Preparing medical students for clinical practice: easing the transition

The transition from medical student to junior doctor – from supported learning to independent practice – is a challenge. In recognition of this, the UK doctors’ statutory regulator, the General Medical Council (GMC), produced a document entitled Tomorrow’s Doctors (now referred to as Promoting excellence: standards for medical education and training) [1], emphasizing the importance of preparing students for the first year of clinical practice as a doctor, known as Foundation Year 1 (F1). However, a large proportion of UK medical graduates admit to feeling unprepared. This was highlighted over 10 years ago by Goldacre et al., who found that over 40% of UK medical graduates felt under-prepared for practice as a doctor [2]. Furthermore, while graduates may feel prepared for basic clinical tasks such as history taking and examination, a lack of exposure to clinical situations in medical school leaves them unprepared for more complex tasks such as management of acutely unwell patients, prescribing, managing workload and on-call duties [3].

Evidence suggests that mortality increases during each August [4], the time when new F1 doctors begin work, as a result of lack of experience, with the first day of work for brand new F1s colloquially referred to as ‘Black Wednesday’. In light of this, many National Health Service foundation schools now offer a period of induction and/or shadowing preceding full commencement of independent practice, in line with GMC guidance [1]. Prescribing errors, the area of clinical practice new F1 doctors are most concerned about [3], can lead to serious or even fatal consequences: the EQUIP study found errors in 9% of hospital prescriptions [5]. Subsequently, the national Prescribing Safety Assessment was developed by the British Pharmacological Society and Medical Schools Council, and rolled out in UK medical schools in 2014.

In response to these issues, we piloted a new ‘Preparation for Practice’ course, using simulation and real-life scenarios to cover common challenges for F1 doctors. This was driven by student feedback highlighting inadequate attention to the practical aspects of the transition from student to doctor. The purpose was to determine whether such an approach could improve participants’ knowledge and ability to manage the situations used, and better prepare them for clinical practice.

Feedback was obtained from 95 of the 120 students: 94 students (99%) gave a rating of 4 or 5 for the overall quality of the program, 91 students (96%) rated 4 or 5 for the relevance of the program content, and the same results were obtained for the schedule of activities. A rating of 5 was awarded by 67% of students for the ward round station, 71% for the prescribing station, 58% for the handover station, and 35% for the lessons learnt station. Students reported increased confidence with prescribing compared with before the session, by at least one point on the scale, and overall confidence of the group was markedly improved (Fig. 1).

The qualitative feedback (free text comments) was overall very positive and was collated in the appropriate domains (general, ward round, prescribing, handover and lessons learnt) (Table 1). This was with the intention of building on and improving the course in the future.

The importance of adequate preparation of medical students for clinical practice cannot be overemphasized [1]. However, this may be suboptimal [6], leaving medical graduates feeling unprepared [2, 3, 7, 8], particularly in more complex tasks such as acute care and prescribing [3, 7]. These concerns are shared by senior doctors [7, 9]. We have designed a simple course to expose graduating medical students to common scenarios faced by junior doctors. We believe that this course has helped improve the transition from medical student to junior doctor by using simulation, such that students were able to actively participate in realistic tasks and experience the scenarios in real-time. In addition, a near-peer teaching approach, with scenarios and workshops led by junior doctors and other junior members of staff, differentiated this from other learning environments such as lectures and consultant-led tutorials. Prescribing was a crucial component, as this is a challenging area for newly qualified doctors [3, 5], in which errors are potentially catastrophic [5]. This course was perceived to be an effective and enjoyable method of preparing for work as an F1 doctor and this was reflected in the positive feedback from final year medical students who participated. Combining this approach with ‘on-the-job’ shadowing time could potentially have far reaching positive effects on newly qualified doctors’ confidence and competence, and more importantly could have wider implications for safety and quality of patient care.