in 2019 to shorten the survey. When Capstone was an elective course, graduates overwhelmingly agreed it was useful in preparing for their responsibilities at the start of residency (97% in 2012–2014, 113/117), and after the course became required, graduates continued reporting generally high levels of agreement (89% in 2015–2018, 231/259), though this represented a small but statistically significant decline in overall agreement (97% vs. 89%; p = 0.02).

Table 4.

Proportion of agreement to early PGY-1 survey regarding utility of Capstone course in preparation for PGY-1

Graduating class	2012	2013	2014	2015	2016	2017	2018
Number of enrolled students	31	60	80	125	94	134	117
Elective vs. required	Elective	Elective	Elective	Required	Required	Required	Required
Early PGY-1 survey response rate	81%	68%	64%	61%	51%	51%	57%
Percent who agreed or strongly agreeda	100%	93%	98%	87%	81%	90%	97%
Mean rating of Capstone course (SD)b	4.7 (0.7)	4.7 (0.7)	4.6 (0.5)	4.2 (0.9)	4.2 (1.0)	4.4 (0.7)	4.4 (0.6)

PGY postgraduate year, SD standard deviation

^aSurvey item was “The capstone course was useful in preparing me for my responsibilities at the start of the PGY-l year.” This item was eliminated from the survey in 2019

^bCalculated based on an average of responses to the item where 1 = strongly disagree, 2 = disagree, 3 = neutral/no opinion, 4 = agree, and 5 = strongly agree

Discussion

Our Capstone course for fourth-year medical students evolved over nine years from a generic, small, two-week elective offered once per year to an expanded and increasingly specialty-specific four-week required course offered twice per year. This evolution was grounded within a multidisciplinary, cross-departmental, collaborative process for course planning and administration since the course’s inception and was guided annually by robust student feedback. A significant aspect to our course is that it involves five full days (6 hours per day) of course sessions per week for two consecutive four-week sessions per year (8 weeks per year).

Our findings build on those from other medical schools on the benefits of a residency transition course. Since 1995, Baylor College of Medicine has offered a single two-week residency transition elective course for 60 students annually that has been rated as educationally valuable and significantly improved self-reported preparation [5]. Similarly, the University of California, San Francisco (UCSF), School of Medicine’s residency transition course has evolved into a three-week, required course that is one of the highest-rated courses in the curriculum and has led to self-reported improvements in 75% of the clinical skills areas in the course (medium effect size of 0.53) [1]. In 2012, Stony Brook School of Medicine implemented a four-week, required residency transition course that led to improvements in ratings by program directors of their graduates compared to before the course [12].

Baylor developed its course based on a needs assessment developed through discussions with medical students and residents [5]. UCSF’s course was informed by discussions with program directors, educators, and residents regarding the skills needed for incoming interns, reviewing transition course curricula from Duke University and University of Washington, and collecting recent graduates’ feedback [1]. Rutgers New Jersey Medical School used a needs assessment process of comparing the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities (EPAs) for Entering Residency as expectations at the time of graduation from medical school to the ACGME Level 1 Milestones expected by emergency medicine residencies. This process was used to create a curriculum for a new emergency medicine boot camp that would help address gaps in procedural skills [7]. Rush University Medical Center developed its internship preparatory course through the leadership of fourth-year medical students [6]. This student leadership was cited as one of the most important aspects of the new course in the post-course survey and successfully addressed gaps in the curriculum after a needs assessment [6].

Several recent reports and manuscripts indicate that similar efforts have been underway at many other US medical schools [13–15]. In 2013–2014, a committee within the Clerkship Directors in Internal Medicine described that 59% (80/136) of U.S. Liaison Committee on Medical Education (LCME)–accredited medical schools required Capstone courses, ranging from several days to four weeks, usually toward the end of the academic year though sometimes interspersed longitudinally [16]. Courses nationally covered medical management in common and serious scenarios, basic science review, procedural skills practice, and the importance of professionalism and communication skills. The most popular sessions were grounded in application of knowledge to intern situations such as responding to pages or managing a code [16]. In 2014, the Alliance for Clinical Education recommended Capstone courses for all medical schools that emphasized cross-cover management, procedures, communication, and sign-out [17].

From 2016 to 2020, the LCME Part II Annual Medical School Questionnaire data indicated that the prevalence of required residency transition courses (required residency transition course for all students and/or required specialty-specific courses) increased from 58% (82/142) of medical schools to 75% (115/153). However, the depth of content and hands-on skills development among required transition to residency courses at U.S. LCME-accredited medical schools as shown in Table 2 is unclear. Appendix B outlines how our Capstone course’s curricular content generally aligns with national trends.

