From theory to clinical practice: unequal exposure to cases

At the end of the emergency rotation, two colleagues compare their notes. One saw dozens of patients with chest pain, shortness of breath and abdominal pain, and followed two cardiac arrests. The other spent much of those weeks on quiet shifts, saw many low-severity cases and never examined a patient with suspected myocardial infarction. Both had the same workload, the same supervising physician and the same grade. They will graduate with very different experiences.

This is the gap between theory and clinical practice that few people name: each student sees different patients, and the curriculum rarely guarantees that everyone sees the essentials. In this guide you will understand what research shows about variation in clinical exposure during medical school, what recent graduates report about their preparation for practice, why seeing a case is not the same as managing it, and how to map and fill in what was missing from your training.

Key points

• In an emergency medicine study, 248 students saw between 1 and 32 patients each, and none saw all the complaints recommended for the rotation (Hoxha et al., 2024).
• Contact with cancer patients during rotations was described as highly variable and dependent on chance (Starmer et al., 2020).
• Recent graduates in the United Kingdom seemed prepared for history taking and examination, but not for prescribing, diagnostic reasoning and emergencies (Monrouxe et al., 2017).
• In Germany, about 60% of physicians with up to two years of practice felt poorly prepared for residency (Ochsmann et al., 2011).
• Having responsibility for management was the factor that most explained students' confidence in each encounter (Harrell et al., 1993).
• You can map your exposure and fill the gaps with cases, simulation and chosen rotations.

Contents

• What the gap between theory and practice is
• Each student sees different patients
• What recent graduates report
• Why seeing is not the same as doing
• How to map your clinical exposure
• How to complete your exposure
• NEXO cases to broaden your exposure
• Frequently asked questions
• Checklist to map your clinical exposure

What the gap between theory and practice is

In the classroom, everyone studies the same list of diseases. In practice, each student meets the patients who appear on the day, in the service and at the time they are there. This difference creates a gap between what the curriculum says you learned and what you actually saw and did. It is no one's fault: it is a consequence of training based on patient care, which depends on who seeks the service.

The problem appears when this gap is not measured. If no one records what each student saw, a gap can run through the entire course without being noticed. The student who never examined a child with fever may reach the pediatric clerkship thinking they know, because they studied the topic. And they may discover the gap in front of the first patient.

Knowing, seeing and doing

It is worth separating three levels of contact with a clinical topic:

• Knowing: studying the disease, the clinical picture and the management.
• Seeing: following a patient with the problem, as an observer.
• Doing: managing the encounter with supervision, from history to management.

Each level prepares you in a different way. The curriculum usually guarantees the first, offers the second irregularly and leaves the third for the few cases in which the student has real responsibility.

Each student sees different patients

A retrospective study in an academic emergency department in the United States analyzed encounters by second- and third-year students on two-week rotations from 2018 to 2022 (Hoxha et al., 2024). The 248 students saw 2,994 patients. The median was 12 patients per student, but the range was 1 to 32 (Hoxha et al., 2024).

The most common complaints were abdominal pain, chest pain and shortness of breath, which accounted for 15.6%, 8.7% and 5.5% of visits (Hoxha et al., 2024). Gynecology and obstetrics, hematological and environmental problems were the least seen. No student saw all the complaints recommended by the specialty internship directors' association. The authors concluded that there was significant variation in volume and in the type of patient.

The cancer case

A study with encounter diaries and focus groups examined clinical-year students' contact with cancer patients (Starmer et al., 2020). Third-year students saw these patients mainly in surgery and general practice, and final-year students in palliative care and otolaryngology. The quality of the interaction varied widely across settings, and in outpatient clinics and on the surgical ward the student's role was mostly that of an observer.

Students reported feeling unsure about the history, the examination and the conversation about death. Many worried about the possibility of examining a primary tumor after graduating without ever having done so during the course. The authors described the exposure as highly variable and dependent on chance, and argued for a more structured approach.

Why the variation happens

The variation has predictable causes:

• Seasonality: some diseases cluster at certain times of year.
• Time of day: the night shift and the day shift receive different patients.
• Setting: a referral hospital and a primary care unit see different profiles.
• The student's role: in some services you lead, in others you only observe.
• Initiative: those who ask to see new cases build more experience.

