Medical students are often an under-utilised asset, but there is a necessary cost to using them before we, and our working systems, can benefit.

When COVID-19 initially hit us, one of the less dramatic changes to roll out in the wards was the absence of medical students.

The wisdom of this measure has since been up for debate, and the nature of how it came to be is unclear. Some have wisely hypothetised that the medical schools feared legal action from the parents of their students, should these students be exposed to the virus or fall seriously ill from its complications. Others suggest that it was a ministry-level policy which had little to do with school administration (though we know that the players involved are not that far apart from one another). Neither is completely correct, as at least one of the medical schools would later on enlist its students as volunteers (read: unpaid locum workers) at COVID testing centres, ironically placing them at risk of infection for no remuneration.

And yet on the inpatient side of things, literally nothing had changed. Ward work proceeded as usual, and if anything, became somewhat easier (quarantine means fewer patients) and harder (quarantine means more PPE and sicker patients) simultaneously. We hardly noticed students were missing, until they started trickling back when plague measures were relaxed, in July of 2020.

This short-lived epoch, for a time, proved the platitude: the presence of medical students in the ward is unimportant to the safe practice of medicine. The medical student is not ordered to function in the ward. Instead, the student is ordered towards preparation for examinations which will qualify them for the (hopefully safe) future practice of medicine.

But the reality runs deeper than this, and shatters the misconception. When these students finally came back as HOs, they were the “COVID batch”. They were handled with velvet gloves and stringently supervised. The expectation was that their work would be inferior in quality to that of their predecessors. The deciding factor in the minds of their seniors was not whether they fared better or poorer on their exams. It was that they had spent far less time on the wards than they should have.

It is not just better for a medical student to be on the ward. The medical student belongs on the ward. It is part of the telos, what makes a medical student a medical student.

If this is the way of things, then, per the principles of classical philosophy, there is a way for a medical student to be ordered. Some students must have some things that make them better than other students. So to speak, there must be the ideal, the form, of the perfect student which is practically unattainable, from which all others, be it the dean’s lister or the chronic web-caster, experience privation. Medical students becomes better by working their way towards this form, and they become worse by straying from it.

Therein lies the secret to making the most out of medical students. Just as the theologian strives to know of goodness through knowledge of the ultimate good, so can we know how to deal with medical students through an examination of this ideal. Here we will attempt do do our best to figure it out, in a scholastic manner, so you don’t need to.

The way things are, and what we can know

As in all sciences, we must begin by establishing definitions. Here, a “medical student” refers specifically to a member of one of our undergraduate schools in NUS or NTU, who is on assignment in a clinical rotation, and is authorised to interact with patients and perform procedures. That is, M3s, M4s, and M5s. It necessarily includes SIPs (“SIP” stands for Student Internship Programme, the local equivalent of a subinternship; subinterns are referred to as SIPs colloquially despite the lack of grammatical sense). Any expectations held of a student must be proportionate to both their seniority and established experience. It is possible for a M4 to be POCUS-qualified while a SIP fumbles through a simple ABG.

Now let us peruse the contents of the SIP Assessment Form from one of our established local medical schools, to see what they deem important in a medical student:

1. Has up-to-date knowledge and applies it appropriately in the correct clinical context
2. Demonstrates reasonable history taking and physical examination skills
3. Demonstrates reasonable approaches to clinical problems as well as reasonable clinical reasoning, clinical decision making and problem solving skills
4. Identifies emergency clinical problems early, responds appropriately to them, and escalates to senior early
5. Appropriately manages transition of care e.g. good patient handover, good co-ordination with other teams
6. Demonstrates good documentation (e.g. notes, referral letter)
7. Communicates effectively with patients and families
8. Communicates effectively with healthcare workers (e.g. succinct, gets read back)
9. Demonstrates self-directed learning
10. Demonstrates patient safety skills (e.g. good hand hygiene, adherence to other infection control measures, uses two identifiers, prevents falls, safety when dealing with high alert medication)

Intuitively, one would be surprised. Some make sense (Points 1, 2, 3, 9, and 10) while the other are not things we would imagine a student doing for the most part. Which student has a good number of opportunities to be in a position to escalate emergencies to a senior (Point 4), hand over a patient to another team (Point 5), or practice read-back with nurses (Point 8)? This list even assumes of students what we would be foolish to expect from many of our HOs at their best (Points 3 and 6). If we were expected to grade any student on all of these points, we would be forced to lie extensively to complete the form.

