I never had exposure to being a crane operator, attorney, engineer, or cruise ship singer before I applied to medical school. All people have to make decisions without practicing everything for a month. At $30k/year for med school, and a ~$80k+/year opportunity cost for every lost year in residency, the process really can't take forever. I almost think that the solution might be to replace fourth year with a medical, surgical, or rotating internship, place the basics in third year, and leave sprinkle some specialty exposure into the first two years. Everyone can't know everyhing, but everyone should know some things, and we do a poor job of distinguishing between the two.
i don't really think there is a simple solution to the whole system. i don't think you need to be exposed to everything. there are surgeons and non-surgeons. there are clinicians and non-clinicians. there are people who like taking care of patients and those that don't. the 3rd year is to give you a base from which to build upon. the problem, i see, with the 4th year is that you need to know what you want to do before you start your fourth year because you have to set up your schedule for that year and apply for residency during the 1st 6 months of that 4th year.
now, the system could be set up that 4th year was sort of a internship (like many of the 3+3 medicine or family medicine programs). the problem see with that is most 3rd year med studs are not ready for that responsibility. so, maybe it should go to a more old european style, graduate medical school, do a rotation internship, work in gen med for a couple years and then apply for a residency. gets people to develop their on style of taking care of patients etc.
i think there needs to be change in the system, splitting up into a ton of subspecialties i don't think is the optimal answer. there may be a change to a 3+ 2 or 3 type of program (in surgery). i do feel that there every resident physician needs to build a base for understanding the basics of patient care and basic surgical techniques. in general surgery, you have multiple aspects that have to be learned other than lap chole's and whipple's; you still have to learn about acute patient care, ICU, and trauma care. so the first 2 or 3 years would be learning these things and basic surgical techniques. then, like with plastics, you apply for your subspecialty (gen surg, CT, vasc, transplant, etc.)
i do think there may need to be an adjustment of the amount of time in the surgical subspecialties because the number of procedures is increasing and each is requiring an increase in surgical skill. with surgeon educator being required to be more hands on secondary to some government regulations (HCFA), non-government regulations (JACHO), and outside influences (malpractice), the amount of time that a young surgeon has to learn his/her craft with out adult supervision is less. also, with money being an issue, the surgeon educator is also influenced by the number of cases s/he an perform and therefore, may step into a case much sooner to get don quicker.
i think prior to the 80 work week, young surgeons operated so much and saw so many patients, that is was not a issue. you would eventually get good at it just because of shear volume. now that the volume will be reduced, how can we as educators improve the amount of education with a shorter time frame. example, it is trauma season, we have had a number of cases added on to the end of my elective schedule (not uncommon). there have been a number of days that i have operated completely by myself. don't get me wrong, i and the staff love it because the cases go much faster; but, these are lost cases to the residents. you may argue, well they don't need those cases. my argument is from what i have seen, yes the do.
ok this is definitely getting too long sorry ... happy easter all