An example of an invisible gap

Imagine a fictional student who did her entire internal medicine internship at a cardiology referral hospital. She saw dozens of patients with heart failure, arrhythmias and coronary syndromes, and she feels confident in these topics. But she hardly saw patients with infectious diseases common in primary care, such as complicated urinary tract infection or pneumonia in a frail older adult. On the exam, she gets the infection questions right because she studied. On her first shift in an emergency care unit, however, she is slow to recognize sepsis of urinary origin that a colleague with a different background would identify in minutes.

Nothing in this story points to a lack of effort. The gap was born from the training setting, and it only appeared when the setting changed. That is why the record of what you saw and did is worth as much as the grade: it shows what the exam does not measure.

What the exam does not show

Grades measure what you know how to answer, not what you have already done. A review on the preparedness of new graduates noted that few studies define what being prepared means, and that most rely on self-report (Monrouxe et al., 2017). This has a practical side: only you know, precisely, what type of patient you have already managed. If you do not record it, no one will notice the gap until it shows up in a patient encounter.

What new graduates report

If exposure varies, preparedness for practice varies too. A rapid review on the preparedness of new graduates in the United Kingdom analyzed 87 articles published between 2009 and 2014 (Monrouxe et al., 2017). Most were based on self-report by young doctors, 65 of the 87 studies, or 75% (Monrouxe et al., 2017). New graduates seemed prepared for clinical history, physical examination and some skills, but not for prescribing, diagnostic reasoning, emergency management, multiprofessional teamwork, handovers and safety incidents.

Another review, with nine studies on the transition from student to doctor, found knowledge and skill deficiencies, especially in prescribing and procedures, among the most cited factors (Alexander et al., 2014). Early clinical experience and shadowing doctors at work before graduation improved preparedness, while lack of support from more experienced colleagues got in the way.

The numbers from Germany and the United Kingdom

In a study of 637 German physicians with up to two years of practice, about 60% felt poorly prepared for residency (Ochsmann et al., 2011). Self-reported deficiencies in electrocardiogram interpretation, treatment planning and intubation were independently associated with that feeling. The authors called for more emphasis on these points in the curriculum.

In a survey of 45 physicians in their first year after graduation, in the United Kingdom, confidence varied across the domains assessed, with lower scores in the referral system and in therapeutic procedures than in vital sign observation (Michaelides et al., 2020). Confidence was not uniform: the same physician can feel secure in one task and lost in another.

The table summarizes what the studies point to as strengths and weaknesses:

Area	Reported preparation	Study
History and physical examination	Good	Monrouxe et al., 2017
Prescribing	Weak	Monrouxe et al., 2017; Alexander et al., 2014
Diagnostic reasoning	Weak	Monrouxe et al., 2017
Emergencies	Weak	Monrouxe et al., 2017
Electrocardiogram	Deficiency associated with poor preparation	Ochsmann et al., 2011
Team leadership	Partial	Barnes et al., 2020

Leadership also depends on experience

A systematic review on the preparation of students and young physicians for clinical leadership included 16 studies and concluded that they feel only partially prepared (Barnes et al., 2020). Preparation was associated with more responsibility, more experience and more time on the job. Recent graduates tended not to question more experienced colleagues for lack of leadership-specific communication skills. The post on clinical leadership for interns and recent graduates explores this point further.

The role of support in the transition

The review by Alexander and colleagues also pointed to personal factors, such as low confidence, among those that weigh on the transition, and highlighted that the lack of support from more experienced colleagues worsened preparation (Alexander et al., 2014). In practice, this suggests that the exposure gap does not have to be faced alone. Telling the resident or the preceptor that you have never managed a case of a certain type is a legitimate way to ask for closer supervision, and it protects the patient. If the situation goes beyond what you can handle, seek the help you need before deciding.

How to talk about the gap with the preceptor

Many students avoid saying they have never done something, for fear of seeming unprepared. But the preceptor has no way of knowing what you saw in other rotations. A simple sentence, said at the start of the shift, already changes supervision: "I have never managed a case like this from start to finish; can I do it with you watching?". This shows that you know your own limits, which is exactly what is expected of someone in training.

It is also worth asking, when there is room, to be called when a type of patient you have not yet seen appears. Many preceptors agree, because they know exposure varies from class to class. Over time, these requests help fill the gaps that chance left behind.

Logging as a habit

An exposure log only works if it is simple. Noting the type of problem, what you did and whether you needed help takes less than a minute per patient. At the end of each month, a quick read shows what repeats and what never appeared. It is this list of absences that guides study and requests to the preceptor the following month. Without identifying patients, the log can also be shared with colleagues, and each one finds out what the other saw.

