Medical graduates are employable, but are they prepared?

There is a lot of pressure put on higher education by governments, policy-makers, employers, parents and graduates when it comes to effectively preparing students for the world of work. Nowadays it is very common to evaluate the quality of a course based on its graduate employment outcomes.

Yet, an important question remains: to what extent do universities actually prepare students for employability?

Traditionally, institutions measure employability by short-term employment outcomes, which are believed to be attained through acquiring human capital (vocationally specific skills and knowledge). This is reflected in academically heavy programmes and the common use of surveys that measure the employment rates of graduates a few months after graduation.

However, increasing evidence shows that to have an effective and productive workforce, higher education needs to prepare students for holistic employability outcomes, consisting of at least four components: employment outcomes, job satisfaction, well-being and sustainability.

The nature of medicine places high importance on equipping students with human capital via a high volume of specialised knowledge and skills. Medical programmes are longer than most other bachelor degrees and heavily packed with crowded academic content, practical assessments and internships.

Underprepared for clinical practice

However, ironically, medical graduates still feel underprepared for clinical practice, which may be due to heavily theoretical teaching and learning programmes.

Recently, ‘integrated curricula’ that incorporate clinical application at early stages of training have become more prevalent as they have been shown to improve study engagement and graduate preparedness. However, the adoption of these curricula is still uncommon and inconsistent guidelines result in considerable variability in how they are implemented.

Another reason graduates feel unprepared is the lack of practically accessible knowledge and skills due to unprofessional training practices at hospitals.

Since the primary function of hospitals is as a public service for treating patients rather than teaching new doctors, systems and structures for facilitating education during these transition years have tended to be poor, with substandard learning environments and reports of unsatisfactory teaching quality and feedback.

This is unsurprising given that bullying in hospital workplaces is rampant, with between 30% and 95% of junior doctors being bullied, often by senior doctors.

This unhealthy environment not only puts considerable psychological strain on students from an early stage of their training but also counter-productively prevents them from acquiring the necessary knowledge and skills to enter their profession.

Yet, despite limited clinical skills, medical graduates have always had excellent employment outcomes. A career in medicine is considered a safe and stable pathway, with data showing employment rates for new medical graduates at over 90% in their first year, according to Australian government figures.

Drop-out rates and burnout

If higher education is judged by high employment rates, it is clear that universities are successful at training medical students to attain employment outcomes. However, the role of higher education in training medical students for employability is questionable when it comes to retention rates and other factors.

This is evidenced by the fact that medicine is also fraught with levels of stress, burnout, career dissatisfaction and depression that are higher than almost all other professions, especially in a COVID world.

A systematic review in the United Kingdom showed that over 50% of doctors experienced burnout and psychiatric morbidity, even before COVID.

Some studies have found that around 6% per cohort of medical students drop out of their course, with 40% attributing their departure to psychological morbidity and recurring feelings of failure and despair.

After all, very few people would consider their career trajectory a success if they managed to keep their name on a contract while being perpetually miserable and dissatisfied in their job.

These issues clearly show that medical graduates are not well prepared for the knowledge, skills and resources they need for employability. One of the reasons contributing to these issues is the lack of resources in higher education programmes to provide medical students with ‘psychological capital’, which refers to skills and capacities to look after their well-being.

Compared to other types of capital, medical graduates report feeling disproportionately underprepared to cope with the psychological challenges of medical practice.

Psychological capital training

For this reason scholars have been calling for better psychological capital training in medical programmes for decades.

Moreover, higher education programmes are also insufficient at equipping medical students with the knowledge and skills they need to navigate the employment dynamics in their workplace. In most countries, public hospitals have a monopoly on medical graduates and career progression is tied to being employed in these hospitals.

Therefore, any medical graduate who wants to work as a doctor or progress in their career has no other option than to settle for what is on offer.

The relationship between employer and employee in hospitals is often strained, yet despite the predictable and significant impact hospital employment has on the mental health and adaptability of medical graduates, students typically receive no training to deal with these issues.

Consequently, a clash of micro-cultures is observed whereby hospitals as employers operate within a culture that prioritises maximal labour to meet demand and senior doctors have high expectations about the work-readiness of graduates, evidenced by their priorities in maximising efficiency, implementing evidence-based practices and minimising patient risk.

By contrast, medical graduates transition from a student culture that prioritises learning and developing to an immediate expectation of intense and error-free productivity. These cross-cultural differences are concentrated in the high-stakes work environment of public hospitals, with medical graduates often being harshly underprepared to manage the often conflicting expectations.

Preparing the doctor workforce

For the last two decades, universities worldwide have implemented an employability agenda that is dominated by human capital theory and a skills-based approach. Rich evidence has identified a range of limitations to these approaches.

An increasing number of researchers have argued that to ensure employability outcomes, students should be equipped with a range of capitals, including psychological, identity, cultural, agentic and social capital.

Medical graduates often face well-being issues and high levels of job dissatisfaction but no opportunity to negotiate their conditions. Therefore, it is reasonable for higher education to anticipate the significant mental health challenges that have been internationally reported and invest in building other forms of capital.

It is time for stakeholders to take action to change this dire situation. Current medical programmes need to diversify their curricula by incorporating resources to teach medical students various employability capitals so that they can not only obtain short-term employment outcomes but also continue and thrive in their long-term career journey.

Additionally, since hospitals are the primary market where doctors are employed, hospital leadership should work with unions and representatives to make hospitals more supportive, collegial and productive for junior doctors.

At an individual level, medical students should proactively seek solutions for limitations in their institutions, leveraging student groups and seniors to create opportunities for early clinical application if integrated curricula are not employed.

Because employability is determined by a range of factors outside of human capital, students and graduates must also build non-human capitals through extra-curricular programmes to have greater control over their career trajectories, especially if institutions and employers do not facilitate this.

Justin Sung is a former medical doctor turned full-time educator. His areas of interest are medical education and learning psychology and examining how individuals can learn in the most efficient way possible under real-world pressures. At Monash University, he is involved in researching how the effectiveness and efficiency of learning strategies can be objectively measured and, outside of this work, he predominantly works in the private education space. He is passionate about facilitating discussion around evidence-based learning through his social media and combining ethical business with education to support gaps in the public system.