Medical students need experience not just competence
Dornan, T., Gillespie, H., Armour, D., Reid, H., & Bennett, D. (2020). Medical students need experience not just
competence.
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Download date:09. Aug. 2022
Competence does not guarantee capability. The need for medical students to have sufficient
clinical experience
Tim Dornan
1
, Hannah Gillespie
2
, Dakota Armour
3
, Helen Reid
4
, Deirdre Bennett
5
1
Professor of Medical Education,
2
PhD Student,
3
Medical student,
4
Clinical lecturer
Centre for Medical Education
Queens University Belfast
Whitla Medical Building
97 Lisburn Road
Belfast BT9 7BL
UK
5
Head, Medical Education Unit
School of Medicine
Brookfield Health Sciences Complex
University College Cork
Cork
Ireland
Corresponding author: t.dornan@qub.ac.uk
Anticipating a serious workforce shortage, the World Health Organisation advocates a paradigm shift in
1
how we prepare clinicians for practice. (1) This editorial is a critical review of medical student education,
2
which supports that recommendation. Curricula vary internationally: students are health workers in some
3
countries and observers in others; they progress from medical school to hospital generalist training in
4
some countries and direct to specialties in others. We acknowledge that variability so far as a limited
5
evidence-base dominated by anglophone publications allows.
6
7
Britain is the main source of evidence about preparedness for practice. This may be because UK students,
8
with little experience of contributing to practice, shoulder heavy clinical responsibilities as foundation
9
trainees (FTs). Despite this inexperience, FTs’ supervision may be ‘arms-length’ when, for example, a
10
hospital specialist delegates patients’ generalist care to them. This baptism of fire may explain why
11
an increasing proportion of UK trainees deviate from the intended training pathway. Two thirds of FTs
12
delay entry to specialties, some taking career breaks out of medicine.(2) The staffing gaps that result
13
make patient care discontinuous, impersonal, and potentially unsafe, and incur eye-watering locum costs.
14
Paradoxically, UK trainees break their training to become better trained. Taking a break from training
15
relieves them from work pressures, unsupportive learning environments, unsatisfactory education,
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disrupted personal lives, and poor psychological health. Some, also, want longer to choose a specialty.(3)
17
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These factors, though, are an insufficient explanation for the UK’s retention problem. Only 10% of
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trainees (interns and residents) in the US, Netherlands, and New Zealand take career breaks (4–6) despite
20
negative psychosocial experiences.(7,8) The relative immaturity of UK trainees cannot explain their career
21
breaks because students enter medicine direct from high school in the Netherlands and New Zealand too.
22
Trainees leave when a final negative experience ‘brings down the tower of blocks’.(9) Negative
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experiences start in medical school (3) and intensify when students become trainees.(10) Trainees with
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the least developed coping strategies are worst affected.(11) Those in the UK certainly need coping
25
strategies because the National Health Service, whilst affording excellent training opportunities, operates
26
under formidable pressure. Promises of ever ‘safer’ healthcare whilst ever less is spent on public services
27
have resulted in expertise being so thin on the ground that work is often shared out rather than
28
supervised. Students need to be very well prepared for work.
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The competency movement has strongly influenced global reforms in medical education.(12) This new
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paradigm has shifted the arbiter of being ready for work from having accrued sufficient experience to
32
having demonstrated competence, off-the job, in standardised tests. By that objective definition, 100% of
33
UK students are ready to practise ‘safely’, yet practice is not demonstrably safer. The General Medical
34
Council’s survey of UK graduates’ experiences of starting work shows that a progressively falling
35
proportion (66% in 2019, compared with 90% or more in the US) find themselves, subjectively,
36
prepared.(13,14) Subjective unpreparedness might be dismissed as ‘soft evidence’ but this predicts
37
dissatisfaction with training, poor wellbeing, and burnout for up to seven years after qualification.(13)
38
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The stressors that test medical graduates’ preparedness include feeling incapable of managing a heavy
40
workload against the clock, on unfamiliar wards, on call, and lonely; facing criticism and conflict; and
41
managing very sick patients who deteriorate despite treatment. Trainees who have only learned part-
42
tasks (eg writing a simulated prescription) find themselves incapable of performing the whole task
43
(treating a sick patient). Unpreparedness is ‘knowing what’ but not ‘knowing how’. It is having such a
44
fragile professional identity that you cannot admit uncertainty.(15–17) Competent but incapable
45
graduates are sitting ducks for psychosocial harm.
46
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There is observational evidence that students can be better prepared by gaining experience in real
48
practice contexts, not just simulation; having longer, better supported experiential attachments; having a
49
placement in a hospital where they will soon work; having generalist rather than specialist experience;
50
and not having constant exam pressures.(18) Narrative evidence suggests that North American students,
51
despite also being in competence-based programmes, have more such experience than UK students. The
52
importance of ensuring that students have had enough experience applies to any job, be it hairdressing,
53
coal-mining, or healthcare. Students become capable trainees by immersing themselves in work,
54
observing and listening, role-modelling, interacting with workers, participating in work practices, being
55
coached, asking and answering questions, reading workplace documents, and writing in them.(19)
56
57
This cautionary tale leads us to propose that medical education does not so much need a paradigm
58
change as a stronger implementation of the World Federation for Medical Education’s paradigmatic
59
standards. These advocate early, progressively increasing involvement in patient care and experience of
60
taking responsibility.(20) Off-the-job training, observing practice, and a relentless diet of assessments
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cannot substitute for experience. On the job learning, alone, can actualise students’ and trainees’ intrinsic
62
motivation to care well for patients.