Capstone course effectiveness has not been fully studied [18]. Two studies suggest that gains in knowledge or skills may be shorter-lived than gains in confidence [16, 19], and three studies have reported the benefits of internship preparatory courses in improving surgical skill confidence and skills with maintenance of improved performance [11, 20, 21]. The fourth year provides a unique point of intervention and innovation for the transition to residency [8]. Capstone courses may be particularly fertile ground for curricular change and implementation of uniform curricular components across medical schools to optimally prepare students for the responsibilities they will assume as interns. They may also help prepare students for the “boot camp” programs and surgical skills courses at the start of many residencies [22–24]. Notably, the Association of Program Directors in Surgery’s recent consensus statement recommends a residency preparatory course for all students entering general surgery internship and that “general surgery programs will more strongly consider candidates who have participated in a residency preparatory course” [25].

Sharing various school-specific approaches in capstone course curricular delivery and student assessment may be of value to the increasing number of schools requiring residency transition courses [4]. The Transition to Residency Course Educators’ Collaborative aims to provide a forum for course educators to openly share resources and curricula and to maintain a database of transition to residency courses at medical schools throughout the USA [26]. Outcome studies may identify optimal capstone course approaches (e.g., curricular content or duration) for residency preparation. Conducting such outcomes studies at a national level may become more feasible given the recent development of the AAMC Resident Readiness Survey (RRS), a national process for program directors to provide feedback to medical schools about the performance of their graduates [27]. A goal of the RRS is for continuous quality improvement of undergraduate medical education curricula. With this national data collection, the extent to which capstone course approaches may be associated with program directors’ ratings of medical school graduates for PGY-1 training can be examined.

Challenges and Limitations

While we speculate that this course’s curriculum positively impacts the transition to residency [3], our Capstone course outcomes data is limited to self-assessment, collected from course participants immediately after course completion and at three months into the start of their PGY-1 training. Additionally, course administration has had several challenges, particularly the March session in 2020 not being in-person due to COVID and likely affecting procedural ratings. Course director leadership has changed three times due to competing faculty commitments, which could affect continuity and efficient course administration. However, the core components have remained intact, and the simulation center director (JW) has remained constant throughout the course’s history. Formative feedback is supplied in small-group sessions, but outcomes assessment of performance in the course is limited to pass/fail on graded aspects. The PGY-1 survey is administered three months into residency and could be affected by recall bias or reflect broader residency preparedness rather than the specific impact of the Capstone course itself. Also, this survey was not given prior to the inception of the Capstone course, and responses from 2012 to 2014 may have been affected by selection bias among students who chose to take the elective course. Amidst these challenges, we have made course content more specialty-specific and continue to have a highly-rated course.

Conclusions

We describe our experience with the Capstone course over the past nine years. Although the course is labor-intensive, it provides content highly valued by our senior medical students after they have completed their residency interviews, submitted their rank lists, and are looking ahead to preparing for responsibilities they will assume in four months or less as residents. The UGRC’s Recommendations for the Comprehensive Improvement of the UME-GME Transition will likely increase interest at the national level for joint efforts by educators across the UME to GME continuum to optimally prepare learners for the start of residency training [3]. The evolution of our school’s Capstone course, providing one such example of joint efforts across the UME-GME continuum, highlights both the opportunities and challenges for innovation in transition to residency curricula and may serve as a template for institutions looking to start a Capstone type course or expand their course content and structure.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author Contribution

All the authors contributed to the manuscript conceptualization, drafting of the manuscript, and provided significant edits. Data were collated and analyzed by TMDF and DAA.

Funding

Not applicable.

Availability of Data and Material

Survey instruments are provided as appendices. The manuscript includes data from the Liaison Committee on Medical Education (LCME) Part II Annual Medical School Questionnaire, used with the permission of Andrew Nees, AAMC data steward for the LCME Part II Annual Medical School Questionnaire. This manuscript was reviewed prior to submission for publication by Mr. Nees regarding the data included in Table 2 and the corresponding text describing the content of Table 2. Data requests for Washington University School of Medicine data from this manuscript should be directed to Dr. De Fer (tdefer@wustl.edu). Data requests for LCME Annual Questionnaire Part II data from this manuscript should be submitted to the AAMC via the “Request AAMC Data” form at https://www.aamc.org/request-aamc-data.

Declarations

Ethics Approval and Consent to Participate

The Washington University in St. Louis Institutional Review Board determined this study was exempt.

Consent for Publication

Not applicable.

Competing Interests

Dr. Andriole is a co-author on this manuscript in her capacity as former Associate Professor of Surgery, Washington University School of Medicine, St. Louis, MO. On behalf of all authors, the corresponding author states that there is no conflict of interest.

Disclaimer

The views expressed herein are those of the authors and do not necessarily reflect the position or policy of the AAMC.