Welcome to the Clinical Years

Welcome to the Jungle

Time to rinse out all you know about aerobic respiration (unless, of course, you intend to be a clinician-researcher or just a Hans Krebs aficionado). Time to take a gander, a claw and a foothold into the world of clinical medicine. Of course, it is crucial to have a strong understanding of basic human physiology and pathology before exploring the practicalities of healthcare, but at this stage it is more important to know where to find information, as opposed to the complex minutiae of medical science itself. So, you’ve made it to the clinical years; this is time to break out the Champagne, the Kleenex and quite possibly the number of that therapist your friend told you about. Do not fret! You’ve made it this far, just a few more years of agonising clinical education to go.

Here are some resources on this website that might be applicable to you:

• T Year MBBS: Clinical Notes, specifically sections of General Medicine, Surgery (Excluding Specialties), and Clinical Neurosciences (In less breadth and depth), and transcribed notes of Dr J Williams' lectures on Cellular Pathology. Sections of The Indigo Book might be useful to your OSCE preparation, but no past year station information is available, and content is heavily designed for senior clinical years. 

• P and F Year MBBS: The Full Clinical Notes and Indigo Book. Mock OSCEs written for specific years are available as well. 

• The Black Book is also available for F Year MBBS students preparing for the SJT. 

I like to think that there are two types of medical students. The first type studies to be a medical student – The laborious grind of rote memory and paper qualifications, run and gun, standing high on the decile ladder, able to recite all structures that pass through the superior orbital fissure.

Then there are the medical students who study to be doctors – practical knowledge, communication and teamwork, and most importantly, espousing compassion. While the vast majority of us do not sit on extremes of the dichotomy, it is important to remember the latter. All your acquired knowledge will sediment unless it is used and used well. So how to approach the brave new world of ward life? Firstly, take your steps proudly – You are one of the team! Never let anyone tell you otherwise. As medical students, we have the time to explore, learn, teach and grow. I have a few suggestions with regards to enjoying your time, and also being productive to yourself and to the ward team:

Prepare for Placements

I would strongly recommend getting the Induction app (A directory of bleeps and hospital phone numbers), the BNF app (the new light-blue icon one, which is a dream to use), Microguide (which contains up to date Trust antimicrobial guidelines, and the MDCalc app (because we are not designed to remember the Wells score by heart). I have included links to these free apps below, for Apple and Android users. 

• If you use a Windows phone,  2011 called and want their smart-multipurpose-telephones back.

• If you use a Blackberry, the George's Drugs and Alcohol Liaison Team is on bleep #6915. Told you the Induction app was useful.

Okay, back to business - Also download a PDF copy of the local guidelines (The Grey Book for George’s, The Blue Book for Kingston, etc. There are too many trust guidelines to list on this site). Keep a copy of the site map (A cheeky google ought to do it) and learn where things (and personnel!) live. Always carry a pen and some paper for that surprise history-taking sesh.

(These are my personal recommendations and not paid endorsements, athough I would be impartial to having a corporate sugardaddy for the right price)

Offer to be the Ward Warrior

Phlebotomy, Cannulation, ABGs, ECGs, Observations, Urinary catheterisation, and everything in between. Build your confidence in these procedures and interpret the results from them and present your findings to staff.

Learn How to Communicate with your Future Colleagues

Add on blood tests by calling the lab, discuss patients with microbiology, beg the on-call radiologist to report urgent scans, talk to GPs about missing past medical history, write discharge summaries. Learn tricks of the trade.

Know Your Limits

I always remind myself before doing anything on the wards that I would not do anything I am not confident in. This holds true especially if doing anything unsupervised, which you should only do if you are allowed to by the ward team.

See Patients Independently (with permission from the ward team)

While this might seem intimidating, most patients are happy to talk to medical students (I have heard plenty of complaints about the bed televisions and the mundanity of ward life, so patients pretty much take whatever they can get). Take a full history, ask about their experiences of illness, learn how to small-talk; These are skills essential to the future junior doctor and keep your OSCE game strong. Keep your stethoscope clean and well-used, and share interesting patients with your colleagues (of course, asking the patients prior before doing so).

There are good days, and there are bad days; Share both

It is always good to celebrate and decompress, while maintaining patient confidentiality of course. Reflecting on a day’s work is an opportunity to grow and learn from our successes and mistakes. If something (or someone!) is bothering you, speak to your clinical supervisors (this can be your named consultant, or any member of the team you feel comfortable discussing the issue with); if you feel like you cannot approach them for whatever reason, speak to the university, or touch base with the university counsellors who can be reached at the SGUL Counselling Service. Healthcare is an emotional (and physical) minefield, so do not be afraid to disarm; Unfortunately, abuse (from patients, colleagues, seniors and supervisors) can be common as well, and it is important to recognise and take appropriate steps to act against it. 

