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Background  Current research shows that many UK medical graduates continue to feel underprepared to work as a junior doctor. Most research in this field has focused on new graduates and employed the use of retrospective self-rating questionnaires. There remains a lack of detailed understanding of the challenges encountered in preparing for clinical practice, specifically those faced by medical students, where relevant educational interventions could have a significant impact. Through use of a novel on-call simulation, we set out to determine factors affecting perceived preparation for practice in final year medical students and identify ways in which we may better support them throughout their undergraduate training.    Methods  30 final year medical students from Imperial College London participated in a 90-minute simulation on hospital wards, developed to recreate a realistic on-call experience of a newly qualified doctor. Students partook in pairs, each observed by a qualified doctor taking field notes on their decisions and actions. A 60-minute semi-structured debrief between observer and student pair was audio-recorded for analysis. Field notes and students’ clinical documentation were used to explore any challenges encountered. Debrief transcripts were thematically analysed through a general inductive approach. Cognitive Load Theory (CLT) was used as a lens through which to finalise the evolving themes.    Results  Six key themes emerged from the on-call simulation debriefs: information overload, the reality gap, making use of existing knowledge, negative feelings and emotions, unfamiliar surroundings, and learning ‘on the job’.    Conclusions  The combination of high fidelity on-call simulation, close observation and personalised debrief offers a novel insight into the difficulties faced by undergraduates in their preparation for work as a junior doctor. In using CLT to conceptualise the data, we can begin to understand how cognitive load may be optimised within this context and, in doing so, we highlight ways in which undergraduate curricula may be adapted to better support students in their preparation for clinical practice. Recommendations are centred around enhancing the expertise of the learner through ‘whole task’ training approaches and integrated learning, as well as navigating negative emotions and supporting lifelong ‘learning while working’.

Exploring why medical students still feel underprepared for clinical practice: a qualitative analysis of an authentic on‐call simulation