How is a lack of intern places impacting our medical students?

A Health+ Family supplement focusing on student life prompts a reflection on the particular place of medical education in Ireland. Traditionally, we have had a large number of medical schools proportionate to our population: visitors to excellent presentations in the Royal Colleges of Physicians and Surgeons of Ireland over the last few weeks will know that Irish graduates represented more than one-third of the doctors in the Royal Army Medical Corps of the British army during the first World War.

Changes in medical education often feature in the media, such as the meaningless and distracting HPat entry examination, or the growing realisation of the high cost of graduate entry medical school.

Less noted, until the recent coverage of a shortage of intern places, has been the huge increase in numbers admitted to medical schools at a time of radical change in our health system.

This massive expansion has been motivated to a large extent as a revenue-raising exercise through fees from non-EU students or postgraduate entry in a cash-strapped university system.

There has been relatively little discussion on how this impacts on the nature of medical education. A particularly important aspect is that, unlike Sherlock Holmes and his mastery of deduction, doctors reason on the basis of induction. In lay terms, this means that instead of thinking from general scientific knowledge to the individual, doctors tend to work on the basis of accumulated individual experiences to formulate diagnosis, combining this with their scientific learning.

This requires exposure to large numbers of patients and the pattern of health and illness with which they present. Medical students also need to listen to many normal chests and tap many healthy knee reflexes to know what is the norm against which they can compare abnormal findings, elements of what is known as the apprenticeship approach.

In this respect, it is hard to appreciate the changes that have occurred over 30 years. My own class size was 65 and we were distributed across eight small hospitals. The intensity of patient care was significantly less: patients were less sick, with in-patient stays often for many days for procedures such as hernias and gall bladders which are now mostly managed as day cases.

Network of support

The low numbers of students, the relatively lower acuity of patients and attachment to a specific hospital also provided a network of support and supervision which facilitated pastoral care of the students from trainees and consultants alike.

The changes have been extraordinary, almost a perfect storm. The number of medical students has expanded exponentially in existing undergraduate – more than tripling in my own university – and new graduate-entry programmes. The numbers of hospitals and hospital beds has dropped markedly and patients are more sick, more intensively treated and remain for shorter periods in hospital. In addition, implementation of the working directive has reduced availability of trainees and consultants, and students may no longer be allocated to individual hospitals.

Such seismic changes require a radical revision of how medical education, which is largely provided by doctors and trainees who are full-time clinical employees, is delivered. It demands substantially better integration, communication, discussion and feedback mechanisms than have been the norm up to now.

It also requires an overview of whether the clinical settings provide an adequate spectrum of the clinical conditions that future doctors will see in practice.

While some of the medical schools have made progress in this regard, this is not universally the case and medical students may neither be fully aware of, nor empowered to react to, deficits in the breadth and depth of their medical education.

In addition, monitoring distress and provision of pastoral care for students in difficulty is much more challenging.

Vital importance

It is therefore of vital importance that the Medical Council, which regulates medical education and some of whose members also represent medical schools, takes a clear-eyed and firm position on how well medical schools have upped their game and dedicated the extra revenue and energies to teaching.

If necessary, it should not draw back from imposing sanctions or reducing student intake, if indicated, to preserve an appropriate educational framework.

In this, the Medical Council should reflect the epigram of the celebrated physician, William Osler, that: "He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all".

A version of this column appeared as a BMJ Blog. Prof Des O'Neill is a consultant geriatrician at Tallaght Hospital and an honorary staff member of Trinity College Dublin.