Clinical placements in medical school are undoubtedly essential components of providing a quality medical education. While the foundation years of the basic sciences aim to provide an understanding of the physical, biological and behavioural sciences, it is the development of clinical knowledge through direct participation in patient care activities that provides the necessary preparation for competent medical practice.

In general, the most productive clinical placements occur when medical students are included as members of the hospital/clinical team, are assigned an appropriate level of responsibility for patients and tasks, and are actively included in the team's educational and review activities. Not only does this provide students with the learning opportunities that they need to develop their clinical knowledge, it also demystifies the function of the unit team, better preparing students for their future careers.

A medical student's level of involvement in the care of a patient generally increases in line with their acquisition of knowledge and clinical skills and vice versa. In some Australian medical schools, the final year of training contains a specific clinical placement referred to as a "pre-internship."

While clinical placements in general aim to develop a broad range of skills and knowledge, the 'pre-internship' placement also has the goal of easing the transition of students into their internship year. This is most often achieved through the student observing and performing appropriate parts of an intern's role under supervision, commonly by way of the medical student 'shadowing' an intern. Specific preparation for internship in the final year of medical school may help to relieve some of the anxiety that new graduates face on commencing work. It must be emphasised though, that it is not the role of undergraduate institutions to prepare medical students to be "work ready" on the first day of their internship. Hospitals must provide comprehensive orientation and induction programs for all interns.

While senior medical students are able to provide an additional resource to the clinical team, pre-internship placements must always maintain their educational focus and should not be used by health departments as an avenue for accessing cheap labour or as a solution to a workforce shortage.

The AMA is opposed to the use of medical students as substitutes for any type of Medical Officer. The primary role of medical students in hospitals and other clinical settings should be focussed on learning rather than fulfilment of any employment-type obligations.

The boundaries of the relationship between a student and their placement hospital can be blurred particularly by the provision of a monetary payment to students in exchange for the completion of clinical duties that form part of their clinical placement.

The AMA strongly supports the concept of pre-internship placements providing the following are adhered to:

• Clinical placements in the final year of medical school should aim to consolidate and further develop clinical knowledge and skills. Pre-internship placements should aim to prepare students for their future medical careers and must not be restricted to learning just what is required to function as an intern.
• Clear learning objectives must be in place and supported by formal educational activities, including opportunities for students to debrief about their experiences and discuss clinical cases
• Students must be appropriately supervised at all times and have a designated senior doctor who is responsible for monitoring their progress and overseeing their integration into the clinical team.
• Comprehensive intern orientation is the responsibility of employing hospitals and should be conducted at the commencement of internship; it is not the responsibility of the medical school.
• Pre-internship placements must always maintain their educational focus and should not be used by health departments as an avenue for accessing cheap labour or as a solution to a workforce shortage.
• There is no monetary payment provided to students in exchange for their participation in a pre-internship placement.

While the integration of medical students into the clinical team should be encouraged, clear boundaries need to be set to ensure that:

• patient safety is maintained at all times
• the health and safety of the student is assured
• the workloads and educational needs of the team members are also considered.

As with all clinical placements, consultation with all levels of the medical staff is essential when determining the details of the pre-internship program. It is also essential that the broader clinical team, including nursing and allied health staff, be involved in this process. Consultation should clarify:

• the numbers of placements required and how best to allocate students to clinical teams
• the learning objectives for the placement including what to expect of the student and how to target available teaching time appropriately
• the appropriate level of responsibility to be held by students including tasks to be performed and their role in day-to-day patient care. Students should only be performing duties commensurate with their level of skill and knowledge. They must not be undertaking tasks that require medical practitioner registration
• the level of supervision required, the members of the team who will be primarily responsible for provide this, and the senior doctor who will hold overall responsibility for overseeing the placement
• the lines of reporting to be followed by students, particularly important in cases where the designated primary supervisor is not present
• the university staff member who is responsible for medical student placements and whom members of the hospital team should contact if issues or concerns arise
  any assessment required of students by supervisors
• the evaluation and feedback mechanisms that are in place to ensure there is continual program improvement, and
• the training and support available to staff who are involved in teaching and supervising medical students to assist them develop their skills in these areas.

The skill of teaching does not necessarily come naturally to all doctors, but it can be learned and teacher-training programs are useful in improving these skills, particularly techniques to integrate teaching into the day-to-day unit and patient care activities. Universities and hospitals should make teacher-training sessions available to staff and should provide these sessions during paid time.

Junior medical officers are often expected to contribute significantly to the teaching and guidance of medical students. This must be recognized and additional support must be provided to interns by universities, hospitals and the unit team to ensure they are adequately prepared and resourced to undertake this role.

AMA Position Statement: Employment of Medical Students in Hospitals 2006.

AMA(SA) Doctors In Training Committee, Submission Regarding The University Of Adelaide Faculty Of Health Sciences Curriculum Review, May 2006.

Crotty, B. More students and less patients: the squeeze on medical training resources. MJA 2005; 183 (9): 444-445.
Lawrentschuk, N & Bolton, D. Experience and attitudes of final-year medical students to digital rectal examination. MJA 2004; 181 (6): 323-325

Olson, L. Hill, S. Newby, D. Barriers to student access to patients in a group of teaching hospitals. MJA 2005; 183 (9): 461-463.

Curriculum information available on medical school websites.

Adelaide University Medical School Placement Information provided to students, supervisors and Clinical Attachment Coordinators.

Postgraduate Medical Council of South Australia Draft Position Statement Role of Interns with Students Interns Aug 2006.