From theory to clinical practice: unequal case exposure
Two students in the same class, at the same stage, can finish the rotation with very different experiences. One saw several children with bronchiolitis; the other, none. One followed the investigation of chest pain from start to finish; the other only arrived after the diagnosis. The theory of the exam is the same for both, but the practice each one took home is not.
NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.
This guide shows what studies find when they count the patients seen by each student, what that changes in preparation for practice and how to complete what the rotation did not offer.
Key points
- Studies with care records show that each student sees a different set of clinical presentations.
- Almost no student sees all the presentations that the curriculum recommends during the rotation.
- New graduates feel more prepared for history taking and physical examination than for diagnostic reasoning, prescribing and emergencies.
- Having responsibility for the patient weighs more on confidence than just observing the care.
- Structured cases help complete exposure, without replacing the patient.
Summary
- What the gap between theory and practice is
- Each student sees different patients
- What new graduates report
- Why seeing is not the same as doing
- How to complete exposure
- NEXO cases to broaden exposure
- Frequently asked questions
- Checklist to map your clinical exposure
What the gap between theory and practice is
In theory, the disease appears complete: definition, typical picture, tests and management. In practice, it arrives through the complaint, often incomplete, mixed with other complaints and in the middle of a shift. The gap between the two is the work of recognizing the picture from the patient, and not from the chapter.
This bridge is built with repeated contact with varied presentations. That is why it matters how many patients and which presentations each student encounters, and not only how many hours they spend in the hospital. The guide to the error notebook shows how to record what was missing in each wrong case.
Each student sees different patients
Pediatrics: almost nobody sees everything
In an Australian medical school, 361 students recorded in logbooks which of 25 pediatric presentations from the curriculum they had seen in an eight-week rotation (Uther and Ooi, 2016). Only one student saw all 25, the median was 14 presentations, and nine of them were seen by less than half the class (Uther and Ooi, 2016). Only fever, difficulty breathing and vomiting or diarrhea were seen by more than 90% of students (Uther and Ooi, 2016).
Emergency: volume and complaints vary a lot
In an American university emergency department, the median was 12 patients seen per student in a two-week rotation, ranging from 1 to 32 (Hoxha et al., 2024). Abdominal pain, chest pain and dyspnea were the most frequent complaints, and no student saw all the complaints recommended by the association of emergency rotation coordinators (Hoxha et al., 2024).
Oncology: opportunistic exposure
In a study with logbooks and focus groups, the authors described students' exposure to patients with cancer as very variable and opportunistic, with less interaction in outpatient clinics and surgical wards (Starmer et al., 2020). Students reported concern about examining, once graduated, a primary tumor that they had never examined in medical school (Starmer et al., 2020).
What new graduates report
Prepared to examine, less to decide
A rapid review of the literature on new graduates in the United Kingdom found that they seem prepared for history taking, physical examination and some clinical skills, but less prepared for prescribing, clinical reasoning and diagnosis, emergencies and handover (Monrouxe et al., 2017). The authors note that 75% of the studies were based on self-report by young doctors, which limits the conclusions (Monrouxe et al., 2017).
Preparation grows, but not in a straight line
In a study that followed 85 participants from two years before graduation through residency, the average preparedness score rose over time, with fluctuations and large differences between individuals (Chaou et al., 2021). The domain in which they felt least prepared at the start was patient management (Chaou et al., 2021).
The opportunity to practice matters
In a survey of Australian final-year students, 87% said they felt adequately or very well prepared for practice, with less confidence in procedures (Louey et al., 2025). Among the factors cited for that confidence were the number of opportunities to practice, experience on placements and assessment with feedback (Louey et al., 2025).
Why seeing is not the same as doing
In a primary care placement, students logged every consultation and the confidence they felt about the patient's main diagnosis (Harrell et al., 1993). The strongest predictor of confidence was having responsibility for managing the problem, ahead of having seen the problem before (Harrell et al., 1993).
Confidence is not competence, and the study measured only the former. Even so, the finding matches what final-year students report: the practice that counts is the one in which you decide something, not just the one you watch. The guide to clinical reasoning in the internship shows how to take on the hypothesis even when the preceptor is the one deciding.
How to complete your exposure
Map what you have already seen
Make a list of the most important presentations in each area, based on your course syllabus, and mark the ones you have already seen with a patient. The ones left blank are your study roadmap.
