What hospital work is really likeBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7126.2 (Published 17 January 1998) Cite this as: BMJ 1998;316:S2-7126
Do medical students understand what they are embarking on? Joe West and Jill Straw report on a new course started at the Derbyshire Royal Infirmary NHS Trust
Many medical school applicants may be attracted by the money, status, employment, variety, and job satisfaction in a medical career. But are these medical applicants making an informed career decision?
A hospital experience course has been started at the Derbyshire Royal Infirmary NHS Trust initiated by the postgraduate clinical tutor who saw the need for prospective medical students to be given a realistic idea of the implications of studying medicine.
In 1994 Grainger surveyed 735 preregistration house officers.1 A postal questionnaire assessed biographical and lifestyle data, career influences, regrets, and intentions. There was a section on careers advice. Half the respondents had received careers advice before they went to medical school. Before applying to medical school nearly all were aware of the length of undergraduate training, but only 54% were aware of the length of postgraduate training, while 35% were aware of hours of work. Thirty seven per cent had spent time with a general practitioner or a consultant and only 6% with a junior house officer before applying to medical school.
It was recommended that schools' careers advice should be better tailored to the needs of potential medical students. In particular:
Sixth formers should spend adequate amounts of time with a consultant or a GP or both, and a preregistration house officer (PRHO)
Adequate information about the realities of medical life should be given
The BMA video “A stressful shift” might be a useful learning tool for students
Schools and local hospitals should develop links to provide hands on experience of medical life for those students wishing to study medicine. Postgraduate deans could facilitate this.
Allen studied cohorts of medical qualifiers.2 They were randomly selected from each of the medical schools in Britain for the years 1966, 1976, and 1981. A parallel study followed up those cohorts and added a new cohort who qualified in 1986.3 Most said that they had received no careers advice before going to medical school. Allen wrote: “There seems to be an urgent need for all prospective medical students to be given a realistic idea of the true implications of studying medicine.” At a conference entitled “Choosing Tomorrow's Doctors” she discussed her findings and said: “The advice from schools was generally agreed to be either non-existent or discouraging, and almost always ill-informed according to our respondents in both studies.” She added: “It seems absurd that so many people enter medical school with so little real appreciation of what it entails. It costs nearly £200,000 to put a student through medical school, and such an investment should not be made on such little information.”4
In response to the deficiencies illustrated by these studies a project was initiated at the Derbyshire Royal Infirmary, based on Grainger's recommendations. In February 1997 the Derbyshire Royal Infirmary Medical Advisory Committee gave its approval to a report recommending the introduction of a structured hospital experience course for sixth formers genuinely interested in pursuing a career in medicine.
Selection should ensure that opportunities are maximised for those who are genuinely committed to applying to medical schools and who have a realistic chance of gaining a place. So the following criteria for acceptance on the course were identified:
A minimum of six A grade passes at GCSE (now a basic entry requirement for most medical schools)
An appropriate selection of Advanced Level subjects (must include chemistry)
A recommendation from the school's careers adviser or head teacher confirming a genuine interest in medicine as a career.
All applicants for the course are sent an admission pack to be completed and returned before acceptance. This ensures that the trust's requirements for health clearance checks are met, that pupils are aware of what will be required of them in terms of their appearance, behaviour, and patient confidentiality, and that parental consent has been obtained. Only sixth form pupils (or older) are accepted on the courses. As the age for first year sixth formers is 16 to 17 the medical advisory committee agreed that this would now be the minimum age at which theatre visits were permitted. Previously the minimum age was 18.
To encourage a wide spectrum of applications we have written to all the careers advisers in sixth form colleges in Derbyshire outlining the course. A poster was included as an advertisement. This has generated an excellent response. All inquiries regarding hospital experience are now processed by the education department.
The aim of the course is to enable students to make an informed decision about applying to medical school. The three day programme is designed to give participants as much exposure as possible to doctor and patient situations - outpatient clinics, ward rounds, theatre sessions - thus giving them a flavour of a career in medicine. Each of the participants shadow a junior doctor, if possible a PRHO. Some will have exposure to the acute medical take with the senior house officer (SHO) on call. At the end of the course the students spend an afternoon participating in an informal and interactive session. First there is a brief introduction by the postgraduate clinical tutor outlining the need for careful, detailed, and objective consideration before undertaking a career in medicine. In the following two hours the participants are given a lecture by an SHO.
