Best practices have been described in implementation of A3YP programs, drawing from the combined experience of medical schools participating in CAMPP. 1 One of the first steps is establishing a clear mission to support admissions, curricular development, partnerships with GME, program evaluation, securing buy-in and additional innovation. An early step must be defining an admissions model. A3YP programs have implemented successful programs ranging from matriculation at admission to delayed admission after the first year of medical school. Additionally, there exist models in which all medical students at an institution participate in 3-year training. Early partnership with residency programs is sought at most medical schools and required for those who seek directed pathways to GME programs at their institutions. Creation of a curricular plan to ensure acceleration while meeting accreditation requirements, university requirements and curricular goals is a critical early step. Policies around deceleration must be developed alongside plans for mentorship, support and remediation. Clearly defined outcomes and associated program evaluation should be planned prior to program launch.   

Medical schools generally need at least six months to a year to plan prior to the start of an admissions cycle. Given that admissions cycles through the American Medical College Application Service (AMCAS) require finalization of program information in the spring prior to applications opening, this means planning typically begins two years prior to students matriculating into an A3YP program. 

Throughout the planning and implementation process, ongoing work should be conducted to ensure broad buy-in, support and resources. Critical partners include residency program directors, designated institutional officers (DIO), the medical school dean or other high level medical school support, medical school curriculum leaders particularly in the 4th year where much of the abbreviation to curriculum occurs, finance and administration, and medical school admissions teams. Concerns and questions should be continuously addressed. Securing support across stakeholders can be framed as a return on investment,2 outlining the unique benefits to medical schools, trainees, residency programs, departments, communities and society. 

This is a critical first step!1 Mission and vision descriptions3 help programs clarify all subsequent steps from admissions, curriculum development, and defining outcomes. A clear mission can also help with securing buy-in and philanthropic support for the program. Most medical schools with A3YP programs include in their mission the reduction of cost of medical training as this is inherent in the model. Beyond this, many medical schools have missions related to workforce development, addressing physician shortages and community needs, and innovation in medical education including advancing competency-based medical education, time-variable education, improving transitions across the continuum, and streamlining training in sub-specialties. Sharing mission goals with internal and external stakeholders can support recruitment, funding, innovation, and even be associated with local, state, and regional government and health system funding and support. 

The LCME requires notification of parallel curriculum; however, most A3YP do not meet this definition (www.lcme.org).1 As long as the medical program objectives and assessments in the required curriculum are identical to the 4-year program, and learning objectives of the institution are met, there is no requirement to call an accelerated pathway a parallel curriculum. The LCME Secretariats are always available for consultation. 

Some universities and states have specific language about the required length of training for a medical degree. As such, it is important to make local inquiries with you state department of education and with your university regents to ensure no policy changes or approvals are needed early in the planning process.  

In order to shorten the curriculum to three years while meeting the LCME requirement of 130 weeks in the medical education program and maintaining all graduation requirements, most A3YP programs decrease elective requirements and unstructured time (often used for vacations or applying to residency) from the traditional fourth year. In addition, many A3YP add curricular time to the summer before matriculation, the summer between the first and second year, and/or delay degree conferral after graduation before the start of residency orientation. Some schools have collaborated with learning specialists to develop a structured step study course which count towards the 130 weeks.  Students must complete all required curriculum, assessments, and must meet all program objectives.   

Despite an accelerated schedule, it is important to ensure time for breaks and vacation in the accelerated program. Most medical schools maintain standard school vacations throughout the academic year for A3YP students (i.e. fall, winter, spring breaks). While scheduling extra curriculum time during the summers, allowing at least 1-2 weeks off for vacation is important for wellbeing and preparation for the next academic phase of training.  

It is important for leaders to be able to speak to the benefits of acceleration related to wellbeing as concerns are often raised about stress and burnout with an accelerated program in the context of increasing rates of mental health concerns amongst medical students broadly. Accelerated students report significantly less burnout with improved learning environment compared to traditional 4-year students.4  This is likely due to decreased stressors around debt, the uncertainty of the match and next steps in training, decreased competition and pressure to perform, strong longitudinal mentorship, and a sense of belonging to a specialty.​

Because of the limitations in time and the stated goals of many accelerated programs to focus on primary care, many programs expect students to have made a decision about their specialties upon entry; however, this is not required. Some programs are open to all specialties, in which case, early commitment is not required. Early advising and mentorship are important to support students as they identify career choices.  

