Underpants Gnome Theory of Medical Education

One of the surprises for me in clerkship has been the unique nature of clinical training for physicians relative to that of other healthcare professionals. Before starting medical school, I trained and then briefly worked as one of these other healthcare professionals, receiving accreditation from my overseeing college and all that. My experience during my clinical training time was substantially different from what I've received in medical school.

The basic structure was similar - each week or so, I'd be assigned a preceptor who was working in the hospital, and I'd report to them for my training, pretty much the same as what happens in clerkship now. The difference was in our respective roles and the level of supervision. My preceptor had a job to do aside from training me. However, my job was essentially to do their job. If they had a task to do, I would try to do that task. The two of us basically shared my preceptor's job that they would normally do on their own.

Being inexperienced, I was obviously quite bad at things in the beginning - I was uncertain of what to do at times, horribly slow, and made a LOT of mistakes. Since what I was doing was still the ultimate responsibility of my preceptors, they kept a close eye on me and provided direct assistance when I started to stumble. As I gained more experience, the amount of support I needed declined and my preceptors started to get more comfortable with leaving me more of the job to do. They stopped watching me as closely and slowly gave me more and more independence. By the end, I was basically doing the work on my own, checking in with my preceptors only in exceptional circumstances. When I transitioned to working on my own, the shift in my responsibilities wasn't all that substantial - I was still relatively inexperienced and had a lot to learn to master my full role, but I had already been doing the bulk of the work for months beforehand, under almost the exact same constraints.

Most healthcare professions seem to work this way. A student nurse in clinical training works basically in a nursing role. A pharmacy student essentially acts like a pharmacist. They generally do the same tasks, have the same responsibilities, hold roughly the same hours, and are expected to have the same knowledge base.

Medical education, by contrast, does not follow this framework. There are distinct roles for medical students, residents (with further splits between junior and senior residents), fellows, and fully-licensed physicians. My roles, responsibilities, tasks, hours, and necessary knowledge diverge markedly from the residents, fellows, and physicians who serve as my clinical preceptors. Since my preceptors have different jobs to do than I do, I've found there's far less investment in whether or not I'm doing my job appropriately. They care about the results of whatever task I've been appointed, but more in the way a coworker cares about your performance than in the way a teacher cares about your performance. The ends seem to justify the means in medical education - it rarely matters how I do something in clerkship as long as it all looks alright in the end, and that leaves open a lot of room for mistakes to go unidentified or only caught after-the-fact.

The sharp divide in roles means competence in medical education is backward-looking rather than forward-looking. In my previous program, I had to be declared competent at the job I was going into before I was allowed to work without supervision. In medical education, everyone seems to move to the next step by demonstrating competence at their current role - student, junior resident, senior resident - rather than competence in their future roles, such as being an attending. Knowledge and skills develop at each step with some continuity, but functional knowledge for the future role isn't instilled, resulting in some very difficult and oftentimes unsuccessful transitions between roles.

The underlying premise of medical education is that exposure is a good enough teacher in itself. Yet, this is an Underpants Gnome approach to competency in medical education:

Phase 1: Exposure to clinical experiences.

Phase 2: ???

Phase 3: Competency!

There's quite a bit of evidence to suggest that our current system doesn't prepare learners well enough for the next step of their journey. There's the July Effect in teaching hospitals. Difficult transitions to clerkship, the first year of residency, or full practice are frequently reported.

Canadian residency programs are trying to adopt "Competency-Based Education" models, which appear to include a specific transition to practice component, and similar reforms are rumored to work their way down to the student level, but I'm skeptical about whether that's going to be a change in the fundamental approach at most programs or just a change in semantics. The division of roles between attending physicians, residents, and students is fairly well ingrained in the structure of academic medicine. Without a meshing of roles, it's hard to imagine medicine will move towards the models of other healthcare professions.