Over the last 10 years, there has been increasing concern about the high drop-out rate of medical students during the transition between pre-clinical and clinical studies, often in the second year. Drop-out rates vary between medical schools, but rates between three per cent and five per cent are the norm. There has been similar concern expressed about students graduating from medical school who thereafter drop out of medical training, amounting to around 10 per cent.
In the meantime, NHS work practices and day-to-day concerns for doctors have changed. As a senior practitioner and teacher of medical students, I have not found these changes discussed at medical school. On speaking to students who have been successful at getting through their studies, I am lead to believe that transitions between pre-clinical and clinical life, as well as the transition into full working life as a junior house officer, can be extremely stressful due to a lack of preparation.
I have tried to summarise three key areas of NHS work which entails preparation in terms of thinking skills. Furthermore, as a psychiatrist, I believe our speciality has a valuable role in facilitating learning in this area for medical students and young doctors.
Clinical judgement
Clinical judgement is best defined as balancing the risks and benefits of a particular procedure to an individual patient when performed at a particular site, at a particular time, by a specific practitioner. At times, the risks and benefits of non-intervention (for example not admitting someone to hospital) need consideration. It is a complex task, usually undertaken by a single doctor, jointly with a patient, his carer and other members of the treatment team. Increasingly, these discussions are guided by the available evidence base, although there are serious ethical considerations in translating evidence of benefit and harm to patients who differ in age, race and the extent of co-morbidity.
Current teaching at medical schools does involve evidence-based medicine, but firstly often ignores the “number needed to harm”, and secondly implies that knowledge of risk benefit is the preserve of doctors alone, needing to be “communicated” to patients rather than being a consultation process. Carer involvement is often not emphasised. I believe the true art of medicine is the process of consultation, free of duress (which can be subtle), that examines the benefits and drawbacks of both intervention and non-intervention in specific circumstances.
Interpersonal Skills
Traditional medical schools concentrate on communication skills necessary for history-taking and delivering bad news. The importance of interacting with carers and other professionals dealing with a patient, often in a stronger therapeutic relationship, is not emphasised.
The National Health Service has recently commenced a process of formally evaluating doctors’ innate preferences when relating to others at the workplace. This is integrated within the appraisal system and uses 360-degree appraisal, as well as personality trait questionnaires such as Myers Briggs. These instruments are designed to provide doctors with feedback about their style of interaction, so that appropriate thought can be given to any changes needed. The main reason for this process is the major limitation of NHS activity due to difficult relationships between staff and patients or carers.
Complaints management and learning lessons from complaints (including avoidance of similar problems), is not discussed at medical school. Students often receive a biased view of these experiences from senior colleagues, the lay press or, at times, from their teachers.
From a mental health perspective, the NHS suffers significantly from dysfunctional illness behaviour due to false or unhelpful beliefs. Doctors often maintain these by inappropriate investigations and referrals. On speaking to “somatisising” patients, they often hark back to a piece of information provided by a doctor early in the process, which may have been either falsely alarmist or reassuring. This aspect of communication needs to be examined at a pre-clinical level to provide students with some awareness of the power of a doctor’s words for good or ill.
Risk awareness and management
This is an area in which medical students are rarely given guidance. Students are taught how to avoid violence, but are not instructed on the risks for vulnerable people, such as the neglect and abuse of children, falls involving the elderly, exploitation, self harm and aggression involving mentally ill or incapacitated patients. Even risks of malnutrition amongst physically ill people are not discussed.
The main risks concerning medication – such as drug interactions, dangerous methods of delivery, and the potential for non-compliance – are inadequately presented, especially when pharmacology is given a low priority. The microbiological hazards of cross-contamination and sexually transmitted disease are also underemphasised. Overall, these risks are mentioned in passing by different tutors or in different clinical study modules, but not as a coherent whole in the preclinical course.
The NHS is instituting a major process of limiting avoidable errors. Within psychiatry, specific expertise has developed in systematically assessing risk in consultation with others in the treating team, a process that will involve patients and carers. Mental health is inherently risky, generating much negative publicity when untoward incidents occur.
I wonder if mental health staff should play a leading role in educating medical students on risk at a pre-clinical stage. Psychiatrists are equally knowledgeable on legal issues involving risk, such as capacity and advance directives – both real life issues for practising clinicians in all specialities.
Specifically, I recommend two modules: clinical judgement, including risk awareness and critical appraisal of evidence; and interpersonal skills, including consultation skills and the ethics of discussing treatment options and prognosis.
From a jobbing clinical perspective, I have highlighted some areas of routine clinical practice in which I believe medical students should have some awareness prior to their clinical studies. The common thread running through these issues is the need to think coherently and become more self-aware as a future doctor. I believe that it would be easier (and safer) for students to be introduced to these topics at an earlier stage, when they have more time to discuss and reflect – time that clinical trainees rarely have.