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Word count: 791 words
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Competing interests statement
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We have read and understood the BMJ Group policy on declaration of interests and have none to declare
68
69
Contributions
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Tim Dornan wrote the editorial and headed the team of authors. Hannah Gillespie and Dakota Armour
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searched information sources to provide the evidence-base for it. Helen Reid and Deirdre Bennett
72
contributed to the drafting and revision of the editorial. All authors approved all drafts, including the final
73
submitted version.
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License
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The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all
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authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and
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80
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81
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82
Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever
83
it may be located; and, vi) licence any third party to do any or all of the above.
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85
Acknowledgements
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We thank Dr Huon Snelgrove and Professor Hiroshi Nishigori for constructive criticisms of our original
87
submission, which helped us focus and strengthen our argument.
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References
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1. World Health Organization. Global strategy on human resources for health: Workforce 2030
91
[Internet]. Geneva; 2016. Available from:
92
https://www.who.int/hrh/resources/global_strategy_workforce2030_14_print.pdf?ua=1
93
2. General Medical Council. 2019 F2 Career Destinations Survey. London; 2019.
94
3. General Medical Council. Training pathways 2 : why do doctors take breaks from their training?
95
2018;
96
4. Bustraan J, Dijkhuizen K, Velthuis S, Van Der Post R, Driessen E, Van Lith JMM, et al. Why do
97
trainees leave hospital-based specialty training? A nationwide survey study investigating factors
98
involved in attrition and subsequent career choices in the Netherlands. BMJ Open. 2019;9(6):1–8.
99
5. Medical Council of New Zealand. The New Zealand Medical Workforce in 2018.
100
6. Lu DW, Hartman ND, Druck J, Mitzman J, Strout TD. Why residents quit: National rates of and
101
reasons for attrition among emergency medicine physicians in training. West J Emerg Med.
102
2019;20(2):351–6.
103
7. van Vendeloo SN, Prins DJ, Verheyen CCPM, Prins JT, van den Heijkant F, van der Heijden FMMA,
104
et al. The learning environment and resident burnout: a national study. Perspect Med Educ.
105
2018;7(2):120–5.
106
8. Pereira-Lima K, Gupta RR, Guille C, Sen S. Residency Program Factors Associated with Depressive
107
Symptoms in Internal Medicine Interns: A Prospective Cohort Study. Acad Med. 2019;94:869–75.
108
9. Liang R, Dornan T, Nestel D. Why do women leave surgical training? A qualitative and feminist
109
study. Lancet. 2019;393(10171):541–9.
110
10. Mata DA, Ramos MA, Bansal N, Khan R, Guille C, Di Angelantonio E, et al. Prevalence of depression
111
and depressive symptoms among resident physicians a systematic review and meta-analysis. JAMA
112
- J Am Med Assoc. 2015;314(22):2373–83.
113
11. Teunissen P, Westerman M. Opportunity or threat; ambiguity in the consequences of transitions in
114
medical education. Med Educ. 2011;45:51–9.
115
12. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and
116
Residency. Carnegie Foundation for the Advancement of Teaching. San Francisco: Jossey-Bass;
117
2010.
118
13. General Medical Council. Progression Reports: Foundation Year 1 Pereparedness. London;
119
14. Association of American Medical Colleges: Medical School Graduation Questionnaire 2019 All
120
Schools Summary Report [Internet]. 2019. Available from:
121
https://www.aamc.org/download/498790/data/2019gqallschoolssummaryreport.pdf
122
15. Illing JC, Morrow GM, Rothwell nee Kergon CR, Burford BC, Baldauf BK, Davies CL, et al.
123
Perceptions of UK medical graduates’ preparedness for practice: a multi-centre qualitative study
124
reflecting the importance of learning on the job. BMC Med Educ. 2013;13:34.
125
16. Monrouxe L, Bullock A, Cole J, Gormley G. How Prepared are UK Medical Graduates for Practice?
126
Final report from a programme of research commissioned by the General Medical Council
127
[Internet]. 2014. Available from: http://www.gmc-
128
uk.org/How_Prepared_are_UK_Medical_Graduates_for_Practice_SUBMITTED_Revised_140614.p
129
df_58034815.pdf
130
17. Lee C, McCrory R, Tully M., Carrington A, Donnelly R, Dornan T. Readiness to prescribe: using
131
educational design to untie the Gordian Knot. PLoS One [Internet]. 2020; Available from:
132
https://doi.org/10.1371/journal.pone.0227865
133
18. Medical Board of Australia and Ahpra. Medical Training Survey 2019. 2020.
134
19. Billett S, Choy S. Integrating Professional Learning Experiences across University and Pratice
135
Settings. In: Billett S, Harteis C, Gruber H, editors. International Handbook of Research in
136
Professional and Practice-based Learning. Dordrecht: Springer; 2014. p. 485–512.
137
20. Basic Medical Education. WFME Global Standards for Quality Improvement. 2015 Revision.
138