The transition from pre-clinical to clinical years in medicine can be daunting, so I thought I would give a few tips based on my experiences. Overall, third year is a great year. There is a lot to learn and I have often been nervous, but being on the wards, seeing real patients and being able to do more practical, hands on medicine makes you feel like you are actually starting to get somewhere with your training.

These tips are of course my own ideas, so feel free to do with them as you wish. But they’re things that I have learnt over the course of the year, so I hope they are of some use to you. 

Get organised…
Organise a framework for your work and stick to it. I began writing about each condition on a separate document, but there are so many conditions to learn about now that you’ll be doing way more work than you need to. 

Medical conditions

  • There’s little use writing individually about every disease or you’ll end up with so many separate documents you won’t know where to start!
  • I’ve found the most effective way is to have all my notes in one place, with different categories for each specialty (Cardiology, Respiratory, Gastroenterology etc.). There you can briefly summarise each condition and have tables where there’s lots of small chunks of information that you need to know. 
  • Generally, I feel the most important bits of information you need are:
    • Risk factors
    • What to ask in a history – what clues can the patient give you?
    • What to examine – what signs/symptoms would you expect?
    • Differential diagnoses
    • Pathology and basic science – and if possible, try and think of how you would explain this to a patient
    • Complications
    • Investigations and what they would show – think bedside tests, blood tests, imaging. Also consider what is the fastest test and what is the gold standard (they like to ask this in exams!)
    • Treatment – it’s not a big part of third year but if you start thinking now it will help for the future. And for some conditions like stroke and sepsis, you’re expected to know about management now
    • Consider what you’d see on radiographs, what histological changes are going on etc. 
    • I’ve found that having a section where you can put helpful mnemonics, links to useful websites, or links to old notes from pre-clinical years helps…it prevents lots of messing about routing through old notes – try to have it all there at hand when it comes to revision!
  • Overall, keep it brief! Breadth over depth is better, but obviously if you understand the basic science it can often be easier to remember it long term

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Example Notes

Differential Diagnoses

  • Patients won’t present with their condition printed on their foreheads, so start thinking of differentials for different symptoms. I found it was handy to make a separate table for these…symptom, list of differentials and whether these differentials have any distinguishing features, questions to ask in a history and what investigations would be the most crucial. Keep it simple, but use it to test yourself

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Example of Differential Diagnosis Notes

Drug Bank

  • If you haven’t done so already, I would recommend making a drug bank
  • Consider briefly the class, mechanism of action, indications, side effects, contraindications and cautions, interactions and how (if applicable) you would monitor it
  • Also consider how you would explain a drug to a patient – in OSCEs and of course real life, you may be asked to discuss a patient’s medication, and they can ask you whether you can take certain drugs together and why they’ve been given certain medication etc.
  • You can probably get a good idea about doses looking at patients’ drug charts, but remember the BNF is always available for this

Be smart with your revision…

  • Revise as you go along! You generally get 3 weeks of learning, with a final week for catching up, but if you can start revising in that final week it will make it easier when exam time comes
  • Revise properly for any mocks!
  • Use online question banks (see links later) – they help test you on a range of topics and although they may not be identical to your exams they do give you an idea of where your strengths and weaknesses are…and they’re also handy when you’re waiting around for a clinic etc. with nothing to do!

Make the most out of ward time, but don’t waste time…

  • You can feel like a spare part – some wards are better than others
  • Take histories and present them to a doctor, or your fellow students, or there isn’t much point otherwise – make sure you get feedback, so you know how to improve. Patients on the wards are often complex and not as straightforward as in exams where they know there’s a time limit and have set answers to give – best get practicing on real people now before you’re doing it as a qualified doctor!
  • Try to examine patients in small groups, 2-3 students, if the patient permits of course. Time each other, come up with differentials and critique each other. It feels awkward at first but when everyone takes part it’s actually really helpful 
  • Make sure you get access to iPortal and the imaging systems ASAP. It’s handy to look at chest radiographs etc. – discuss them with doctors or students, compare what you think, compare it against the radiologist’s report. I still don’t really know what I’m looking at on a CT scan, but I guess I’ll have to keep doing this myself to get better!
  • If you see a patient, ask yourself what the differentials would be, what tests you’d do and how you’d manage them. Then read the notes and compare.
  • Look at drug charts – discuss how each drug works, it’s side effects, indications etc. Work out why the patient is on it, why a drug was stopped or started and what conditions that patient may have. It’s worth learning pharmacology now and getting familiar with doses whilst you can.
  • Ask if there are any jobs that need doing – venepuncture, cannulation etc. 

