Making Medical School Training More Realistic Will Improve Safety In Teaching Hospitals

New interns — doctors who have completed four years of medical school — often don’t order the right treatments for common medical problems. New interns specializing in emergency medicine often aren’t able to place an intravenous line, let alone manage a cardiac arrest on their own. During their first weeks on the job, or sometimes months, interns need another doctor to monitor every single order for lab testing, imaging, and medications.



Yet that’s what I see as the senior emergency medicine resident supervising new interns at two Harvard-affiliated hospitals, Brigham and Women’s Hospital and Massachusetts General Hospital. Interns are especially prone to making medication errors. This problem isn’t specific to Harvard-affiliated hospitals; it spans academic hospitals across the country.

I worry about these deficits. You should, too, especially if you find yourself in a teaching hospital in July, when interns begin to work.

These observations of mine feed into the longstanding question of whether a cause-effect relationship exists between new interns and in-hospital deaths. According to the National Bureau of Economic Research, adjusted mortality within teaching hospitals rises 4 percent in July, the month interns first descend on wards and emergency departments. A 2010 University of California, San Diego, study went further and found a 10 percent rise in fatal medication errors in July in counties with teaching hospitals; no spike was seen in counties that did not have teaching hospitals.

I’ve begun asking interns I work with from multiple specialties — internal medicine, anesthesia, emergency medicine, and orthopedics — who rotate through the emergency department if and why they feel unprepared during their first week of residency. The most common answer was some form of this:

“I feel underprepared mostly because I have never had to put in computer orders by myself before” for things like laboratory tests, imaging, and medications.

I certainly know the feeling. It’s how I and most other new doctors felt on day one of our intern year.

The short explanation for why interns have difficulty selecting orders — and thus managing their patients — is that they had limited opportunities in medical school for active engagement in patient care, including working side by side with experienced physicians to understand why they selected particular tests and treatments.

The importance of having medical students work closely with seasoned physicians lies largely in the opportunity for discussion about why certain tests and treatments are ordered. This process is essential for learning because it helps build cognitive links for students between the varied clinical presentations (the combination of a patient’s medical history; vital signs like heart rate and respiration rate; and the physical exam) and suitable testing and management. Without this process in medical school, senior residents like myself are left walking interns through ordering nearly every test and treatment.

Without sufficient experience placing orders during medical school, interns are able to apply rote knowledge, like a medication name, but will be deficient in important details of clinical decision-making, such as dosing and identifying the severity of an illness. For example, interns know that albuterol is the treatment for a flare-up of asthma, but they might not know the proper dose, or that adding steroids is appropriate when the patient’s lungs sound particularly tight and wheezy.

Requiring medical students to be more engaged with their supervisors while placing orders will undoubtedly improve interns’ clinical effectiveness when it comes time for them to begin placing orders for blood tests and medications.

Another solution to improving intern preparedness is to incorporate “boot camps” in medical school during the spring before starting internships in July. In these boot camps medical students can practice the skills most pertinent to their upcoming residency or specialty training.

The work for creating boot camp curricula has already been done by various institutions, and can be adapted for broader use. For example, the Harvard Affiliated Emergency Medicine Residency has a boot camp for interns that teaches skills such as how to place ultrasound-guided intravenous lines and managing mock cardiac arrests and medical resuscitations. Another improvement could be a crash course in monitored bedside manner training and breaking bad news to patients and their family members.

According to Dr. Christa Zehle, the associate dean for students at the University of Vermont College of Medicine (where I went to medical school), such boot camps should not only be placed earlier in the medical training timeline, specifically during medical school, but there is the potential to standardize care delivered by interns by incorporating them into what the Association of American Medical Colleges calls the core entrustable professional activities, which are essentially the requirements for beginning a residency program.

Although naysayers will point out that these solutions are a burden on supervisors, either residents or attending physicians, or that it merely shifts intern year into medical school, it is certainly a safer alternative than having new physicians who feel uncomfortable independently placing an order. It is also more sensible than one doctor reviewing every order by another doctor, which is what I and senior residents across the country do during the month of July, sometimes for five or six interns at a time.

Improving medical school training in these areas has implications beyond better patient care, including positive effects on interns’ mental health and wellbeing. Constantly being questioned by supervisors makes an already emotionally taxing experience — dealing with life-and-death situations while sleep deprived from intense work hours — much worse.

Interns should be coming to work with clinical competencies that fill them with immense pride. And while they eventually establish this workplace confidence, it should come much earlier, during medical school, not after they have added the title M.D. to their names.

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