The Chasm Between Pre-Clinical and Clinical Medical Education

Depending upon which school you attend, the first one to two years of medical school are predominantly classroom-based learning. As medical students, we spend countless hours memorizing facts about disorders and diseases. We pore over diagnostic criteria, look for the minutiae in radiographs, and stress about the side effects of antibiotics and other medications.  While all of this information is useful and important, the reality of medical education soon changes when students start spending time in the hospital and in various clinics.

In transitioning from pre-clinical to clinical education, it soon becomes clear to medical students that what you learn in class and what you actually see in patients is quite different. Furthermore, even when presentations are clear it is still not trivial to determine what an actual patient’s diagnosis may be.

One poignant example, which I remember well, occurred while I was shadowing a local pain management Physician as part of the early clinical exposure course at our school. The patient whom we saw had a textbook case of C-7 radiculopathy with associated shoulder pain and loss of sensation. We had learned about radiculopathy in medical school, and I had a working knowledge of the diagnosis.  After I had spent some time interviewing the patient, my preceptor asks me what I thought the diagnosis was. I had some idea that the patient had a radiculopathy, but in my nervousness and uncertainty all I could muster up were a few whispers and murmurs.  My preceptor turns to me and basically says that this was a very clear case of C-7 radiculopathy.  After hearing the diagnosis, I distinctly remember thinking that I had known the disorder and had seen the symptoms in the patient, but had been unable to connect the dots.

The ability to connect the dots and turn pre-clinical knowledge into data that is useful in a clinical setting is a difficult skill to acquire.  You have to deal with patients that have varying presentations and many associated comorbidities, both situations that are not emphasized in much of the book and lecture-based learning of the pre-clinical years.  The only real method to attain proficiency in a clinical setting is hands-on experience.

Noting this need for hands-on experience, medical school curricula has changed substantially over the last decade. More medical schools now offer early clinical skills and patient experiences in their curricula, hoping to bridge the chasm between pre-clinical and clinical education. At the school that I attend, we start to see real patients in the second week of our first year. In the second semester of our first year, we embark on a year-long experience in local clinics where we work with practitioners to learn the ins-and-outs of clinical medicine and practice. Most other schools have implemented similar programs. Furthermore, the trend towards shortening pre-clinical education to one to two years is a direct response to student need for early clinical experience.

While early clinical exposure is important in medical education, it must occur with a solid foundation of preclinical knowledge.  Balancing knowledge acquisition with practicing clinical skills is a juggling match every medical student must deal with. Luckily, we don’t have to learn all of it during medical school, as medicine is a lifelong learning experience.

Featured image:
stethoscope by Dr.Farouk

Ankur Narain

Ankur is a medical student at the Johns Hopkins University School of Medicine, Class of 2017. Ankur graduated from U.C. Berkeley (2011) with a degree in Molecular and Cellular Biology. He did his undergraduate thesis in the laboratory of Dr. Jay Hollick, where he studied epigenetic effects on the inheritance of plant color in corn. After college, Ankur worked for two years in the laboratory of Dr. Keiko Ozato at the National Institutes of Health. Ankur studied the role of histone H3.3 in activation of the innate immune response in macrophages. Outside of school, Ankur enjoys sports and movies. He is a die-hard San Francisco 49ers, San Francisco Giants, and Golden State Warriors fan. His favorite movie is The Usual Suspects, with Infernal Affairs coming a close second.

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