Critical exposure: the role of medical school intensive care unit rotations

Introduction

Intensive care unit (ICU) experiences in medical school improve self-assessed preparedness and confidence for ICU rotations in residency and may enhance an intern’s ability to provide care for critically ill patients at the start of residency training.^1-4 ICU rotations during medical school also improve critical thinking, diagnostic and management skills, and are associated with better clinical evaluations during internship.5 On the first day of residency, interns must be able to recognize critically ill patients, order appropriate diagnostic studies, and initiate basic resuscitative management. However, many interns feel underprepared for this responsibility, as less than half of medical schools require critical care rotations and there is significant variability in the type and quality of ICU experiences.^4,6,7 It is important to explore the reasons why current interns chose or chose not to rotate in an ICU before residency and the ways in which those experiences impacted their intern year. With the benefit of hindsight, understanding how a medical school ICU experience was perceived and how it influenced intern year provides insight into the value of undergraduate critical care education. Therefore, we sought to evaluate the potential advantages and disadvantages of completing medical school ICU rotations from the perspective of residents at the end of their intern year.

Methods

A 17-item survey (Qualtrics, Provo, UT, Version XM) was distributed electronically in June 2024 to interns at the University of Colorado during the final two weeks of intern year. The survey included specialties requiring an ICU rotation: anesthesiology, emergency medicine, family medicine, general surgery, internal medicine, medicine-pediatrics, and pediatrics. Participants were classified as ward-based (internal medicine, family medicine, medicine-pediatrics, pediatrics, preliminary neurology, preliminary physical medicine and rehabilitation) or non-ward-based (surgery, anesthesia, emergency medicine, preliminary ophthalmology, preliminary urology).

Demographics, prior ICU experience, and rotation details were collected. Respondents provided Likert-scale ratings on perceived value, satisfaction, and curricular requirements, as well as open-ended reflections. Those without ICU experience were asked a yes or no question on whether they wished they had completed a rotation. For those who answered yes, we asked them to expand on the reasons why. Descriptive statistics and group comparisons (Chi-square or Fisher’s exact tests) were performed. Open-ended responses were analyzed using thematic analysis, with deliberate attention to identifying both favorable perceptions and contrasting perspectives, including perceived challenges or drawbacks of ICU rotations. Data were stored and analyzed in Excel. The study was deemed exempt by the University of Colorado Institutional Review Board.

Results

Of the 178 interns invited to participate, 100 (56%) representing 52 different medical schools completed the survey (response rate 56%) (Table 1). Sixty-six respondents (66%) completed an ICU rotation during medical school, and for twenty-eight respondents (42%), it was required. The most common ICU experience was a four-week acting internship in a medical ICU during the fourth year. Among interns who had not completed an ICU rotation, 72% wished that they had done so (Table 1).

Table 1.

Demographic information of survey responses, characteristics of intensive care unit (ICU) rotations. 100/178 interns responded (response rate 56%).

Specialty	Completed an ICU rotation (number of respondents required to complete an ICU rotation/number of respondents that completed an ICU rotation (%))	Did not complete an ICU rotation (number of respondents)
Anesthesia	1/5 (20%)	1
Emergency Medicine	3/7 (43%)	3
Family Medicine	4/5 (80%)	4
Internal Medicine	9/25 (36%)	10
Medicine-Pediatrics	0/0 (0%)	2
Neurology	1/1 (100%)	0
Ophthalmology	3/3 (100%)	1
Pediatrics	4/11 (36%)	6
PM&R	0/0 (0%)	1
Surgery	0/3 (0%)	1
Urology	1/1(100%)	0
Did not report specialty	2/5 (40%)	5
Total	28/66 (42%)	34
Residents who completed an ICU rotation (66)
Time completed
	First year	0 (0%)
	Second year	3 (5%)
	Third year	17 (31%)
	Fourth year	35 (64%)
	Gap or research year	0 (0%)
Duration of ICU rotation
	Less than one week	0 (0%)
	One week	2 (3%)
	Two weeks	11 (17%)
	Three weeks	7 (11%)
	Greater than or equal to four weeks	46 (70%)
Type of ICU rotation
	Medical	39 (48%)
	Surgical/trauma	15 (18%)
	Pediatric	8 (10%)
	Neonatal	5 (6%)
	Mixed	5 (6%)
	Cardiothoracic	5 (6%)
	Neurologic	4 (5%)
	Burn	1 (1%)
Characterization of ICU rotation
	Acting internship (AI)	48 (62%)
	Elective	20 (26%)
	Open ICU	7 (9%)
	Shadowing	2 (3%)
Residents who did not complete an ICU rotationa (n = 34)
	Wished they had completed an ICU rotation	24 (72%)

^aOne resident did not answer the question regarding whether they wished they had completed an ICU rotation.

