Practising doctors
- Tamsin Mackay
The journey to become a medical practitioner is challenging on multiple levels, but how prepared are young doctors for internship and practice?
Trepidation. For many young medical practitioners, this is the word that most accurately describes how they feel about their internships, the two years in which they immerse themselves into their profession and actually get to practise. It is a sense of unease felt by many students, stemming from the feeling that they do not have the skills that they need to thrive in this very demanding role.
Preparing to practise
“We asked students who had finished Med School to record audio diaries for us and we found that in some ways our graduates are very well prepared, such as with clinical knowledge and skills. They’re good at safely looking after a patient from day one of their internship,” explains Stuart Redvers Pattinson, from the Unit for Undergraduate Medical Education in the µÚÒ»³Ô¹ÏÍø School of Clinical Medicine. “However, where they really struggle is with the skills that they need to cope with an incredibly demanding role.”
The intern’s role, according to one research participant, is the “engine room” of the hospital. They need to deal with massive workloads in resource-constrained environments that require skills beyond just clinical knowledge. They need efficiency, organisational acumen and they need to be proactive and adaptable.
“Patients are in good hands,” says Pattinson. “The trust element comes down to building confidence in the interns’ ability to learn these additional skills and to develop their practical know-how.”
The issue of preparedness to practise has been something that universities have been grappling with for some time. There’s a growing recognition that it is important to look beyond knowledge and competency.
‘Entrustability’
“From a postgraduate perspective, there’s growing recognition both locally and internationally of the importance of more workplace-based training and assessment,” says Professor Richard Cooke from the Department of Family Medicine in the µÚÒ»³Ô¹ÏÍø School of Clinical Medicine. “Originally, the work came out of Utrecht University under the leadership of Ollie ten Cate and a concept called entrustability in medical education. It has focused on the curriculum at the postgraduate level and factors like the final exam and how this impacts on a student’s future.”
The exam is incredibly high stakes but has been designed to be as practical as possible – it’s a once off exam, scheduled for a specific date and all the colleges attend. However, there has been a question for many years that this form of examination isn’t entirely equitable.
“You could have a bad day after four years of postgraduate training and fail the exam and that isn’t fair on the student,” Cooke says. “There is also a significant power differential between your inexperienced registrar and the examining profession, an imbalance made even more challenging in South Africa. We need to be more cognisant of how many factors can impact this high-stakes exam. We need to ask what alternatives there are and how we can better align the training and assessment of postgraduate students, and how we can pull these learnings back into the undergraduate space.”
There is a growing movement towards multiple low-stakes assessments with feedback, each one contributing a small component to the overall assessment of competence, a form of entrustability.
“Much of our time is focused on preparing students to pass these assessments and their own energy is focused on passing them, but what we need is to really trust them to be part of the team so they can learn how to do the job that they’re going to be responsible for doing,” says Pattinson. “In order to trust the student, we need to give them clinical experience early on so that by the time they are senior students, they can really get involved in care.”
Building this trust comes down to getting to know the students and what they are capable of achieving because then you can trust them to be more involved with patient care. “One of the biggest things to come out of my research is that students are seen as separate to the clinical team when we need to trust them to become part of it. As soon as students feel useful, they feel motivated to learn,” he says.
Early exposure builds trust
Solving this trust issue in the future comes down to ensuring that students enter the clinical space early on in their degree with more longitudinal placements. That way students can develop a relationship with the team and the team can see how they develop over time, allowing each side to build trust.
“If you observe someone in context, you can accurately assess their competence or interest ability,” says Cooke. “We’ve taken all the knowledge and skills that we think a registrar needs for a postgraduate and we’ve grouped them under entrustable professional activities, or units of professional practice. These give us clarity around what we need to be entrustable and this, when added to small, summative assessments, gives us a richer picture of a postgraduate’s ability. If we get it right, they will be significantly more prepared for practice.”
This trust changes trepidation to confidence, especially if systems adapt to give students more opportunities to immerse themselves in the clinical space from very early on in their education.
“We need more longitudinal placements. If we want to build trust within teams, we need less emphasis on high-stakes assessments, so students don’t see study as the reward,” concludes Pattinson. “We need to reward medical expertise and involvement and their ability to apply their knowledge. This way, trust is felt both by the teams embracing students because they can contribute from the outset, and by students who know they can be more of an asset than a burden.”
- Tamsin Mackay is a freelance writer.
When students speak, who listens?
Author: Paula Barnard-Ashton
Life Esidimeni tragedy is perhaps the starkest recent example of what happens when cost-saving is prioritised over quality of life. During 2016-2017, at least 144 people living with severe mental health conditions died after being transferred from specialised Life Esidimeni care facilities (such as the Waverley Care Centre) to unlicensed non-governmental organisations.
A formal inquest concluded that the deaths were caused by negligence and systemic failures within the Gauteng Department of Health. In April 2026, the National Prosecuting Authority confirmed that criminal prosecutions will follow, nearly a decade after the first patients died.
What many do not know is that a group of 47 µÚÒ»³Ô¹ÏÍø Occupational Therapy students entering their final year of study were brave enough to submit a formal letter to senior Gauteng health authorities on 18 January 2016.
These students advocated against the planned closure of the Waverley Care Centre in Germiston and the proposed transfer of long-term psychiatric patients to community care settings.
Since their first year as undergraduates, the students had spent time treating the residents at the Waverley Care Centre. The students understood not only the value of the occupational therapy that the residents received but also the importance of the structure, routine, familiarity, independence and interprofessional collaborative care offered by the Centre. This is where the residents had built a meaningful and dignified life.
In their formal letter to the Gauteng health authorities, the students questioned whether these vulnerable people could safely absorb such abrupt transition to under-resourced, ill-prepared and unskilled community care, where just the provision of medication had been deemed sufficient. The students were also worried about potential abuse, as is often the case when people are not experienced at caring for those with mental health conditions.
Their letter was ignored, prompting a meeting between the Head of the µÚÒ»³Ô¹ÏÍø School of Therapeutic Sciences, the Heads of the µÚÒ»³Ô¹ÏÍø Departments of Occupational Therapy, Nursing, and Psychiatry, and Gauteng Health in April 2016.
The warnings expressed in the students’ letter and at the meeting went unheeded. The Life Esidimeni tragedy is the result.
What we need to ask now is: how do we build a listening culture into our higher education settings where the voices of students are valued and trusted? To do this we need to give students the platforms to speak safety, actively look for threads within student reflective journals and case reports, tune into the informal corridor conversations and then, as leaders, support their stance in the same way that the µÚÒ»³Ô¹ÏÍø Occupational Therapy Department supported the class of 2016.
- Adjunct Professor Paula Barnard-Ashton is the Assistant Dean: Teaching, Learning and Undergraduate Affairs in the Faculty of Health Sciences.
- This article first appeared in CURIOS.TY, a research magazine produced by  and the .
- Read more in the 21st issue, themed #Trust — the invisible glue binding society, science and technology.