As one might imagine, I get a lot of questions from medical students. Many are on clinical topics. Most relate to my role with the MD program. Usually, they’re questions I’ve heard in various forms in the past and so can draw from previous experience in considering what to say.

Occasionally, I am posed a question that is completely fresh and rather profound. Such questions cause me to pause, reconsider previous assumptions and go back to first principles. I am grateful for such questions and regard them as one of the real benefits of working with bright and inquisitive young people.

One such question came recently from a third-year student about to start the clinical clerkship. The question came after we’d chatted about the clerkship experience in general terms and went something like this:

“I’m worried about a lot of things. I know that’s my nature and I know most of it will eventually turn out OK. But what do you think I really need to be worried about and focus on?”

Wow! Insight like that, I felt, deserves a thoughtful response. And so, I’ve been reflecting afresh on what the world must look like from the perspective of a student at the mid-point of their medical education, about to enter the world of clinical medicine for the first time. Of all the things they could worry about, what should they worry about?

So, here goes…

My young friend’s question and struggle is rooted in what has become in recent years a highly troubling conflict with respect to the objectives of the clinical clerkship. Pedagogically, the clerkship is intended to provide clinical experiences that will allow students to consolidate and refine the fundamental knowledge and skills they’ve acquired in the pre-clerkship years. It’s a protected, highly supervised proving ground where they will encounter real patients in authentic clinical situations. It’s intended to allow students to transition from the abstract and theoretical to the “real world” of clinical medicine, encountering patients who are, in whatever means available to them, seeking help as they suffer from medical issues.

As they engage the clerkship, students will gain much knowledge about clinical medicine and how it’s provided in all its forms and settings. They will gain practical skills in the procedures that are commonly carried out by doctors. They will become familiar with the various settings in which medical care is provided in our institutions and communities, and about their comfort within each. They will learn how to work with doctors who are engaging various medical roles, and collaboratively with nurses and a myriad of highly skilled allied health providers.

But the most profound learning they will experience is about themselves. Specifically, about how they will accept and respond to the experience of engaging patients in need. For the first time, in real life settings, they will encounter real patients (not actors, not “virtual” patients) who are truly suffering in some way and our students will be, in some small way, in a position to contribute to their care.

They will need to find a way to relate to those patients. Those relationships, to be optimally effective, must be rooted in a genuine sense of caring about the welfare of that person they are encountering for the first time. They can’t fully care for a person unless they care about that person. Will they be able to find that delicate balance that allows them to fully commit to the patient while still retaining objective judgement about the circumstances and options available?

Achieving all this requires immersion in a clinical setting, close supervision with ability to review problems that arise, and sufficient time to develop a relationship with patients through their illness experience. None of this is specialty specific. These encounters, and the essential skill development that they allow, can occur for a student in a great variety of clinical settings. The ability to engage and connect with a patient is not dependent on the condition or problem for which they are seeking help, or the setting in which it is being provided.

And therein lies the existential conflict and the core of my student’s question.

The modern clerkship has become, at least in equal parts for most students, an exercise in career exploration and preparation for the residency match. Consequently, the focus has shifted over the years from long, immersive placements in medical care settings, to a series of much briefer discipline-based exposures with a generous admixture of electives, all intended to provide the maximal number of experiences and exposures. It has become the medical education equivalent of choosing to visit 12 European countries in 14 days rather than spend the entire two weeks in one place. The consequence is that student interactions with individual patients, although numerous, are increasingly brief and superficial. Their exposure to faculty members is similarly brief, often far too fleeting to allow for the development of relationships that provide deep teaching or the development of true mentorship. All this is degrading the educational experience in favour of specialty tourism.

Importantly, this is not their fault. Students are essentially forced to adopt such strategies to navigate what has remained a highly balkanized educational process with rigid separation of the university-based undergraduate experience from the discipline-based residency process. The result is a jarring transition from the one-size-fits-all MD program to approximately 30 entry level residencies, eventually leading to over 100 specialty programs.

It’s also not the fault of undergraduate programs which have adapted to meet the needs of their students, which is their primary obligation. It’s not the fault of the myriad college-based specialty programs which are rightfully focused on providing valid training programs leading to qualification in their various specialties.

The solution to all this lies collectively within the broader profession and the plethora of deeply entrenched institutions involved in various ways with important but unaligned components of the education and qualification of doctors. We have collectively been either unwilling or unable to look beyond our individual institutional responsibilities and engage the larger problem, which is eroding and, importantly, progressively lengthening the process by which we train doctors, all at a time when our country desperately requires qualified physicians, particularly in generalist roles. The issue facing our universities, colleges, specialty committees and regulators is not whether the collective system of education needs to change or whether they need to be involved in that collective “re-think”. The question is who will blink first and be willing to rise above their parochial interest to begin the process.  

And so, given that this will not be solved within the next year, what advice for my young friend and all the students of today?

I’m tempted to draw their attention to an oft-quoted fake-Latin phrase that appears in Margaret Atwood’s Handmaid’s Tale. It goes “nolite te bastardes carborundorum”.  Basically, don’t let the system get you down. Stay true to your roots and educational purpose. Yes, you need to think about specialty choice and navigate an admittedly perverse process, but you will be best served both in the short and long term by developing your fundamental skills in the many opportunities that are available to you. Engage the patient first, the problem second. Seek out role models, watch what they do, and seek out their guidance regardless of their specialty. You will be surprised at how welcoming they will be and how willing they will be to engage an eager learner.

Because that is what we do. That is how you will develop as a doctor. That is how you will find the fulfillment and satisfaction that this wonderful career you have chosen truly provides.