Of course, there is hard work involved, but I can say with all honesty that if you stay true to the goal of developing yourself towards being a doctor as opposed to simply studying to be a medical student, academic success will naturally follow you.

It won’t be long before you’re coming to the end of the year, when you face the beast; one of the biggest questions asked is how to prepare for examinations in the clinical years. How do you fit in the time to study in addition to your placement commitments? What’s this I am hearing about having to actually do something with a stethoscope for real? Doom and gloom aside, the clinical years are a time for you to flourish. And at the end of this period of flourishing, the gardeners would like to check in to see if you’re ripe for the harvest, also known as the reaping, or more commonly known as the Foundation Programme.

Here are a few simple pieces of advice for the budding bud:

Things getting tough? There is always help!

If you feel like things are getting heavy, or are going through a difficult period in your life, consider booking an appointment with the SGUL counselling service - They have many appointments available, and can see you sooner than you think. Again, have a look on SGUL Counselling Service; In addition to mental health services, they are a good first-port-of-call for linking your needs with what the university might  be able to provide and accommodate. If that isn't for you, consider seeing your GP, who can put you in touch with other counselling or therapy. It is always important to look after yourself, and looking out for your friends and peers, through this long and arduous journey ahead!

Prepare early

Cramming might work for some, but there is not faster way to end up hypertensive. In T year, I would advise reading up before each placement block, taking advantage of the gaps during PBL blocks to catch up. Invest in Investigation of Disease (IOD); they provide a good fundamental knowledge of the pathologic basis of disease. For P year, I would advise starting slightly before and around each new placement (ie, read paediatrics before seeing paediatric patients) in order to maximise your understanding of what you are looking at when on the wards or in clinic.

Here are some of the books I've used in making my notes, which you might find useful to your own revision as well; They are usually well-stocked in the library, and some of them are stocked as e-books as well. See SGUL Library E-books for more details. 

Don’t overdo it, though

Clinical years are marathons. Sprint and you will be shorter of breath than a 60-pack-year historian. Do not fall for the arms race and constant out-gunnery of others. Everyone has their own pace of learning, try to focus on your own process and ignore the pressure from others. Give yourself a break here and there, have a good holiday when you have the opportunity to, and keep a life out of medicine while you still have it.

Common things are common

Don’t sweat the small stuff until you have a strong grasp of everything else. The official Clinical Priority list, released by the university, is very useful in guiding (read: suggestive but not prescriptive) how you learn. Know everything about ACS and COPD, but you can be comfortable with knowing that Chuvash polycythaemia exists, or that the Tityus genus of Central/South America are responsible for majority of scorpion pancreatitis. 

OSCEs are how most people stumble

As a fellow victim of OSCEs, I am afraid I am a poor provider of advice on this sore thorn. Perhaps the only scrap I can offer is to practice early, and with as many different people as you can – especially real patients. OSCE cases with Mark Schemes and The Unofficial Guide to Passing OSCEs come to mind. Also, if you have noticed, even the damn book says “passing”. This isn’t exactly a gentle beast.

Even then, failure is an inevitable part of life

I know it is a bit defeatist to think in such a way, but in the event that the stars do not quite align for you, get back on that horse and keep going. The best doctors know adversity and grow callouses from it.

And always remember: 

You are studying to be a doctor, and not studying to be a medical student. Grades are nice, deciles are pretty, but always look at where your feet are actually taking you while chasing your laurels. 

Out of the frying pan: Applying for the Foundation Programme

While many people will tell you to gun for the moon, I will provide some contradicting advice: Look into publication only if it something you are keen in, slog through an intercalation (which I highly recommend) only if you are interested in a topic. Ultimately, all feeble attempts are trying to control where you land on the FPAS ladder will be determined by the most extensive random number generator (RNG) of them all - the Situational Judgement Test. After all, if it were truly a good test, why would it be ethical to starve regions outside of London of supposedly morally-superior doctors? 

If I could give any advice on the matter, for which I am barely an authority on aside from the fact I am living through the fires of it, is that its more important what jobs you choose as opposed to your deanery. I think it is also important to choose a locale that has a reasonable social life (or links to centres with such), as you would want places to wind down after a long day at work. You would also like to be near friends/family as they will be the people who piece you back together after what I call 'disaster-days'. 

Jobs wise, I highly, highly recommend taking general jobs in F1, namely Acute Medicine, General Medicine, General Surgery, Intensive Care and Emergency Medicine (at the few trusts that do offer the option to F1s). If you were to take a post in General Practice, it might be best to do so towards the end of the foundation programme so you build yourself as a hospitalist prior to going to work in the community. I wouldn't recommend jobs which are especially niche, especially ones where there is no on-call requirement, as this will starve you of many real-world learning opportunities (as well as come with an anaemic paycheck). I would recommend prioritising jobs where you would be on the on-call rota first, so you equip yourself with the skills of independent practice early on. Finally, I would also recommend working in centres where F1s do night shifts, because the nocturne is where the wild things are.