What’s missing from medical education?

This important topic is explored in our Winter journal JHH19.3

Editorial by David Peters, Hugo Jobst and Louise Younie

With student burnout at an all-time high and many trainees leaving the NHS for easier work abroad, can medical schools find better ways to equip graduates for the rigours of clinical life? ‘What’s missing?’ is one way of asking what’s to be done, but as we shall see other less obvious, vexing questions circle around it. All around our universities we see how societal breakdown, austerity, and mental health challenges weigh on healthcare. Our profession is having to deal with information overload, ever-increasing complexity and litigation. Our educators too are overwhelmed and working flat out.

This issue of JHH gives us the student perspective on how ‘the system’ turns them into practitioners. Your three o-editors must declare their interests in this. David is a retired GP academic researching NHS burnout and resilience. Louise is a recognised innovator in medical education and creative enquiry. Hugo, a final year medic in Glasgow, organises the Humanising Medicine Forum.

‘As a final year medic, I can see student dissatisfaction growing and its insidious consequences manifesting in individuals and at the systemic level. There are so many people with good ideas out there, and the feeling that medical school misses the mark is felt by many. Now is the time to come together for cultural, systemic change in medical education. The articles in this issue give students a voice to say what they feel is missing from their learning experience.’

Hugo Jobst

We share a disquiet about the wellbeing of our colleagues and alarm at the healthcare professions’ direction of travel. We worry together about the industrialisation of medicine and education and what happens when their nourishing humanising currents dry up. Over decades, since the General Medical Council’s comprehensive recommendation, medical schools have reformed their course content, reformed ways of teaching and reformed assessments. Medical schools strive to provide what’s needed for the professional journey ahead in an uncertain world, and much of what they offer (though by no means all) is necessary. But clearly it isn’t sufficient: student burnout is common, and many junior doctors have felt unprepared for the demands of their foundation year (Gale et al, 2022). In recent times as many as half of our would-be trainees leave the NHS at the end of foundation year 2, many of them to train outside the UK (https://blogs.bmj.com/bmj/ 2020/02/06/why-are-so-many- doctors-quitting-the-nhs). Perhaps this is an indicator of the pressures on our junior doctors in a struggling NHS, but is there more that medical schools can do?

Business as usual isn’t working and in a medical system so evidently in trouble we need to ask what medical schools might do to adapt and mitigate. Too many young clinicians are in distress, though it’s a moot point whether this calls for better education, access to psychological support, or better working conditions. Probably all three, the balance depending on how we conceive the purpose of medicine. However, there are and ever have been ‘key tensions inherent in the professional socialisation of doctors – between “objectifying” and “humanising” currents’ (Cribb & Bignold, 1999). These longstanding disagreements are about why, where and how the practice of medicine can strike a balance between ‘objectifying’ cure and ‘humanising’ care. Without this new consensus medical education will stagger on in its current unsatisfactory trajectory.

In the BHMA’s survey of medical students and foundation doctors (still under way), just over half of the responders so far feel the curriculum is adequate, yet very few say that medical schools look after them or take their views into account. This disparity between content and process suggests it isn’t simply knowledge that’s missing. Technical fact-based aspects, even if overloaded, may be good enough, but feeling listened to or supported are emotion-laden issues. The perceived lack might have to do with the swelling medical school intakes, or students’ increasing workloads and the heavy systemic demands on their educators. Yet we suspect there’s more to it than this: the hidden curriculum and the traditional doctor persona – emotionally detached and stoical – encourages a macho non-engagement with the challenges, especially the emotional labour of our work. Even where extensive student support is available, our students and doctors have tended to hold back from asking for help.

The 2022 BHMA’s annual Kilsby Essay Prize asked healthcare students to tell us what’s missing. In this issue we present the winners and some runners up in the form of essays and artistic responses. Relatedness seems to us to be an emerging theme: students and medical teachers have contributed articles on ways to escape the limitations of the lecture room and the encroachment of online teaching and virtual consultations that can put an unhealthy distance between student and teacher. Several articles raise concerns about these power dynamics whether in the clinic or by the hospital bed, and particularly if online consultations were to depersonalise the patient and submerge the humanity of the doctor.

Our profession should take these concerns seriously at a time when many doctors fail to flourish, and when they burn out their unhappiness impacts on patients and on the leadership and morale of the workforce. Can medical schools become altogether less anxious and competitive places, teach a more future-proof curriculum, where educators expand their imagination and students learn more effectively? If ever they are to flourish together in a long and satisfying patient- facing daily life they will need time for personal development, and to be psychologically and socially, as well as technically, well-informed. We are told in this issue of JHH that space
will have to be made beyond the confines of the teaching hospital space for creative engagement in the community,
for authentic reflection, and healthful recreation.

  • Cribb A & Bignold S (1999) Towards the reflexive medical school: The hidden curriculum and medical education research. Studies in Higher Education, 24(2) 195–209, doi 10.1080/03075079912331379888
  • Gale T, Brennan N, Langdon N, Read J, Keates N, Burns L, Khalil H, Mattick K (2022) Preparedness of recent medical graduates to meet anticipated healthcare needs. GMC. Available at: www.gmc-uk.org/-/media/documents/p4p- research-final-report-feb22_pdf-89855094.pdf (accessed 2 December 2022).