This list likely aims to project the ideal SIP as the equivalent of a fully-functioning HO. It correlates well with the structure of a HO’s Core Competencies Assessment:

1. Medical Knowledge
2. Patient Care
3. Interpersonal and Communication Skills
4. Professionalism: Honesty, Reliability, Self-awareness and Humility
5. Practice-based Learning and Improvement
6. Systems-based Practice

But the truth remains that no student, not even the greatest SIP, can ever function as a HO. If this were the case, then the addition of students to a team will normally speed up work processes. But applied to the realm of ordinary daily changes, students are inherently nerfed in both administration and function. Take, for example, this thought experiment, which could be set in any Tuesday on the ward:

A student applied to a HO’s usual clerical duties will always require a certain investiture of time and resources, both in learning these duties, as well as ongoing administrative support to ensure the completion of these duties, as described. The result is the slowing down of said work, and a state of relative suffering in the team they are attached to.

Turning the paradigm around

If we continue to think of students as quasi-HOs in the given manner, we will always end up disappointed. Many of us would even be disappointed to expect our HOs to act like HOs, but that’s another problem for another discussion.

To recognise the necessary place of a medical student on the team, we must depart from this idea that they must only imitate a HO in their typical daily functions. Learning how to be a HO is part of their educational duty and moral obligation to their future patients, as it prepares them for the job, and makes their work quicker and safer. This learning is good, but proportionally costly to their team.

Now consider this: the work scope of a HO is not limited to the medical or clerical duties which a student is obliged to gain competence in. These might include duties such as ordering and administering medications, putting up progress notes, making referrals, discharging patients, updating families, taking corroborative history, or completing physical examinations in loco magistri.

A typical HO will be thrown around to various other duties which, in many cases, might be either too professionally distant from or too far beneath them — not that any duty is really beneath a HO (or, in postings with no HOs, the MO in charge), but there is a mountain of other scut work which could be accomplished by suitably-endowed circus animals. Professionally distant tasks include having to act as the physiotherapist or the social worker for patients, especially in cases where the allied health staff are themselves overwhelmed by the load of referrals. Circus work is highly variable, but includes critical nonsense like running through every ward in the hospital looking for the last stock of an item needed for an urgent procedure, or spending literal hours on the phone with one patient’s family member.

This is not to say that medical students should be doing these tasks, any more than a HO or MO should be doing them. It merely exposes one of the frontiers in which medical students are better suited to help out in. In status quo, a small minority of students are thus involved, and so it stands to reason that only a minority of students are good students.

However, to think of a student’s ability to accomplish these particular task as the trait which makes them good students, puts the cart before the horse. A student’s effectiveness is not the cause of his or her quality as a good student. It is merely a symptom of it.

We propose this: the trait that defines a medical student’s quality, is their deliberate integration into their team, to the extent that they are able to intuit how they can optimise the life of the team in whatever capacity they occupy.

In a word: industriousness.

Industriousness applied: case studies from the front lines

As there are many kinds of teams with many styles of work, there are equally many ways in which students on these teams can apply themselves.

Take these recorded (for all intents and purposes, completely fictitious) instances of medical students supporting HOs in their everyday work:

These students demonstrated enough familiarity with the flow of an active call to know how they could contribute. They would be less effective at preparing notes (since they were new to the EMR and still had pending access to NEHR) but they could act as a force multiplier for their HO by being in multiple places at once. Their history and examination, while likely being inadequate for final documentation, could provide at least sufficient information for the purpose of triage.

This account showcases a successful exercise in understanding the dynamics among individuals in a team. A student might imagine that they could benefit from more extensive teaching during rounds, but these ones were able to see the bigger picture and thus give a higher priority to the welfare of their seniors. This also benefits students themselves, as HOs with more free time can in turn spend this time teaching the students how to do other sorts of changes, or supervising them with procedures.

