Proper preparation and planning…

There is a basic assumption that medical schools prepare medical students to become doctors.

One might expect that medical schools prepare medical students to broadly similar standards, and that by extension, their students would be broadly prepared for practice when they emerge blinking onto the wards each August.

In a fascinating paper, Goldacre, Lambert and Svirko have analysed the latest responses to a questionnaire sent to each and every newly qualified doctor (from UK medical schools) registered with the GMC in 2008 and 2009.

The responses show an overall improving perception of preparedness amongst our most junior colleagues.  In 1999/2000 only 36.3% of medical graduates agreed or strongly agreed that their training had prepared them for practice, and in 2008 and 2009 this was 53% and 49.4% respectively.

So, things are getting better . Why they seem to be getting better is not clear.  Is training really improving the preparedness of graduates, or is the increasing level of supervision in the workplace protecting today’s FY1s from the worst ravages that previous generations were exposed to?

However, in spite of the improvements, can it really be true that we are barely able to equip half of our medical graduates to feel prepared for work when we unleash them after 5, 6 or even more years of training and education?

And what are the responders unprepared for?  The questionnaire offered some domains for further comment.  In 2008/2009 responders felt unprepared in terms of:

  • clinical knowledge 17.5%
  • clinical procedures 21.3%
  • administrative tasks 31.8%
  • physical/emotional/mental demands 26.4%
  • interpersonal skills 2.7%

Reassuringly the proportion of responders who felt their unpreparedness was a ‘serious’ problem was low at 2.7%, and was a ‘medium-sized’ problem for a further 22.6% (again, a reduction on similar cohorts in previous years)

In addition to the analysis offered in the main paper, the online supplementary data reveals even more stories -for example, one medical school increased preparedness in their students from 33% in 1999-2005 to 62 and 61% in 2008 and 2009, and yet one school continues to have graduates that feel unprepared – with only 24% feeling prepared in 2009, and similarly only 30% in the 1999-2005 period.

So – what is the message here?  There are almost too many conclusions one could leap to, but for me there are some urgent points which need addressing:

1:  There is unwarranted variation across medical schools.

It may be hubris on the part of the full list of graduates from medical school 12, but more than 80% of the graduates of 2008 and 2009 felt well prepared, and yet in comparison, from school 16, 38% strongly felt that they were under prepared.

This kind of variation is not unexpected given the variety of courses, curricula and training opportunities available to the different medical schools in the UK, but for over a third of graduates to feel strongly that they were underprepared for practice demands further attention.  This attention is vital, as the data shows that over time schools can improve, and the domains for which FY1 doctors felt least prepared for are all vital to maintain a safe, efficient and effective workforce (administrative tasks and physical / emotional resilience)

2.  We are not preparing our students for they key aspects of the jobs they are taking on.

The finer details of the survey show that of the domains graduates feel least prepared for, administrative tasks, and the physical/emotional/mental demands of the job rank highly (figure here).

The authors argue that preparedness for administrative tasks could be seen as ‘trivial’ and do not comment further on the physical, emotional or mental impact of working as a junior doctor. Clearly medical schools are not responsible for all of the factors which affect preparedness for practice, but it is vital that as a profession we start to value our most junior colleagues – even before they start to work with us, and ensure that they are developing the tools to help them cope with the demands of what can be a very stressful career.

With proposals to move the date of full registration with the GMC to that of graduation from medical school, the concept of preparedness amongst medical graduates has never been more topical, and if some of our institutions are falling as short as they seem to be in preparing the next generation of doctors, some action is required.


  • Fiona Moss

    Is the solution (a) changes to undergrad education (b) much better induction by hospitals – although now much improved – still lots could be done (c) improve the Foundation role?
    My view combination of (b) and (c)

    • tobyhillman

      I think that induction needs to be fit for purpose – see my thoughts here for an expansion on that (

      However, I do think that undergraduate education could be reformed, or the opportunities for undergraduates expanded. The variation in preparedness unveiled in this paper shows that the lowest performing could do better…

      I think that UK medical students, once a clinical attachment is passed – and sufficient experience gained, should be able to work as amanuenses as in other European countries.

      I know that in Finland, students are able to gain experience, develop career intentions, develop professional attitudes, and earn money by providing a valuable service in this way.

      • Will Barker

        Hi Toby, we have created a website to help in part with the stress of starting a new job. Its called Dr Toolbox, and it allows doctors to create and maintain their own hospital wiki on the nuances of making referrals and ordering investigations. Its free, and already at over 30 NHS hospitals.

      • Bob Klaber

        Great blog Toby, and as you highlight this area is likely to be one of increasing interest if the ‘Shape of Training’ proposals around full registration come to fruition.

        In my opinion peer-mentoring, across the junior doctor-medical student chasm, has a big role to play in all of this. Many medical schools have developed really successful programmes of peer-learning and peer-mentoring, typically between senior clinical students and students early on in their medical careers. I would have thought more could be done to explore these models and programmes with Foundation Year doctors and students in the year or two before they qualify?

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