Career exploration/shadowing in the first year and the summer between first and second year can provide opportunities for career exploration. These experiences can be embedded into the curriculum or exist as extracurricular experiences depending on the nature and goals of the program.  Clerkships are another opportunity to incorporate extra exposure as either a required or elective component. Connection with career and department-specific mentors and advisors early in medical school is essential. Trusted mentors can support students in identifying career choices early (for those in delayed entry A3YP programs) while ensuring students are confident in choices. While delayed admission allows more time for exploration before decision, career exploration should be encouraged for all students to ensure confidence in choices and broad training and exposure. 

In a directed pathway match, residency programs designate program positions for the A3YP program students. Students still participate in the NRMP match process, but typically only rank that program; similarly, the program only ranks their designated A3YP student. Directed Pathway residency programs will need to create an NRMP program code that is specific for the applicants from the A3YP. This is what the students will use for ERAS application and NRMP program selection. If all the incoming intern positions for a particular Directed Pathway Residency program are expected to be taken by graduating A3YP students that year, the Directed Pathway Program needs to “deactivate” the program in the Match for external applicants. The A3YP needs to coordinate with the Directed Pathway Program regarding the last date in the M3 year at which an A3YP student can decelerate so that the residency program may need time to interview additional applicants for that position as unfilled Directed Pathway positions will revert to open residency positions that will fill from the rank list. Per the NRMP, Programs involved in the Directed Pathway will need to have a statement on their residency website indicating this, for external applicants, e.g. “Up to X of our Y incoming residents may be matched through an accelerated 3-year training program offered at our affiliated medical school, XX School of Medicine” 

In contrast, A3YP programs with match waivers allow students to forgo the match entirely, guaranteeing a residency position in the linked program for students in the A3YP program. Very few programs have been granted a match waiver.  Medical schools and residencies will need to contact the NRMP directly to apply for a waiver and confirm messaging regarding the waiver is approved.  

he mission and goals of the A3YP program are often the driving factors behind choosing an approach to admissions. Direct admission (pre-matriculation) and delayed admission (after the start of medical school) have pros and cons for both the student and the school.1 Of note, some medical schools offer both models for subsets of students. 

In the direct, pre-matriculation admission model, schools can use the accelerated program to support recruitment. However, this requires careful selection of students with a strong commitment to specialty or setting. These programs have the advantage of flexibility in starting the program prior to the 4-year program matriculation, allowing easier achievement of the 130-week LCME curricular requirement while maintaining more flexibility for exam preparation and vacation. Students can begin building professional identities early by developing mentoring relationships, immersing themselves in earlier clinical experiences, and pursuing other non-clinical experiences within their defined specialties from the start.  

In a delayed admission model, students may be more confident about their career interest and the school or A3YP may be more confident in an individual student’s potential for academic success. Students also have more opportunity for career exploration and meeting with career and residency mentors before making a commitment.  However, the later students are selected, the more difficult it becomes to meet the 130-week curricular requirement without a delayed graduation model.  

When building an A3YP with directed match to residency, it is essential to work collaboratively with your UME admissions and GME teams and equally balance priorities and selection criteria of both priorities. Be clear about the mission of both programs and select students whose interests align best. By developing clear metrics and objective criteria, one can ensure the process for selection is unbiased. Collaboration with the UME curriculum team is essential to ensure that students selected for the pathway are able to succeed.  Despite the daunting task of selecting appropriate students pre-matriculation, attrition is low across A3YP programs.5 Building a CQI process with an understanding that selecting students will be an iterative process is critical.   

There are several potential advantages to an accelerated pathway. Acknowledging these advantages and potential challenges of acceleration and discussing openly with candidates is important in the selection of successful students.2 

• Completion of medical school in three years, allowing an earlier start to residency and professional practice and service to the community. 

• Reduced educational costs and one fewer year of living expenses. 

• Early mentorship, advising, and career development within the selected specialty. 

• A more streamlined transition into residency, often with reduced stress related to the residency application and match process. 

There are also potential challenges to consider: 

• Less time to explore other specialties before making a final career decision. 

• A more condensed curriculum with fewer opportunities for electives, research, or additional experiences outside the chosen field and potentially less time off, especially the first summer if curriculum is inserted during that time. 

• If career interests change, transitioning out of the pathway may require additional planning and could affect the timeline to graduation depending on how the accelerated curricular path has been developed. 

• The pace of an accelerated program can be demanding, requiring strong organization skills, commitment and resilience. 