Prioritize what is serious and rarely seen
Some presentations appear rarely on placements and weigh heavily when they do. Editorial examples: the child with febrile seizure, the pregnant woman with bleeding, poisoning, the patient with acute neurological deficit. For these, the structured case is often the only contact before the shift.
Use cases that force you to decide
Read the case as if the patient were yours: summarize the problem, list the hypotheses and only then look at the answer. Virtual patients and case-based learning are formats designed this way.
Go back to the patient
The structured case prepares recognition; the patient teaches the rest. When a presentation from your list appears on a placement, ask to follow it.
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NEXO cases to broaden exposure
NEXO publishes a new clinical case every day, the same for all players, which gives the whole class the same presentation to discuss. The case arrives in up to six clues, and with each guess you see the proximity in ICD-10 across five levels, which forces you to commit to a hypothesis before seeing the answer.
On the Modes screen, the Archive gathers the previous daily cases, useful for covering an area left blank on your list. Multimedia brings cases with imaging and auscultation, and Continents changes the epidemiological setting of the case. How each mode is unlocked is on the NEXO economy page.
If you coordinate a medical school, a student league or a residency program and want to give your class the same base of cases, take a look at NEXO Closer. Researchers who study clinical exposure and preparedness for practice can propose studies through NEXO Researcher. Doctors who review cases in their specialty take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.
Frequently asked questions
What is clinical exposure in medical school?
It is the set of patients and presentations that a student encounters on placements. Studies using logbooks show that this set varies a lot from one student to another (Uther and Ooi, 2016).
Do all students see the same cases on placements?
The variation is large. In a university emergency department, no student saw all the complaints recommended for the rotation (Hoxha et al., 2024).
In what areas do recent graduates feel least prepared?
A British review pointed to prescribing, clinical reasoning and diagnosis, emergencies and multidisciplinary teamwork among the weak points (Monrouxe et al., 2017).
Do structured cases replace the patient?
They complete the exposure and prepare recognition, but contact with the patient remains necessary. Being responsible for management weighed more on the student's confidence than having already seen the problem (Harrell et al., 1993).
How does NEXO help broaden exposure?
NEXO offers a new case every day, the Archive with previous cases and modes with images, auscultation and scenarios from other continents. To learn about the game, read what NEXO is.
Checklist to map your clinical exposure
- List the main presentations of each area of your course.
- Mark the ones you have seen with a patient, not only in class.
- Highlight the severe and rare ones to see.
- Study the ones left blank with structured cases.
- Commit to a guess before the answer in every case.
- Ask to follow the presentations on your list when they appear.
- Review the list at the end of each rotation.
Want to see a new case every day? Play the case of the day on NEXO.
References
- Uther P, Ooi CY. Paediatric clinical exposure for medical students: Are they seeing enough? J Paediatr Child Health. 2016. https://pubmed.ncbi.nlm.nih.gov/27655017/
- Hoxha I, Hekman DJ, Schnapp B. Second- and third-year medical students' clinical encounters in the emergency department. AEM Educ Train. 2024. https://pubmed.ncbi.nlm.nih.gov/38504802/
- Starmer DL, House CL, Langworthy KM. Student Exposure to Cancer Patients: an Analysis of Clinical Logbooks and Focus Groups in Clinical Year Medical Students. J Cancer Educ. 2020. https://pubmed.ncbi.nlm.nih.gov/31001741/
- Monrouxe LV, Grundy L, Mann M, et al. How prepared are UK medical graduates for practice? A rapid review of the literature 2009-2014. BMJ Open. 2017. https://pubmed.ncbi.nlm.nih.gov/28087554/
- Chaou CH, Yu SR, Chang YC, et al. The evolution of medical students' preparedness for clinical practice during the transition of graduation: a longitudinal study from the undergraduate to postgraduate periods. BMC Med Educ. 2021. https://pubmed.ncbi.nlm.nih.gov/33957907/
- Louey CYM, Zeng A, Roberts S, et al. Graduating medical students' perception of preparedness for practice: experiential learning is key. BMC Med Educ. 2025. https://pubmed.ncbi.nlm.nih.gov/41074078/
- Harrell PL, Kearl GW, Reed EL, Grigsby DG, Caudill TS. Medical students' confidence and the characteristics of their clinical experiences in a primary care clerkship. Acad Med. 1993. https://pubmed.ncbi.nlm.nih.gov/8323654/