The learning objective here is not just a practical one. Students like this do not become technically proficient overnight. They usually start practicing as early as their M3 ward postings even if training objectives at that point do not emphasise procedures (it is common practice to offer to sign students’ logbooks without having actually watched them do anything). Having the perspective to develop prowess in something they are not graded on is another way in which an industrious student can apply themselves to the big picture. And, if not already mentioned, a student cannulating a neck vein on call is absolutely legendary.

These are just distinct stories, but students have found themselves productive in innumerable other ways, such as delivering MCs from office to ward (in those not-so-ancient days when MCs still needed to be hand-signed), helping HOs look for special procedural items like formalin for a pipelle in a hospital with no gynaecological service, or even something as simple as bringing food for HOs who simply have no time to buy any for themselves. All of these activities, in their particular ways, help to illumine what it means to be a good medical student.

This is why a medical student does not become good by leaving the ward the instant permission is granted, implicitly or otherwise. Content can be studied at home, and procedures can be rehearsed on task trainers (of course, nothing beats actually doing them). A student’s real learning is from witnessing the industriousness of their senior HOs and MOs in their approach to all problems at work, both clinical and banal, and to draw from their virtue to cultivate their own. To be exposed to this, they must be immersed into the society of the ward.

What we need to offer

An industrious medical student being placed into a team is not unlike a seed planted in a plot of soil. To germinate, the seed does not require much: just oxygen, water, and heat. The health of the plant which grows, and the nutritiousness of its produce, however, tends to come from the richness of its soil, since a plant does not synthesise its own minerals. Likewise, a student’s presence requires little to no effort at all, but true training, and the realisation of their industriousness, requires real input from the other physicians in the team.

All physicians would universally disagree to the proposition that they have no obligation towards students. After all, the care of disciples is key feature in the Hippocratic Oath (on the other hand, Do No Harm is nowhere to be found in it). The most basic manifestation of this happens every day. Which physician, when buying a meal or a coffee with a student tagging along, will not instinctively pay for them?

Many of us, when encountering students, seek to be the physicians we wanted to work for when we were students. Invariably, this results in us being eager to get rid of them. It is a superficial win-win, as we work faster without them, and they (most likely) have student lives to live while they still can. Yet, the student’s place is on the ward. The ward is their soil, and removed from it, they are not growing.

This makes much more sense when considered from a longitudinal perspective. Consider this: the medical student we spend 1 hour teaching how to set an IV cannula today, will become the HO who saves over 100 hours in on-call time for his MOs by not having to escalate difficult IV cannulations to them. The medical student another HO or MO once trained to insert a flatus tube, can become the HO on a Medical team who can insert and troubleshoot the flatus tube for their own patient without needing to keep calling the Surgery MO down to look at it.

As we earlier concluded, the medical student’s attainment of virtue over the course of his or her ward attachment is far superior to any procedural training they may gain, because the former is something they can never practice outside of work. This is in a way easier for the HO or MO they are tagged to, since whereas teaching a student a procedure requires specific dedicated teaching and practice, the virtues of work can be demonstrated in any setting. Furthermore, much of its speaks for itself. It is implicit rather than explicit, and adds to the mystery of Medicine as a moral practice rather than a technical one.

A lesser student in this scenario would have whined about the outcome, as it failed to meet her expectation to practice a procedure. But even the most technically awful student, if appropriately ensouled, would come to appreciate the wisdom of it. This student’s ability to recognise such wisdom does not makes her a good student; it is the process of embracing it into her own framework of practice with instantiates goodness in her.

It is likewise for other virtues in practice. It can be seen in daily practice that only a minority of HOs doing radial artery sampling, even from a stable patient, will assess for collateral circulation beforehand (c.f. the Modified Allen’s Test). Most of these HOs would simply remark that, when it was taught to them by a senior long ago, this is also the technique which the senior demonstrated. Whereas nearly all students will practice radial stabs in the abovementioned safe manner on mannequins as part of standardised procedure training, since it is a possible MBBS station, most forget that such a practice exists. The learning here evidently does not come from the senior’s demonstration of procedural technique, but from the mindset of caution the senior imparts to the student in the line of work itself.

