All of the following views are mine alone.
I could be wrong.
I am not an investigative journalist, a qualified educationalist or a member of the GMC’s board.
For some time, I have been becoming increasing critical of the medical education system that I have grown up in. Recently, I have had 2 physicians associate (Pas) students attached to my team on the ward and it has made me think that the current medical school model is redundant. These PA students get about 18 months of theory teaching at the medical school before they start placements for 1 year and then they are fully qualified. These PAs essentially carry out the same job as an FY1 with 4 years less “training”. However, I would like to propose that these PAs are not “under-trained” doctors; they could be “more efficiently” trained clinical ward staff.
The role of an FY1 varies between consultants, wards, departments and trusts but in essence you need a basic grasp of common pathophysiology, anatomy, knowledge of guidelines on how to diagnose and treat, the basic clinical skills of examination and blood taking plus a few extra skills like ABGs, cannulas, NG tubes, catheters and communications skills. The PA students seem to be able to acquire most of this basic knowledge in less than 2 years, so why does it take medical students on average between 4 and 6 years?
Currently, there is tradition, there is regulation and there is common practice. Mostly, the reason it takes 6 years to train a doctor is because the EU stipulates that it takes 6 years or so many thousands of hours of “learning”. Three years of this training is supposed to be on clinical placements gaining experiential experience from exposure to a vast variety of conditions. To get access to these placements, the government essentially pays the trusts £35,000 per student per year. This money is nominally marked as “educational funding” and is meant to be spent on training the students, whether it is, is anyone’s guess?
I decided to set up an online survey and ask current medical students what they thought of their current placements, but also, more importantly, how much time they actually spent productively on placement?
My hypothesis being that current clinical placements are only useful for a few hours a day, mostly the time spent on the ward round and maybe an extra hour or 2 examining patients or observing a case in theatre. The rest of a medical student’s time would be far better spent reading guidelines, lectures, books etc, practicing their examining skills on their friends or having a life. If we are being really honest, the only reason we go to medical school is so that we can pass the final exams and become a doctor, but what if you could gain the knowledge and skills need to pass the exam in only 2 years rather than 4 or 6?
An online survey of medical students’ opinions of their clinical placements
The survey was produced by myself, using Google Docs and hosted on the QuID website. It was then shared via social media. It has been live for just for 8 months.
https://docs.google.com/forms/d/1d_nLuyYqhROIMtI65C3yY9aCDHZ_Vmo7YycEUa1R000/viewform (If you would like to complete the survey then please do, or if you would like to work on a similar project then please get in touch)
(Please feel free to skip the stats and jump to the exaggerated conclusions)
The survey was answered by 65 current medical students. The participants were asked to report their current decile ranking within their year and there was a fairly equal spread of participants from all deciles with 18.5% reporting that they were in the top decile and 2% saying they were in the bottom decile. Participants were also asked to describe what kind of medical student they were: 19% said they were “very keen”; 46% choose “quite keen”; 27% chose “average” and only 7% thought they were “less keen than most”. 18% were in their 1st clinical year, 39% in their 2nd and 43% in their last year. 85% of participants were between 21 and 27 years old. The participants had been placed in trusts all across the UK. This is a small but hopefully, fairly representative sample for this argument generating study.
Assessment of the Placements
85% of the medical student participants attended clinical placements 4 or 5 days a week on average. None attended more than this but about 15% said they attended 2 or 3 days a week.
57% of participants had to “sign in” once a day on clinical placements, while 22% signed in for both the morning and afternoon, while 21% did not have to sign in at all. When asked what they thought of having to sign in, most participants resented this.
30% thought that their clinical placements were poorly organised.
Only 46% said that these placements allowed them to meet the majority of their learning objectives.
Results of How Medical Students Say They Learn
When asked about teaching methods, most participants said they received lectures while on placement and over 80% found these useful. Likewise, they had all received tutorials and 95% found these helpful. All were expected to visit the wards and clinics for clinical exposure.
When asked how they worked to meet their learning objectives: 52% choose talking to and examining patients; 24% choose ward work; 24% simulation; 20% attending clinics; 16% choose teaching by doctors; 25% choose book work (Participants were allowed to choose multiple “methods” which is why the percentages don’t add up). However, when asked to pick what method was the best for passing the end of year exams 52% choose book work.
Interestingly, 26% stated that on average they did not examine a single person per day while on placement, while 40% said they examined only 1 per day and 23% said up to 3 patients per day on average.
Is it Time Well Spent?
64% reported that they were expected to attend placement for the full duration of the working day (8 or 9 to 5), every day. However, 15% reported leaving most days before 2pm and a further 56% said they left before 4pm most days.
25% stated that less than 2 hours a day on placement was productive. With only 9% stating that over 5 hours a day on placement was productive.
47% reported spending more than an hour a day doing book work, with 18% reported doing over 3 hours a day of additional reading.
While this survey had a small and probably biased sample, it does produce interesting reading. It would seem that the assumption that spending more time on clinical placements is beneficial to medical students is not supported by the beliefs of a large minority of the students. Most students, it would appear, would rather have the afternoon off to do their own thing and to get on with their own learning.
This could be because the current NHS is full of co-morbid, elderly patients who are awaiting social care, which means that the majority of patients that students are exposed to all have similar conditions. Examining 1 person with COPD is very much the same as examining 50.
There is a widespread fear of litigation and a belief in competency based tick-boxes and simulation. Students must be signed off on plastics arms before they are allowed to touch a patient. This culture has produced a situation where students are less able to get involved with practical experiences such as clerking patients in A/E or learning how to do procedures, such as joint injections on the patients. Older doctors are always telling us "see one, do one teach one", well now its "don't see any because they are in specialist centres, don't do one because you haven't been signed off and you might be sued and don't teach one because you don't have a teaching qualification.! The learning paradigm has changed and it may improve patient safety but it has made learning a slower and more complex process, that spending time on a ward doesn't necessarily achieve.
So, if clinical placements are not seen as beneficial by a large proportion of students, shouldn’t the government stop wasting so much money funding these placements? Also, there needs to be far more transparency of accounting on what this medical education funding is actually spent on. Some trusts do provide an excellent library, common room and simulation facilities but others simply provide a student name badge that allows access to some of the wards and a nominated “clinical supervisor” that may or may not take any interest in the students assigned to them.
With the increasing growth of free online and up-to date medical literature, question banks, clinical videos, “murmur and chest sound audio libraries” and simulation facilities; is there even a need for modern medical students to even attend placements? I predict that students could learn all of the basic skills via theory and simulation (the cheap version is practicing examination on your friends, like we already do before OSCE's).
So, if 3 of the 5 years of medical school are in effect a very inefficient means of producing clinically competent FY1, why not make them shorter, or fill them with “supervised, competency based activities”? After all, the students and the government are paying the trusts to teach them, not just let them roam around the building, if they feel like it.
Does the career path of a “doctor” need to evolve for the 21st century? Should we just scrap medical students?
An alternative path would be to make everyone a PA in 2 years (cutting the student debt significantly) and then, increase the amount of post graduate training, so that PAs can then go on to become physicians or surgeons with more specific and shorter “competency-based” training pathways. The era of the generalist doctor is coming to an end with the increasing move to sub-specialisation and “conveyor belt hospitals”, isn’t it time that medical education had an equally radical shake up to produce more efficient training pathways?