Intended for healthcare professionals


Medical students need experience not just competence

BMJ 2020; 371 doi: (Published 12 November 2020) Cite this as: BMJ 2020;371:m4298
  1. Tim Dornan, professor of medical education1,
  2. Hannah Gillespie, doctoral student1,
  3. Dakota Armour, medical student1,
  4. Helen Reid, clinical lecturer1,
  5. Deirdre Bennett, head of unit2
  1. 1Centre for Medical Education, Queens University Belfast, Belfast, UK
  2. 2Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
  1. Correspondence to: T Dornan t.dornan{at}

Competent but unprepared new graduates are sitting ducks for psychosocial harm

Anticipating a serious workforce shortage, the World Health Organization advocates substantial changes in how we prepare clinicians for practice.1 A look at current medical student education supports that recommendation.

Curriculums vary internationally: students are health workers in some countries and observers in others; they progress from medical school to hospital generalist training in some countries and direct to specialties in others. However, the main source of evidence about preparedness for practice is the UK. This may be because UK students, with little experience of practice, shoulder heavy clinical responsibilities as foundation trainees. Despite their inexperience, foundation trainees’ supervision may be arm’s length—for example, when a hospital specialist delegates patients’ generalist care to them.

This baptism of fire may explain why an increasing proportion of UK trainees deviate from the intended training pathway. Two thirds of foundation trainees delay entry to specialties, some taking career breaks out of medicine.2 The resulting gaps in staffing make patient care discontinuous, impersonal, and potentially unsafe, and incur eye watering costs for agency staff.

Paradoxically, many UK trainees break their training to become better trained. Taking a break relieves them from work pressures, unsupportive learning environments, unsatisfactory education, disrupted personal lives, and poor psychological health. Some also want longer to choose a specialty.3

These factors, though, are an insufficient explanation for the UK’s retention problem. Only 10% of trainees (interns and residents) in the US, the Netherlands, and New Zealand take career breaks456 despite negative psychosocial experiences.78 The relative immaturity of UK trainees cannot explain their career breaks because students enter medicine straight from high school in the Netherlands and New Zealand too.

Trainees leave when a final negative experience “brings down the tower of blocks.”9 Negative experiences start in medical school3 and intensify when students become trainees.10 Trainees with the least developed coping strategies are worst affected.11 Those in the UK certainly need coping strategies because the NHS, while affording excellent training opportunities, operates under formidable pressure. Promises of ever safer healthcare with ever tighter budgets have resulted in expertise being so thin on the ground that work is often shared out rather than supervised. Students need to be very well prepared for work.

The competency movement has strongly influenced global reforms in medical education.12 This has shifted the arbiter of readiness for work from having accrued sufficient experience to having shown competence, off the job, in standardised tests. By that objective definition, 100% of UK students are ready to practise safely, yet practice is not demonstrably safer.

The General Medical Council’s survey of UK graduates’ experiences of starting work shows that a gradually falling proportion (66% in 2019, compared with 90% or more in the US) think that they are prepared.1314 Subjective unpreparedness might be dismissed as soft evidence, but this predicts dissatisfaction with training, poor wellbeing, and burnout for up to seven years after qualification.13

The stressors that test medical graduates’ preparedness include feeling incapable of managing a heavy workload against the clock, on unfamiliar wards, on call, and lonely; facing criticism and conflict; and managing very sick patients who deteriorate despite treatment. Trainees who have learnt only part tasks (such as writing a simulated prescription) find themselves incapable of doing the whole task (treating a sick patient). Unpreparedness is knowing what but not how. It is having such a fragile professional identity that you cannot admit uncertainty.151617 Competent but unprepared graduates are sitting ducks for psychosocial harm.

Observational evidence suggests that students are better prepared by gaining experience in real practice contexts, not just simulation; having longer, better supported clinical attachments; having a placement in a hospital where they will soon work; having generalist rather than specialist experience; and not having constant exam pressures.18

Narrative evidence suggests that North American students, despite also being in competence based programmes, have more such experience than UK students. The importance of ensuring that students have enough experience applies to any job, be it hairdressing, coal mining, or healthcare. Students become capable trainees by immersing themselves in work, observing and listening, role modelling, interacting with workers, participating in work practices, being coached, asking and answering questions, reading workplace documents, and writing in them.19

This cautionary tale leads us to propose that medical education should align closely with the World Federation for Medical Education’s guidance. This advocates early, gradually increasing involvement in patient care and experience of taking responsibility.20 Off-the-job training, observing practice, and a relentless diet of assessments is no substitute for experience. On-the-job learning is the only way to actualise students’ and trainees’ intrinsic motivation to care well for patients.


We thank Huon Snelgrove and Hiroshi Nishigori for constructive criticisms of our original submission.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have none to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.