Clinical experience is the sine qua non of medical education. Teachers and students often assume this is synonymous with “seeing more patients.” We wish to highlight what else it might be. The COVID-19 pandemic limited clinical access for many students and raised concerns about the consequences for students’ training. Since we often only appreciate things when they’re gone, the lack of clinical access prompted us to consider what it was that students missed out on. Was it just seeing patients? Clinical access and experience have a diversity of meanings to different observers.

At the 2015 conference of the Association for Medical Education in Europe, Jonas Nordquist extended an architectural maxim that “communities are what happen between buildings”[[1]] to “learning is what happens between lecture theatres.” We posit that “learning is what happens between seeing patients.” Although interviewing and examining patients is central to achieving basic clinical competence in recognising both the normal and the abnormal, generic clinical competence requires more than this. Current medical school accreditation ensures that new graduates are well prepared, as individuals, to assess single patients presenting with uncomplicated presentations of common conditions, but these standards do not necessarily ensure that graduates are prepared for the messy reality of working as part of a team to treat multiple patients simultaneously, often with complex presentations of varying acuities, at unpredictable times.[[2]] Dealing with multiple patients simultaneously within a team is not an innate skill. Rather, it is learned by observing and participating in team activities and team discussions, many of which are “between patients.” Given this, and through mutual discussion and drawing on our interests in workplace learning[[3,4]] and work readiness,[[2,5]] we propose an extended set of competencies afforded by clinical access, beyond those related to direct patient contact. We hope this makes explicit the tacit skills that could be lost if there is insufficient clinical contact.

• Recognise and contribute to the collective competence of multidisciplinary teams. Being a participant/observer in a clinical team enables us to learn how the collective competence of the team delivers care[[6]] and how interdisciplinary and interpersonal challenges are overcome.

• Apply project management principles to the complexities of clinical care. Aspects of clinical practice such as discharge planning or complex coordination of care require balancing multiple competing priorities against the changing availability of resources.[[3]] Understanding how the team addresses this requires a sophisticated understanding of the principles of project management.

• Integrate personal and team-based clinical reasoning. Listening to team discussions about diagnostic and management dilemmas and how evidence-based guidelines are modulated to each patient’s sociocultural context assists students to learn real-life clinical reasoning.

• Deliver patient-centred collaborative care. Seeing how a management plan is developed collaboratively with the patient and all members of a multidisciplinary team models interprofessional skills and patient-centred practice.

• Achieve an integrated perspective of clinical care. Understanding a whole episode of clinical care clarifies the contribution, and importance, of the component parts.

• Demonstrate adaptability to health systems. Learning to operationalise patient care under time pressure in heterogenous health systems, such as a variety of IT systems, prepares students to work effectively in a variety of clinical workplaces.

• Consolidating professional identity formation. Meaningful interactions with other team members allow them to observe and imitate role models and to “act” as future professionals.[[7]]

The pandemic highlighted how effective simulation can partially compensate for more limited direct clinical access and the importance of stimulating reflective discussions between students about their clinical experiences. However, simulation often focuses on the direct student-patient interaction. The competencies highlighted above go beyond this. Although these competencies can be proactively planned into simulations, they should also become explicit outcomes of clinical contact. Clearly direct engagement as a participant in a junior apprentice role in clinical teams could provide excellent preparation to acquire these competencies. It will require development of appropriate objectives, and valid assessments, related to the themes we have identified above.

Most of these skills are generic across medicine. Effective embedding in an apprentice-style role requires attachments of significant duration, and this means that not every student would be able to have such an experience in every discipline. The pandemic highlighted that experiences in one discipline are often close enough to those in another to allow students to meet global competencies and graduate. This may provide an uncommon opportunity to change how students rotate through different disciplines, at least in their final year.

We see such developments as critical to improving the work-readiness of our graduates. This requires refinement of medical school and accreditation bodies’ definitions of “clinical experience” to incorporate the suggested competencies.