Perspectives on the value and requirement of medical school critical care rotations and classroom-based curricula varied based on prior ICU experience and specialty. Irrespective of ICU experience, the majority endorsed inclusion of ICU rotations (77%) and classroom-based critical care curricula (67%) as required elements of medical school. Interns who completed an ICU rotation were more likely than those without ICU experience to support requiring ICU rotations for medical students (85% vs 67%, P = .02). There was no significant difference between groups for classroom-based curricula (82% vs 73%, P = .23). Interns in ward-based specialties were more likely than non-ward-based specialties to endorse mandatory ICU rotations (82% vs 57%, P = .02) with no significant difference between groups for classroom-based curricula (74% vs 52%, P = .06). Students who completed an ICU rotation during medical school reported higher satisfaction with ICU exposure in medical school compared to interns who had not completed an ICU rotation (80% vs 41%, P = .001).

Thematic analysis of free text responses on the value of a medical school ICU experience revealed three key themes: greater exposure to critical care medicine, improved ability to recognize and manage critically ill patients, and better preparation for residency. While most respondents described perceived benefits of ICU rotations, a subset of participants expressed contrasting dissenting perspectives. Representative free text responses are listed in Table 2.

Table 2.

Themes of free text responses on perceived value of completing an ICU experience in medical school. Specialty is listed in parentheses. For the 36 open responses from those who had completed an ICU experience in medical school, we identified three contrasting viewpoints that described negative experiences.

	Completed ICU rotation	Did not complete ICU rotation
Greater exposure to critical care	“Gave me sufficient experience caring for patients with complex needs and leading difficult conversations on goals of care and end of life” (pediatrics) “I think exposure to ICU is helpful for all specialties, especially as a lot of them have to do ICU in residency” (internal medicine)	“Most things were foreign to me when I started my first ICU rotation, and exposure would have made me feel more familiar and comfortable making difficult medical decisions” (internal medicine) “Exposure to the complexity of these patients is invaluable and until you see many of these interventions, it is tough to have a strong idea of how to manage them” (internal medicine)
Improved ability to recognize and manage critically ill patients	“It was my first opportunity to take charge in the care of critically ill patients, suggest diagnostics and treatments, and work through how to execute those plans” (surgery) “Seeing critically ill patients in medical school was so valuable for identifying them in the future” (medicine-pediatrics)	“I wish I did ICU to not only to get early exposure to managing or witnessing the management of sick patients, but also to help visualize a “sick” or “not sick” patient” (internal medicine) “Taking care of and recognizing critical care patients would have felt much less daunting” (preliminary)
Preparedness for residency	“ICU was the most challenging rotation of medical school, I felt it was the only rotation that truly simulated how it would feel to be an intern” (internal medicine) “I felt it was the only rotation that truly simulated how it would feel to be an intern” (internal medicine)	“The principles, pace, and priorities of ICU are different than on the wards and I felt inept and lost when my first time in the ICU was as a doctor” (internal medicine) “I never saw a sick patient in medical school and felt I wasn’t prepared for intern year” (did not report specialty)
Dissenting perspectives describing negative experiences during medical school ICU rotations	“I carried two patients, did not get any didactic learning, and felt like I left the ICU with no increased knowledge or preparation for residency” (internal medicine) “[The ICU] was mostly a waste of time, didn’t get to do any procedures, feedback was minimal and almost no teaching” (emergency medicine) “In the NICU, physician practices vary so widely that much of what I had learned was not useful. My medical school’s NICU also had a bad culture and did not prioritize teaching or the medical student experience” (pediatrics)	N/A