When the gap appears after graduation

Some gaps only appear in the first job, when the recent graduate no longer has a preceptor at their side all the time. That is why the first months deserve the same care as the internship: log what appears, study the same day what raised doubt and keep in touch with more experienced colleagues to discuss cases. Asking for a second opinion at this stage is not a sign of weakness. It is part of the process of turning what you learned in theory into safe practice, one patient at a time.

Why seeing is not the same as doing

An old but still useful study followed 60 third-year students during a primary care placement in the United States (Harrell et al., 1993). Each student logged every encounter and rated their own confidence in the main diagnosis. The average was 99 encounters per student. Three factors together explained 54% of the variation in confidence: having responsibility for managing the problem, having seen the problem before, and having ordered tests during the encounter (Harrell et al., 1993). Responsibility for management was by far the strongest factor.

This helps explain why the student who only observes comes away less prepared than the one who manages. Seeing a patient with heart failure teaches you how it presents. Managing the encounter, with supervision, forces you to decide which test to order, which medication to adjust and when to reassess. It is in the second case that knowledge becomes practice.

The role of the placement setting

The format of the placement changes the kind of exposure. During the pandemic, a South African school distributed students across rural and urban services outside the academic hospital, in a 12-week integrated placement (Couper et al., 2024). Students described a more practical experience, which increased confidence in clinical skills and made them feel part of the team. They also described it as variable, with a lack of standardization between sites.

In an Australian program, students with long training periods in rural sites had overall performance similar to that of their peers in the capital on practical exams, and were better at communication, with an average of 84% versus 67% (Khoo et al., 2026). There was variation between sites in some areas. The setting changes what you see, but it does not on its own define how much you learn.

Longitudinal placements

Integrated longitudinal placements, in which the student follows the same patients over months, are a response to fragmentation. But they also leave gaps. A scoping review on these placements and surgical teaching found 37 studies that addressed some surgical aspect, and most did not detail the experiences, the expectations or the skills students acquired (Moya-Mendez et al., 2024). Only 3 studies reported formal assessment of surgical skills such as suturing. No format on its own guarantees complete exposure.

How to map your clinical exposure

The first step to filling in what is missing is knowing what is missing. The studies that measured exposure used encounter logs, and you can do the same. A notebook or a simple spreadsheet is enough:

1. List the core complaints and conditions of each area. Use the placement objectives or the residency exam syllabus.
2. Log each encounter in one line. Complaint, diagnosis, whether you saw or managed it.
3. Mark the level of contact. Know, see or do.
4. Review the map every month. Look for the empty lines.
5. Prioritize high-risk gaps. Emergencies and conditions that cannot go unnoticed.
6. Ask your supervisor for specific cases. Say you have not yet managed a case of a certain type.
7. Fill in what the service does not offer. With cases, simulation and elective placements.

The post on how to track your study progress offers ways to keep this record, and the post on elective placements helps you choose where to look for what was missing.

How to complete your exposure

Not every gap can be closed with patients. Some conditions are rare, others are too serious to be left to chance. For these, the literature offers alternatives. A systematic review on case-based learning in the health professions described it as a method that integrates the basic, social and clinical sciences with patient presentations, linking study to real-life situations (Thistlethwaite et al., 2012). The review included 104 articles, of which 23 were considered of higher quality, and concluded that students and teachers like the method and see it as motivating, although the data on the effect on learning, compared with other activities, are inconclusive (Thistlethwaite et al., 2012). Cases are a way to broaden exposure, as long as you do not confuse satisfaction with effect.

Simulation with deliberate practice showed an advantage over traditional clinical teaching for reaching specific skill goals, in a meta-analysis of 14 studies (McGaghie et al., 2011). For procedures and emergencies you may not see during medical school, it is a way to guarantee at least the first contact. The post about emergency care simulation shows how to set up this training.

Cases for what you did not see

Written clinical cases or cases in game format do not replace the patient, but they let you see many presentations in a short time and train the decision before you need it. The post about case-based learning in clinical practice explains how the method works, and the post about clinical case simulators for residency compares formats. The key is to choose cases based on your map, not at random.

Kassirer argues that clinical reasoning is learned best through repeated, deliberate exposure to actual cases, chosen because they show various aspects of reasoning, and with a tutor who points out and discusses errors as soon as they appear. For him, actual cases are preferable to cases assembled from memory, because they bring the false clues and misleading test results of daily practice (Kassirer, 2010).