The lecture consists of material drawn from personal experiences of applying to medical school and working as a junior doctor.
It is emphasised that a successful application requires a variety of skills and attributes. The academic standards set by medical schools are only the beginning of a long hard campaign. To impress an admissions committee the students will have to develop a comprehensive portfolio. They must gain first hand experience of the working environment they wish to enter. At all times they must demonstrate enthusiasm for what they have done and wish to do in the future. The information they gain about medical school and life after graduation will improve their chances of entering the profession.
Participants' attention is drawn to the problem of low morale and stress in junior medical staff. They are told that the potential causes are the length of postgraduate training; hours of work; salary; additional duty hours; rotas; postgraduate examinations; and flexible training.
At the age of 17, however, these issues may seem irrelevant. It is easier to rationalise the problems if they can be displayed to the students as real scenarios. For example, an outline of a week in terms of hours quickly demonstrates that a 72 hour on call rota combined with sleeping, eating, and studying leaves little time for relaxing. It is useful to compare and contrast different career pathways that the students could take. Most will have the academic capability to choose from a variety of university courses. Some courses, such as law, offer vocational training schemes at postgraduate level with a projected salary in excess of that of a junior doctor at the same age.
Few of the students have had a clear idea of length and structure of postgraduate education and training. This is one of the key areas which contributes to stress and low morale among junior doctors. The hierarchy of hospital medicine is outlined, along with the length of time spent at each grade, remuneration, and opportunities for progression in hospital medicine and general practice.
There are many difficult concepts to grasp about the reality of being a doctor, including breaking bad news, death and dying, making mistakes, and guilt. The BMA's video “A stressful shift” is used to focus on some of these issues. It portrays a junior doctor working a shift in an accident and emergency department and attempts to emphasise the continued pressure of time and the stress of decision making. There has been a mixed reaction to the video, but it has provoked interesting group discussions. Many of the students expressed surprise at the level of anxiety and stress displayed by the central character after he had finished his shift. There were comments such as, “you have to leave your work at work,” and “surely he is over-reacting.”
The students are asked to identify the problems encountered and skills used by the doctor throughout the shift. Issues such as time management while at work and away from work were also raised. Most of the students note that the doctor was having difficulties in his relationship with his partner. This illustrates how shift work, long hours, geographical separation, six monthly jobs, and competition for career grade posts can have an effect on personal relationships. All students are given a handout containing most of the above information.
The feedback from students has been positive. All have enjoyed the clinical sessions, particularly the occasions when they have shadowed a junior doctor. Some have indicated that they would like to spend more time shadowing junior doctors and that a longer course would be beneficial. The final afternoon session including the lecture and video has also been well received.
Consultant staff have responded enthusiastically to requests to participate by accepting sixth form pupils at agreed sessions and by allowing their juniors to be shadowed. The scheme has benefited them in that there is now an agreed system for providing hospital experience and they do not have to become directly involved with requests from friends and family to organise these events. The junior doctors have also enjoyed the process and appreciate the opportunity to show the pupils the reality of day to day life as a junior doctor.
A few problems have been identified. Students may regard the lecture session as an opportunity to gain as much information as possible for the sole reason of getting into medical school. They will undoubtedly have an advantage in the eyes of an admissions committee, but the aim of the course is to allow the student to make an informed decision. There are profit making organisations which claim to give “a valuable insight into the challenges of applying to and working within a medical school” during a conference programme, but it is unclear if they address the realities of working as a junior doctor. At the Derbyshire Royal Infirmary this subject is made a priority.
It is important not to be too discouraging. The pupils who attend are highly motivated and initial feedback has shown that all have left the course more enthusiastic than when they arrived. It may be that some participants decide not to continue with their plans to apply to medical school as a result of attending the course. If this happens it might stop a young person embarking on a career which makes him or her an unhappy doctor.
I would like to thank Mr SY Iftikhar, postgraduate clinical tutor, and Dr Deirdre Mitchell, medical director, Derbyshire Royal Infirmary NHS Trust, and Dr Caron Grainger, consultant in public health medicine, NHS Executive, Birmingham.