Before choosing a directed-match or specialty-specific pathway, it is important to honestly assess how certain the student is about their career goals. Medical schools provide exposure to many specialties, which is much more limited in a 3-year curriculum. Students who value exploration and flexibility may prefer the traditional four-year curriculum. Ultimately, the best candidates for A3YPs are students who have a clear interest in a particular specialty, have significant prior clinical experiences or lived experiences that have informed their decision, are comfortable with a focused educational plan, can manage a rigorous academic curriculum, and understand and value the benefits of an accelerated pathway. Students who are still exploring their options may be better suited for a traditional four-year pathway and may benefit from additional time to discover which specialty they have the most interest and alignment. 

Some students know very early that they want to pursue a specific specialty and are clear about this commitment prior to matriculation.6 These pathways are designed for students who have a strong commitment to a particular field and are excited about the opportunity to begin focused specialty preparation early. A specific admissions process with application questions and interviews probing students about exposure and experience in their pathway specialty is critical. While attrition can occur, a minority of students leave A3YP programs due to changed interest in specialty.5 Stated clear interest in a specialty is the strongest predictor of long-term retention in a pathway.7, 8, 9 A return-to-home phenomenon has been well-documented to be associated with sustained interest in primary care and rural interest.9 The pathway specialty needs to fit students’ personal and professional goals and the pathway curriculum should continue to have mentorship and specialty experience in medical school that highlights future career opportunities within the field.10 

Programs must decide whether accelerated students will be held to the same standards as other students or to modified standards, in order to ensure appropriate progression through the curriculum.5 Schools may choose different approaches. For example, they may allow accelerated students to have the same number of “competency not met” incidents, fewer such incidents, or none at all.  

When designing these expectations, programs should consider when remediation can occur and the potential risks to both students and the program if standards vary. For instance, setting a lower tolerance for “competency not met” incidents may increase stress for accelerated students and could be perceived as inequitable compared to other programs. It is essential that programs clearly articulate the rationale for any differences in standards. 

A formal committee to review academic records and hear from students—along with an advocate—is essential. This committee may be established within the governance structure of the accelerated program or function as part of a broader medical school structure. If the committee operates at the medical school level, it is important to ensure that the unique aspects of the accelerated program are adequately represented. This can be achieved by including members from the accelerated program on the committee or by ensuring that a knowledgeable representative is present during deliberations. This helps ensure that all members of a committee understand the specific context and requirements of the accelerated program.  

Transitioning out of an accelerated pathway is difficult for students, regardless of the reason for deceleration. It is important to follow standard processes so that students have clear expectations, unbiased support, guidance, and a student-centered approach to the altered curriculum. It’s also important to determine early whether students will receive “credit” for activities specific to the accelerated pathway that do not have an equivalent in the traditional curriculum. It is also important to ensure that students who are re-entering the 4-year track continue to be supported by medical school faculty in this transition to ensure a successful residency and career trajectory.  

The accelerated track director/s should have access to all the A3YP student academic information. Close monitoring of the first few M1 courses is essential to identify any struggling students. An understanding of the relationship between student performance in your core curriculum and later performance in USMLE exams or clinical clerkships is essential (e.g. a student who is consistently borderline passing exams or courses may have challenges with passing USMLE Step 1 or have problems in the clinical year). Close collaboration with your Office/Dean of Medical Education and Office/Dean of Student Affairs is important.5  

Accelerated programs have limited time for remediation of poor academic or clinical performance. They also do not have the availability of additional time to prepare for USMLE Step 1 and 2CK. It may be difficult to predict at admission which students may or may not thrive in an accelerated pathway, as most of their academic experiences still lie ahead. Many accelerated programs have mechanisms in place to ensure that student progression through the program is closely monitored and achieved to ensure competence at graduation. Some examples include early identification and intervention, such as enrolling students into tutoring, mentoring or coaching programs.11,12 Some schools set academic standards for accelerated programs that are more stringent, such as policies stating that failures in the pre-clerkship stage prompts a formal review or that failure of any clinical subject exams in the core clinical clerkship phase necessitates a review of the student progress or even automatic transition out the accelerated program. Early access to learning support services is important and A3YP programs may consider mandatory learning support. Programs may also consider incorporating learning support or dedicated curriculum around learning strategies in the summer prior to matriculation.  