From observation to management

When you are on a service, you can turn observation into something close to managing the case. Before the supervising physician decides, say out loud what your management would be. Then compare. This simple habit brings seeing closer to doing, because it forces you to make the decision, even if you are not the one who carries it out. The post about clinical reasoning in the internship brings other ways to take part actively.

NEXO cases to broaden your 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. The cases are fictional with a real clinical presentation.

On the Modes screen, the Archive gathers the previous daily cases, useful for covering an area that was left blank on your list. Multimedia brings cases with imaging exams and auscultation, and Continents changes the epidemiological setting of the case. How each mode is unlocked is on the NEXO Economy page. The guide about what NEXO is explains the whole match, and the NEXO Blog gathers other texts about medical training.

If you coordinate a medical school, a student league or a residency program and want to give the class the same base of cases, see NEXO Closer. Researchers who study clinical exposure and preparation for practice can propose studies through NEXO Researcher. Physicians 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

Do all students see the same cases?

No. In an emergency study, each student saw between 1 and 32 patients, and none saw all the recommended complaints (Hoxha et al., 2024).

Do recent graduates feel prepared?

Partly. They report good preparation for history taking and examination, but not for prescribing, diagnostic reasoning and emergencies (Monrouxe et al., 2017).

What else builds confidence in a consultation?

Having responsibility for management, more than just observing (Harrell et al., 1993).

Does training outside the university hospital hurt?

In an Australian program, students trained in rural areas had similar overall performance on practical exams (Khoo et al., 2026).

How can I know what I have not seen?

Record each consultation with the complaint, the diagnosis and whether you saw or managed it, and review the gaps every month.

Does simulation replace the patient?

It does not replace the patient, but it helps reach skill goals that traditional teaching does not always guarantee (McGaghie et al., 2011).

Checklist to map your clinical exposure

• List: define the core complaints of each rotation.
• Record: note each consultation on one line.
• Level: mark whether you knew about it, saw it or did it.
• Review: look for the empty lines every month.
• Priority: start with the high-risk gaps.
• Request: tell your preceptor what you have not yet handled.
• Supplement: use cases, simulation and electives.

Want to start closing the gaps today? Play the case of the day on NEXO.

References

1. Hoxha I, Hekman DJ, Schnapp B. Second- and third-year medical students' clinical encounters in the emergency department. AEM Educ Train. 2024. PubMed
2. 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. PubMed
3. Monrouxe LV, Grundy L, Mann M, John Z, Panagoulas E, Bullock A, et al. How prepared are UK medical graduates for practice? A rapid review of the literature 2009-2014. BMJ Open. 2017. PubMed
4. Alexander C, Millar J, Szmidt N, Hanlon K, Cleland J. Can new doctors be prepared for practice? A review. Clin Teach. 2014. PubMed
5. Ochsmann EB, Zier U, Drexler H, Schmid K. Well prepared for work? Junior doctors' self-assessment after medical education. BMC Med Educ. 2011. PubMed
6. Michaelides A, Mahr M, Pydisetty G, Loyala JV. Assessing the preparedness of foundation year 1 (FY1) doctors during the transition from medical school to the foundation training programme. BMC Med Educ. 2020. PubMed
7. Barnes T, Yu TW, Webster CS. Preparedness of medical students and junior doctors for their role as clinical leaders: A systematic review. Med Teach. 2020. PubMed
8. 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. PubMed
9. Couper I, van Schalkwyk S, Blitz J, Fish T, Viljoen K, Smith L. It's all about the patients: a shift in medical students' approach to learning during a novel distributed integrated clinical rotation. BMC Med Educ. 2024. PubMed
10. Khoo A, Michelmore P, Joseph S, Szep M, Wozniak M, Gleadle J. Clinical examination performance in rural longitudinal medical programmes. Educ Prim Care. 2026. PubMed
11. Moya-Mendez ME, Thornton S, Rhodin KE, Gao Q, Leraas HJ, Vatsaas CJ. Longitudinal Integrated Clerkships and Undergraduate Surgical Education: A Scoping Review and Gap Analysis. J Surg Educ. 2024. PubMed
12. Thistlethwaite JE, Davies D, Ekeocha S, Kidd JM, MacDougall C, Matthews P, et al. The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Med Teach. 2012. PubMed
13. McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB. Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011. PubMed
14. Kassirer JP. Teaching clinical reasoning: case-based and coached. Acad Med. 2010. PubMed