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Mitigating Skills Decline in Fourth-Year Medical Students

By Dustyn Williams, MD April 16, 2019

The interval between fourth-year residency applications and the first day of orientation the following July is a well-documented nemesis for most medical students. The demands of preparing applications, the time investment in the interview process, and the typical period of decompression and leisure following Match Day result in an extended period of disuse of—and concomitant massive decline in—the medical knowledge and clinical reasoning skills they built up with so much labor in their first three years.

The decline manifests itself on Day One of residency when unrealistic expectations come into stark relief on both sides of the table: on one side, students anticipate that once they show up for orientation on July 1, their program will help them get up to speed, give them time to warm up, and show them the path, just as it was in medical school. On the other side, the programs expect that the new crop of students will arrive ready to hit the ground running, and will need no remedial instruction or special help to excel. But with the exception of a few “cutting edge” programs that offer either a very basic intern boot camp (which may be optional) or a “warmup” month, the vast majority of programs do not provide any such remedial support, nor generally, do students arrive with an intact skillset or the momentum to amplify their progress and success. The result is that students start residency behind the eight ball, requiring endless hours to reattain their former competencies.

The question, then, is how best to combat this skills decline, while still allowing for a “recharge” period of leisure before students begin residency. (For a discussion of the skills students will need that are not taught in medical school, please see this companion piece: “‘Intern Boot Camp’: The Cure for Resident Burnout.”)

The welcome truth is that maintenance of skills requires much less energy than their initial or re-acquisition. Thus, full-time study is not a necessary part of any proposed solution, nor will it be necessary to set aside time continuously from March through June—applications and interviews are a full-time job in themselves. Instead, a good starting point is to schedule some “free time” for after Match Day and then plan for a modest amount of daily study until orientation. Just as with physical exercise, repetition is needed for intellectual exercise. And just as with physical exercise, overtraining is not ideal.

Residency is all about treating patients, and treating patients is accomplished through a mix of medical knowledge and clinical reasoning. While clinical reasoning is introduced in medical school, the structure of its use changes drastically once in residency. Whereas before, the student would be presented with a vignette featuring only the pertinent information, and a series of next steps to choose from, leading to a single correct answer, in residency the vignette becomes a real patient, the “pertinent information” morphs into the History & Physical in which pertinent and impertinent live side by side, and the multiple-choice answers disappear. Of course, in dealing with real people, the presentations almost always deviate from the illness script, meaning that there may be no “right” answer, but instead only a risk-benefit analysis of multiple bad options (though probably better options than dying, which might happen if nothing is done).

This is hard . . . how can it be trained for? Where can one get the necessary “reps” to develop these muscles? By seeing virtual patients and being forced to answer complex questions that challenge clinical reasoning.

Skills-decline mitigation methods, therefore, should meet two basic criteria:

  • They should simulate the clinical experience that the intern will face upon entering residency. The study tool will feature real people (ideally with an audiovisual component, to enhance verisimilitude and strengthen the personal element), whose presentations have some complication or additional feature that moves them one standard deviation from the classic illness script learned in medical school, which will thus require a degree of complexity in reasoning to determine the diagnosis and course of treatment.

  • They should simulate the experience of the EMR. The student should get practice in locating and using patient histories and records, and in navigating the technology in general.

Both of these should foster the transition from student to resident.

Existing products tend to over- or undershoot the ideal in these respects. On one hand, the nature of case reports is to be hyperspecific, answering too-detailed questions about disease presentations that are rare or unique, too advanced for new residents, and not likely to conduce to the development of broadly useful clinical understanding. On the other hand lies test review, which remains in the classic illness script, too remedial for the intern experience. And attempts have been made to explore the possibilities of integrating case reports with multimedia interactivity. While each of these has its uses, none simulates the experience of residency.

Moreover, none of the existing study options follows a Socratic approach, which is ideal for stimulating true understanding. The Socratic approach would lead students through a case and the physician’s process of reasoning by a series of questions and an incremental revelation of new information (mirroring the reality of the hospital, where lab results take time to obtain, and imaging can be subject to a waiting list). This would include everything from maladies, to signs, symptoms, previous medical history, labs, imaging, diagnoses, courses of treatment, complications, and resolutions. With a stepwise increase in difficulty, or an unveiling of new data as the case progresses, complex topics such as competing diagnoses, therapeutics as diagnostics, and the impact of one disease’s treatment exacerbating a coexisting comorbid condition, can be discussed in detail.

Through our envisioned study tool, the student’s challenge will be to synthesize a diagnosis from all this information, develop a treatment plan, and know what to type into the computer to get the right thing to happen. Medical students learn to take a history and analyze the labs, then present to their senior, and they are told what to do. Second-year residents, by contrast, are the ones telling people what to do. Intern year is the transition from a student who reports and interprets data, to a resident who owns the patient encounter and makes decisions independently.

All of this is on the table on Day One of the internship. Rather than start cold turkey, we recommend building up momentum and confidence ahead of time by studying cases written in such a way and through the use of such technology that the residency experience is most closely simulated. This will help solidify the reporting and interpretation skills acquired in medical school (mitigating skills decline), as well as force the user to think in a way beyond what any test will demand—to think about what one would actually do in the moment, with a real person.


Don’t let your skills decline, start now! Click here to start challenging yourself through virtual cases and the Intern Bootcamp will tell you everything your residency program expects of you on day 1. 


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