This, therefore, is what we truly need to instill in our students. Not all the post-rounds coffees in the world (though absolutely essential) can match the weight of a feather of virtue. In practice, this translates into keeping our students around as long as they are able, letting them follow us into difficult situations, and ensuring that they understand not just how, but why, we do certain things of moral import.

Measly but priceless fruits of labour

A medical student who is truly good, in the manner we have set out to establish, is unlikely to be given any tangible reward for his or her efforts.

2 types of students are given public honour. The first are the academically excellent ones. Grades are determined through a calculus of how well they did for their examinations and how much their clinical supervisors favoured them on their various postings. These become the dean’s listers and book prize winners, and a valedictorian is selected from this pool. The second are the researchers. These are the ones who go high dining with the faculty.

A good student is unlikely to fall into either of these categories. Time spent on the ward means less time doing research or rote-studying (though a select few may be prodigious enough to juggle both). They will assist their teams in manners more appreciable by their HOs and MOs, but not directly by their Consultants. Their degree rolls will more likely read “MBBS Lite” than “MBBS Hons”.

Instead, the fruits of a good student become apparent when they start work. They receive and follow instructions well, because they did the same as a SIP. They are procedurally more competent than their peers, because the majority of their practice was on actual patients in real-world settings. They have better control of their feelings and temper, especially in emotionally-charged situations, because they have seen their HO do it before, and know first-hand that they can do the same. They have a fair margin of stress, and will not decompensate easily, because they have seen their HO overcome a brutal call. They are realistic about their abilities, because they have watched their HO fail. They have a more instinctive and accurate clinical judgment than their junior status belies. When they become our HOs, we are proud that they are working with us. No further reward is necessary.

If any of us were to recall the legend of the Trojan War, and were asked who we could consider the greatest figure from the Achaean army, names which easily come to our mind may include Achilles, Odysseus, Ajax, Agamemnon, and others of similar stature. These heroes have persisted into legend for their greatness, but in their time, they were better remembered for their blunders and atrocities. Achilles’ acts of bloodlust following the death of Patroclus, and subsequent desecration of Hector’s corpse, were sacrilegious and caused offense to the gods (contrary to what Coldplay suggests, he was not known for his gold). Odysseus’ franchise of deception fueled his hubris to the point where he was forced apart from his family and homeland for 20 years. Ajax committed suicide after Odysseus won the armour of the dead Achilles over him. Agamemnon sacrificed his daughter to the goddess Artemis so that the Achaeans could go to war, and on his return to Mycenae, his wife and her lover murdered him.

On the other hand, for those of us who have really studied the Iliad and its spin-off works, we can know of other heroes who truly deserved renown, and still received (relatively) happy endings. Among these is Diomedes, the King of Argos. He — not Odysseus — had the greatest favour of the goddess Athena. He rivalled Ajax in martial prowess, and was the only mortal to wound 2 Olympian gods in battle in a single day. Yet he never succumbed to hubris as Odysseus did, and did not match Achilles in pettiness when he was insulted by Agamemnon. A substantially long aristeia — an epic poem celebrating a hero’s deeds — dedicated to him spans the length of 2 chapters. Homer evidently thought highly of Diomedes, yet most of us do not think of him at all. He is not a role worth Hollywood portrayal.

The paradox of a good student is the same. Improving the life of the team is meaningful in the moment, but does not deserve the lauds given to others. To our understanding, there is no school-sanctioned award for the “Best SIP”.

The best SIP, or the best medical student in general, is simply the one we care enough to cultivate. Our example will show through in the next generation, be it positive or negative. The same industriousness that can be pressed into the service of the team and its patients can also regress into a competitive kind of sloth.

It is granted that some students come to their postings with their minds made up. They have decided, on the advice of bad seniors or otherwise, that they will learn nothing on the ward. They will come for rounds — if they come at all — and vanish afterwards for “tutorials”, never to return. They will castigate their peers who dare to show their faces beyond these hours for not being team players. And when they do decide to hang around, nothing much happens, fueling their confirmation bias and sense of diminishing returns.

Those who do present themselves longer than they need to, are the ones who deserve our investment all the more. Though we may not see it yet, they will experience the growth for themselves. And by their mere existence, they will pay it back.