Overall, use your time wisely, even if there is noone around to formally teach you. BUT…if you feel you’re really not getting anywhere, go and study, or find another ward/clinic to go to. Use your time wisely!

Practice your practical skills..

It’s easy to shy away from this, especially when you lack confidence with practical skills like me, and when you need to practice on patients with terrible veins or who cry at the mere site of a needle…but it’s essential!

From what I’ve found, the best places are:

  • Pre-admissions – sign up to spend time with a HCA and take blood, do ECGs, just see what turns up on the day
  • If you have spare time on the ward, ask the nurse in charge, usually there’s something that needs doing
  • Use your A&E week wisely – they always have jobs that need doing and obviously the longer you spend there, the more opportunities you will have
  • Spend time with the anaesthetist if you’re in the operating theatre – they’re usually happy to let you cannulate if you show some enthusiasm
  • You can volunteer in the operating theatre too – see which surgeon you get and judge how confident you are – I was told off for being too slow catheterising a patient in theatre and told to stop by the surgeon! Don’t let things like this knock your confidence, just try your best

Exams

  • Think of the obvious – at our stage you need to recognise major clues they will put in the exam questions. As with OSCEs, they won’t give you patients with a rare disease – don’t over complicate it and you will be fine
  • Don’t worry about OSCEs – more than ever before, you will be doing the same things you’ve spent doing pretty much every weekday for the past 7 months, except now there is someone watching (easier said than done I know, but I guess it is true)
  • Time yourself! Both in OSCEs and written exams. I found exams this year took me alot longer and I barely had 5 minutes to spare – some people time themselves on question banks and this is probably a good idea, so you know how you’re going to pace yourself…just don’t get hung up on too many MCQs or before you know it you will be out of time…
  • Prepare scenarios and be a patient for your friend to interview. Come up with questions for afterwards like a real OSCE. Do this once a week all year and you’ll already be in the mindset of thinking about all the different rotations and what conditions might come up

Give yourself some time off!

The days are longer in third year compared to pre-clinical years, and you will find that despite being on the wards and in seminars all day you still need to do some work later. Try to make time on a few nights a week or weekends where you are always off. It’s very easy to let exercise slip because you need to make more notes, but ultimately you end up really tired and don’t take anything in!

Try and have the fourth weekend of each block off, so you feel refreshed for the next one and make the most out of the lighter blocks (Elderly care and Mental health) as they’re generally not as intensive so you can afford to have a little extra time to yourself. 

In summary…

Enjoy it! It’s great to actually see signs you only ever read about in books and to apply what you’ve learnt to real life. I personally find medicine very up and down – there are days in which I just seem to know things, I answer questions correctly, I know what is wrong with patients and I feel very pleased…the next day I don’t know a thing, I get criticised for not asking certain questions and I miss a vein 3 times whilst trying to cannulate. I’ve learnt to get used to it, never be arrogant and just keep going. It will get much harder as we go along, but hopefully also, even more interesting!

Helpful Links

  • Passmedicine 
    • The cheapest of all the online question banks (~£25 for 12 months)
    • It’s not exactly like the actual exam questions but you can select different subcategories if you want to revise specific topics
    • It helps you see where your strengths and weaknesses are
    • It has a textbook where you can search for different conditions – it gives a good concise overview of different conditions which is great when you revise and need to top up your knowledge – you can also add your own notes to it too
  • Geeky medics
    • Amongst many things, they have mark schemes for histories and exams which is great for OSCE practice
  • Fastbleep – Helpful medical website
  • Life in the Fast Lane – Another helpful website, but it has a great section on ECGs

 

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