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March 13, 2018

There’s Light at the End of the Tunnel – or is that the Approaching Train?

As we are now in our final year, we have been experiencing the joys of final exams over the past month or so. If the truth be told, the exam season actually kicked off at the beginning of December with the Situational Judgement Test, and we had the Warwick Safe Prescribing Assessment (SPA) exam at the beginning of January (plus the odd mock exam here and there) but it really got underway in earnest with OSCEs (structured clinical exams) on 12 February. With just a month separating the OSCEs and our last scheduled exam in the first sit (this is the national Prescribing Safety Assessment), it’s been a tough old run and most of us just want a few days to sleep and hibernate.

After the written component of our assessment (SAQs and MCQs), our cohort was assessed via the OSLER (Objective Structured Long Examination Record) method. There was a very famous Canadian physician called Dr William Osler (he of the eponymous nodes) and I have often wondered if there is a connection between him and the rather clunky acronym for our exams. Maybe I’ll make it my mission to find out when we’re all done – that is, if I still have the energy!

We haven’t got our results from any exam yet aside from the SPA, so these could be my famous last words, but all in all I found the OSLER process quite manageable. We each were assigned a full day and a half day of OSLERs. I was in a group of people who started our OSLERs very late in the week and thus most of my cohort had had their full day before I did. Of course nobody shared specifics of their cases with anyone else, but I was told that the time does pass quite quickly during the day when you’re actually doing it – and I found that to be the case as well. All of the patients whom I examined were really nice and friendly, and it seemed like they really wanted each student to pass and do well. I am always grateful to patients who give up their time to help us medical students learn and be assessed – they seem to enjoy themselves and it must be great fun to watch students come through all day. I might get tired of being examined repeatedly, but none of them seemed to mind that much. Maybe there was more variation in exam technique than I realised!

Recently our allocations to the Foundation Programme were released. This is the region of the country – known as the deanery – in which we will be doctors for the next two years. This was really exciting for everyone, as it’s a combination of a few things – both our educational performance ranking (for which we get 50 points out of 100) and the results of the SJT exam sat back in December (for which we get the remaining 50 points). Our combined score decides our ranking against all of the other 7,000-odd applicants from all over the country (and even the world, as there is a sizeable international component) and this in turn dictates which of the programmes we are allocated to. It’s very exciting to ponder the next step of our lives, and it’s really hard to believe that in a few short months, we will be sent to all corners of the country to start the next phase of our careers!


February 22, 2018

In the Thick of It

We are in the middle of our final exams period, and, as expected, it is quite full-on. These are basically several sets of comprehensive examinations covering everything that we have learned at medical school since starting on the course, and so the topics are understandably really vast. It’s so difficult to even begin to prepare for these exams and I think that everyone has basically just been reading and covering anything and everything that they can, and practicing our examinations all the time, in the hopes that any work is good and useful work – and by and large it seems to be.

By now we have already had our OSCEs (Objective Structured Clinical Examinations) and sat our written papers, and we just have our OSLERs (long cases) to go – more on those below! In previous phases, our exams have consisted of fifteen OSCE stations, and 180 marks each for SAQ (short-answer) and MCQ (multiple-choice) papers. But this time we only had 10 OSCE stations and 150 marks for the MCQ paper (although the SAQ paper was the same 180 marks). It has been really tiring so far, and I’m glad that we have the rest of the week to relax/recover from these exams, especially the written ones – as looking after our mental health is a very high priority at this stage.

Without giving away any information on the actual content of the exams, I can say that the people setting them up did a very good job to ensure that they have all been very comprehensive and that many aspects of the Specialist Clinical Placement blocks that we had in Phase III were covered adequately. We weren’t tested on everything, of course, but there was a sufficient amount represented from various different aspects of our medical syllabus to feel like it wasn’t too concentrated in any one area. Whilst OSCEs seemed to cover more adequately the clinical side of medicine (these are the common, everyday tasks that F1s and beyond will have to do in hospital), the written papers tested our book knowledge about lots of different conditions, as is expected.

It seems like we are all old pros at sitting written papers and at doing OSCEs, since we’ve all done a few rounds of each, but the OSLERs (Objective Structure Long Examination Record) are a new kettle of fish for all of us. We’ve had several practice OSLERs (some more realistic than others) since clinicals started at the beginning of 2016, but this is of course a different scenario – among other things, we are being examined with a real, live patient instead of an actor. And there are other components to the OSLERs as well that we’ve not yet encountered before in the exam setting – having a mini-viva where we are asked about the presenting condition, having to explain a medical procedure to the patient, etc. – so it will be interesting to see how it goes. Hopefully the next time I post, I will be on the other side from all of these exams – wish me luck!

February 12, 2018

Before the End, the Beginning

Next week marks the start of our finals-exams period, and with it comes the usual mix of emotions. Because so much is riding on the next few weeks, I’m nervous and anxious (I think there’d be something wrong if I weren’t), but I’m also pretty excited and looking forward to seeing what it’ll be like. We’ve put so much effort into the past few weeks, months and, yes, years that it will be interesting to see what sorts of topics we are examined on, and how it comes about. I’m looking forward to applying my knowledge.