From the perspective of residency program directors,2 participation in a directed match of A3YP students facilitates very early engagement with learners as early as the time of medical school application through participation in admissions or selection of applicants, allowing engagement with committed students. This promotes longitudinal mentorship and the development of professional identity formation early and longitudinally.  Students in A3YP tend to be competitive applicants, typically accepted to multiple medical schools and rarely decelerate for academic reasons which may reassure program directors with concerns about early acceptance of residents.5 Participating in assessment and teaching allows for a transparent handoff at the transition to GME, providing entering interns who are well-known to the program in terms of strengths, areas for growth, interests and goals. Many students participate in specialty research in their department creating an opportunity for an additional three years of meaningful scholarly productivity at the time of residency graduation. Residency leaders have fewer spots to fill in their programs from a general pool, knowing the A3YP students are a “known entity”.  Finally, many residency leaders are motivated to participate in cutting edge medical education innovation and consider opportunities for time variable education, competency based medical education, individualized learning plans, and collaboration from UME to GME as primary reasons to engage.  

There is a growing literature describing the outcomes in medical school and residency of A3YP students and graduates. While in medical school, students in accelerated programs perform comparably to their 4-year counterparts. A3YP students have slightly lower USMLE Step 1 and 2CK scores, and higher scores on USMLE Step 3.11,13 No significant difference has been demonstrated on clinical grades or performance on NBME shelf exams.14 Performance in residency at 6 and 12 months is not significantly different when comparing A3YP and traditional 4-year MD program graduates as assessed by ACGME milestones.15 In internal medicine, interns graduating from A3YP and four-year programs performed equivalently on milestones with the exception of professionalism and patient care which were significantly higher in graduates of A3YP programs.16 Similarly, in family medicine, a milestone analysis demonstrated statistically significant higher milestone achievement among graduates of A3YP programs in medical knowledge, professionalism, practice-based learning and improvement, and communication.17 Graduates of A3YP programs report feeling equally prepared for residency compared to 4-year program peers.4   

The involvement of Graduate Medical Education (GME) programs is instrumental to the success of A3YP programs. A foundational tenet of these programs, particularly those with directed pathways to residency, is the continuum of learning and professional development that bridges undergraduate medical education (UME) and graduate medical education. This integrated approach facilitates a seamless transition from medical school to residency training and supports learner progression across the educational continuum. 

GME programs are often involved in the admissions process to help ensure alignment between the student and the specialty. Similar to residency selection, it is important to establish a strong, mutual fit between the learner and the training program. Early engagement by residency leadership can help identify students whose interests, career goals, and aptitudes align with the mission and expectations of the specialty broadly, and their program specifically. In addition, many accelerated pathway programs incorporate structured mentoring relationships, specialty-specific advising, and early clinical exposure opportunities that allow students to explore their chosen field in greater depth. These experiences help students make informed decisions regarding their specialty choice while simultaneously providing GME programs with longitudinal opportunities to assess student engagement, professional development, readiness for residency training, and continued suitability for participation in the accelerated pathway. 

Ongoing evaluation and assessment of students in accelerated pathways are essential to ensuring readiness for early graduation and successful entry into residency training. Approaches vary across institutions; however, many programs incorporate both UME and GME leadership in the assessment process to provide a comprehensive evaluation of student performance. These holistic assessments consider achievement of required competencies and milestones, overall clinical performance, and specialty-specific experiences to determine preparedness for the intended residency program and to support decisions regarding progression through the accelerated curriculum and transition into residency training. Participation also facilitates an informed handoff to GME training with transparency around strengths and opportunities of the learner and the ability to continue to support the trainee in their personalized professional growth. Ideally, updates should continue after the completion of the MSPE and after the match to ensure a seamless transition. 

Cost savings to students should be considered as both savings from a year of tuition and earnings from an earlier entry to workforce. Accelerated 3-year MD programs provide an estimated Net Present Value (NPV) that is $240,349 higher per graduate than traditional 4-year programs.18 A3YP programs with missions focused on workforce and physician shortage have had success in partnering with health systems and philanthropy to support scholarships and other workforce development programs including loan repayment.2  

The administrative costs of running an A3YP are typically low as much of the infrastructure to support programs already exists within UME and GME programs: admission, student affairs, curriculum, etc. At minimum some funded support for a program director and coordinator or manager is required. Many programs also fund specialty specific faculty roles to support students across the continuum from medical school into residency training. Thus, a medical school’s largest investment relates to the loss of tuition from shortening training to three years. The institutional benefits of this investment can be considered in terms of reduction of overall student debt, retaining students locally in residency programs, retention of students and residents in the local workforce and faculty roles, and institutional engagement in innovation.