The clinical years.
Authors: P Richards
Journal: BMJ (1983)

Students suddenly emerge from what may sometimes seem to be two years of non-clinical frustration into an apparently bright and exciting world of clinical medicine, a world which all too easily collapses in a sense of anticlimax. The anticlimax occurs partly because the pace of learning suddenly slows and method and approach become more important than fact. Learning is from patients with a haphazard selection of diseases and not from well structured books and lectures. Teaching is geared to helping students discover for themselves and is only an intermittent refinement and gloss on the product of the student's own initiative and application. More importantly, the anticlimax may occur because getting alongside patients who are ill and often tired may not be easy and some students find it very hard. Clinical education is a composite of learning facts, acquiring practical skills, taking responsibility, and developing the ability to make decisions. Medicine is a curious mixture of art and science, its clinical bedside method a sharp contrast to the exactness of science and to the complexity of laboratory and radiological investigation. Yet failure to become competent at this stage in listening to and examining patients may result in failure ever to acquire a solid foundation in practical clinical skills. At this early stage of the course there is time to practise non-complex but in fact not so simple skills over and over again without great pressure to amass a pile of detailed theoretical knowledge of disease. Several schools start the clinical course with a nursing attachment, a most appropriate introduction to clinical medicine. For one week each student keeps the hours of a nurse and undertakes the same duties, learning the ward routine and discovering the teamwork essential to good medical care. The nursing week ensures that future generations of doctors will not be deluded into thinking that patients in hospital are kept clean, tidy, fed, and cooperative without a great deal of effort. This introduction should help to stifle at birth any temptation to medical arrogance. Medical students have much to learn from nurses; even as recently qualified doctors they learn to rely heavily on the judgment and experience of the ward sister. The ward sister in charge of the ward is a key person in every clinical student's life (sometimes for life, but that's another matter). Time spent in developing a harmonious working relationship is time well spent. There is a tendency to react to what may seem to be a slow and pedestrian start to clinical medicine either by indulging, to the detriment of attendance on the wards, in all the sparetime pursuits dropped on the approach to the 2nd MB or by with? drawing into the library. The practical skills of medicine can no more be acquired by reading books than a driving test can be passed by studying the Highway Code. Sometimes students are discouraged by having to wait around for their teachers: neither teachers nor students should keep the other waiting. It is true that teachers have a normal day's clinical work to fit in around their teaching and that emergencies upset the best laid plans, but the remedy is largely one of good organisation.