Clinical experience is the sine qua non of medical education. Teachers and students often assume this is synonymous with “seeing more patients.” We wish to highlight what else it might be. The COVID-19 pandemic limited clinical access for many students and raised concerns about the consequences for students’ training. Since we often only appreciate things when they’re gone, the lack of clinical access prompted us to consider what it was that students missed out on. Was it just seeing patients? Clinical access and experience have a diversity of meanings to different observers.

At the 2015 conference of the Association for Medical Education in Europe, Jonas Nordquist extended an architectural maxim that “communities are what happen between buildings”[[1]] to “learning is what happens between lecture theatres.” We posit that “learning is what happens between seeing patients.” Although interviewing and examining patients is central to achieving basic clinical competence in recognising both the normal and the abnormal, generic clinical competence requires more than this. Current medical school accreditation ensures that new graduates are well prepared, as individuals, to assess single patients presenting with uncomplicated presentations of common conditions, but these standards do not necessarily ensure that graduates are prepared for the messy reality of working as part of a team to treat multiple patients simultaneously, often with complex presentations of varying acuities, at unpredictable times.[[2]] Dealing with multiple patients simultaneously within a team is not an innate skill. Rather, it is learned by observing and participating in team activities and team discussions, many of which are “between patients.” Given this, and through mutual discussion and drawing on our interests in workplace learning[[3,4]] and work readiness,[[2,5]] we propose an extended set of competencies afforded by clinical access, beyond those related to direct patient contact. We hope this makes explicit the tacit skills that could be lost if there is insufficient clinical contact.

• Recognise and contribute to the collective competence of multidisciplinary teams. Being a participant/observer in a clinical team enables us to learn how the collective competence of the team delivers care[[6]] and how interdisciplinary and interpersonal challenges are overcome.

• Apply project management principles to the complexities of clinical care. Aspects of clinical practice such as discharge planning or complex coordination of care require balancing multiple competing priorities against the changing availability of resources.[[3]] Understanding how the team addresses this requires a sophisticated understanding of the principles of project management.

• Integrate personal and team-based clinical reasoning. Listening to team discussions about diagnostic and management dilemmas and how evidence-based guidelines are modulated to each patient’s sociocultural context assists students to learn real-life clinical reasoning.

• Deliver patient-centred collaborative care. Seeing how a management plan is developed collaboratively with the patient and all members of a multidisciplinary team models interprofessional skills and patient-centred practice.

• Achieve an integrated perspective of clinical care. Understanding a whole episode of clinical care clarifies the contribution, and importance, of the component parts.

• Demonstrate adaptability to health systems. Learning to operationalise patient care under time pressure in heterogenous health systems, such as a variety of IT systems, prepares students to work effectively in a variety of clinical workplaces.

• Consolidating professional identity formation. Meaningful interactions with other team members allow them to observe and imitate role models and to “act” as future professionals.[[7]]

The pandemic highlighted how effective simulation can partially compensate for more limited direct clinical access and the importance of stimulating reflective discussions between students about their clinical experiences. However, simulation often focuses on the direct student-patient interaction. The competencies highlighted above go beyond this. Although these competencies can be proactively planned into simulations, they should also become explicit outcomes of clinical contact. Clearly direct engagement as a participant in a junior apprentice role in clinical teams could provide excellent preparation to acquire these competencies. It will require development of appropriate objectives, and valid assessments, related to the themes we have identified above.

Most of these skills are generic across medicine. Effective embedding in an apprentice-style role requires attachments of significant duration, and this means that not every student would be able to have such an experience in every discipline. The pandemic highlighted that experiences in one discipline are often close enough to those in another to allow students to meet global competencies and graduate. This may provide an uncommon opportunity to change how students rotate through different disciplines, at least in their final year.

We see such developments as critical to improving the work-readiness of our graduates. This requires refinement of medical school and accreditation bodies’ definitions of “clinical experience” to incorporate the suggested competencies.