The hidden curriculum: Are medical students adequately prepared for life on the wards?

Dear Sir

Every year, at the end of August, there is an influx of new doctors on the wards of hospitals around the United Kingdom. These are medical students that have succeeded through years of examinations and appraisals and are expected to possess the attributes of the General Medical Council's Tomorrow's Doctors (GMC 2009).

However, there have been concerns as to whether the new flock of doctors are adequately prepared for life on the wards. A recent study in the UK showed that medical patients admitted a week after these doctors began their new jobs had a higher early death rate by 6% (Jen et al. 2009). The authors cited issues regarding patient safety and process measures that could have influenced these results.

We believe that working full-time in a hospital demands attributes and knowledge that are different from those gained at medical school and it is this ‘Hidden Curriculum’ that most students are unaware of. Sixty-eight percent of a group of local final-year medical students that we surveyed also agreed that they were inadequately prepared for starting their new job. The main concerns were regards to their lack of knowledge about hospital dynamics, handing over clinical information to seniors and initial assessments of ill patients.

The Department of Health recently began a mandatory ‘Preparation to Practice’ module this August to address this. Although there were variations according to hospital and foundation school it mainly consisted of lecture-based tutorials and shadowing period for prospective FY1 doctors on their new jobs for a few days. There is no data yet to see whether this has had a direct impact on patient care.

Our experience as junior doctors that have undertaken this scheme has still left us wanting. We feel that the culture of hospital work and the attributes that are necessary can be better instilled at medical school by introducing shadowing periods in the final year. It is also necessary to introduce ‘near-peer’ led sessions involving current foundation year doctors for this. This would ensure that new concepts such as managing shift work and real-time interaction with other health professionals are introduced earlier making students more familiar with the work ethic of a junior doctor.

Despite competence in theoretical and clinical knowledge being examined at medical school, the key to practicing safely as a junior doctor is through this ‘Hidden Curriculum’. This requires trialling various education lead initiatives through cooperation with hospital induction organizers, final-year medical students and current foundation doctors.