Discussion

To our knowledge, this is the first survey examining the benefits of an ICU rotation in medical school from the viewpoints of residents at the end of their intern year. Our findings indicate that structured ICU experiences are perceived by trainees as valuable and influential in their self-assessed preparedness for the clinical demands of internship. This study offers a unique perspective on how ICU experiences during medical school shape interns’ perceived preparedness and practical skills during the initial stages of residency training. These observations also reinforce calls for integrating critical care training into medical school curricula to bridge the gap between undergraduate and graduate medical education.^7-9

Trainees perceive that medical school ICU experiences increase exposure to critical care medicine, improve their ability to recognize and manage critically ill patients, and improve preparation for residency. These insights are supported by prior research demonstrating that critical care experiences in medical school enhance clinical decision-making and patient management skills, and are associated with improved intern performance evaluations.^2,3,10 Our findings align with prior surveys that showed higher self-reported confidence and preparedness after ICU rotations or simulations and add to a growing body of literature that supports structured critical care experiences in undergraduate medical curricula.^1,4,6,9 Future research is needed to evaluate the specific components of undergraduate critical care education that may have contributed to higher self-perceived preparedness and confidence for intern year. Additionally, evaluations of satisfaction and perceived effectiveness highlighted areas for improvement, emphasizing the importance of ongoing curricular refinement to maximize the educational impact of ICU experiences.

Opinions on mandatory ICU rotations differed between ward-based and non–ward-based interns, underscoring the need to consider how ICU experiences align with specialty-specific training demands. Among respondents who had not completed an ICU rotation during medical school, 72% reported they wish they had done so. This suggests that the value of critical care exposure is often recognized only retrospectively. As both interns with prior ICU exposure perceived it as beneficial preparation for residency and the majority of those without such experience expressed a desire for earlier exposure, our findings suggest that undergraduate critical care education may enhance self-perceived preparedness for the transition to residency, especially for specialties that require critical care training during residency.

This study has several limitations. As a single-center study, our findings may not be generalizable, as intern experiences and ICU exposure vary across institutions, specialties, and training environments. However, representation from 52 different medical schools offers a diverse range of pre-residency educational experiences and perspectives. Furthermore, the survey item that asked whetherrespondents “wished” had completed an ICU rotation with the follow-up elaboration limited only to affirmative responses may have introduced a positive response bias. However, there were other open-ended items that were structured to elicit both perceived benefits and disadvantages. Perceptions of preparedness and the perceived impact of prior ICU experiences may have been shaped by the specific structure, intensity, and support of ICU rotations at our institution, as well as by the clinical demands and educational culture of the residency programs. Additionally, this cross-sectional assessment captures intern perspectives at the end of the intern year, and responses may reflect experiences and challenges unique to intern year. Future multi-site studies across diverse training settings could clarify the generalizability of these findings.

Overall, ICU rotations during medical school are associated with improved confidence, self-assessed preparedness, and satisfaction during intern year, highlighting the value of structured, well-designed critical care learning experiences to improve the transition from medical school to residency and enhance the intern year experience.

Author contributions

Dr Rose and Dr Gergen contributed to conceptualization of the research idea. All authors contributed to creation of the survey and methodology. Dr Rose contributed to data collection and projection administration. Statistical analysis was designed and completed by all authors. Dr Rose contributed to writing the initial draft, and all authors reviewed and edited subsequent drafts.

Supplementary material

Supplementary material is available at ATS Scholar online.

Conflicts of interest

Please see the ICMJE disclosure forms, which have been provided as supplementary material. Dr. E.V.R. has no conflicts or interest, financial or otherwise, to report regarding the content of this manuscript and no involvement with organization(s) with financial interest in the subject matter. Dr. D.J.G. has no conflicts or interest, financial or otherwise, to report regarding the content of this manuscript and no involvement with organization(s) with financial interest in the subject matter. Dr A.T.N. has no conflicts or interest, financial or otherwise, to report regarding the content of this manuscript and no involvement with organization(s) with financial interest in the subject matter. Each author contributed equally to the creation of this manuscript.

Artificial intelligence disclaimer

No artificial intelligence tools were used in writing this manuscript.