On the one hand, it’s daunting because the scope of material we can be asked about is just so broad: the body of knowledge that a medical student is expected to have upon graduation is truly vast. I don’t quite know what I was expecting, but there is just so much to know! On the other hand, we have spent years accumulating knowledge, building upon it and putting it into practice. This in itself is really important to bear in mind when coming up to exams: sometimes it feels like we’ve not learned a lot, but in reality we all know a lot more than we realise or give ourselves credit for. And yet on another hand, I think that by this point most people just want exams to be behind us. We want them to start but, more importantly, we also want them to end.

Our first round of exams this time is the OSCE segment. This stands for Objective Structured Clinical Examination. Normally we have our written exams first, but it’s swapped round for finals – I don’t know why. For this exam (as in Phase II), OSCEs take place on one day. The entire cohort is split in two; half the cohort is assigned to a morning slot and half the cohort gets an afternoon slot. We are split into groups of about 12 students and each of these cycles through a set of ten stations (with a couple of rest stations built in) – and of course several cycles run concurrently. Once the morning group are done, they are sequestered in a room until the afternoon group starts – the purpose of this is to avoid anyone from the morning group sharing information about stations with anyone from the afternoon group. The set-up of doing all stations in one shot is actually fantastic if not exhausting – in our first year, OSCEs were three or four stations spread over four days and everyone was very tired of it by the end of the last day. This way, at least they will all be out of the way at once and we can focus on the written component, which is coming up next week.

One key element to our education process that often gets overlooked is that we as students need to pay due attention to our own mental health as individuals. Since this is such an all-consuming point in a pretty demanding course, it is really easy to let the little things slip – exercise, eating well, taking breaks, etc. We all want to do so well (or even just make it through) that we focus perhaps too much on revision to the exclusion of much else. I’ve started forcing myself to go swimming again a couple of times per week, if nothing else just to make sure I have an outlet for my energy and that I sleep better at night. So far, it seems to be paying off!


February 05, 2018

Final Exams Approaching…

As final exams are approaching, our cohort is getting really stuck into the revision block now and, as expected, it seems like there's never enough time to do what we want and need to do. At least that's how I seem to feel these days - and from what I gather, most other people feel the same. I have a list as long as my arm of things that I need to cover before exams (which are looming ever closer...) and of course it seems like it's growing every day. I'm pretty used to this state of being, however - we've been through this a couple of times before with Phase I and Phase II exams. The only thing that's a little more daunting this time round than previous times is the sheer volume of information - it's really difficult to find time to cover everything!

The med school have been quite good about setting up revision sessions for us, though. We have had several tutorials at our base hospitals and also have some clinical-skills sessions set up as well in the next couple of weeks. These are useful (well, some are more useful than others...) because they allow us to focus our knowledge and highlight where there might be gaps and where we need to pay more attention. It's also very helpful to have several sessions packed into one day so that we can minimise the time spent traveling back and forth to hospital or other places. Every second counts these days!

I think the most important challenge to us as final-year medical students these days is more just keeping engaged and motivated; our exams (well, those we've not had yet) last a month, and remaining energised to stay engaged is going to be the biggest challenge for all of us. There is a level of stress and tension which I think we've not experienced so far. I think we all just need to find the right way of dealing with it.

This morning as I was walking into hospital after parking up (and preparing for another long day of revision), I happened upon a group of ten or so first-year students who were coming in for their Friday-morning 8:00 am lecture. I remember these lectures well - of the 26 Fridays we had in our first year, we had 8:00 am lectures on 24 (not that I counted!). It was so exciting to see them talking and laughing amongst themselves, and ready to spend another day in hospital learning and growing as medical students. That was exactly the kind of inspiration I needed: after feeling a bit worn down and anxious and every other emotion under the sun, reminding myself of what it was like to be a first-year student again (and excited about EVERYTHING to do with medicine) was enough to light the fire under me - for a few days at least!


January 16, 2018

Revision as far as the eye can see

At the end of 2017, we completed our year of Specialist Clinical Placements, which for us was marked by the end of the Psychiatry block, which I actually enjoyed far more than I thought I would. It wasn’t until we’d got to the end of the year, though, that we’d realised how quickly it had flown by! Forty-eight weeks of fifty (with just two weeks off in August) is really hard going, no matter who you are. I always had more time off than that when I was working. At least over Christmas, most of us had some time to relax and some good excuses to be a little lazy. I had the chance to spend some time out of the UK for a couple of weeks, and I’m really glad that I did – it helped me appreciate the West Midlands much more when I got back, and I really needed a change of perspective.

Our final exams start in just over a month, and it’s really difficult to believe that they’re almost upon us. I don’t quite know what to expect. I’ve sat Phase I and Phase II exams (of course) and they’ve been… tough but not impossible. Phase I was relatively straightforward as the content was (mostly) presented to us throughout the course of the year; the pace and the volume was a huge struggle, but it was obviously not entirely insurmountable. I personally found Phase II exams to be a lot more unexpected in content and nature than Phase I, but thankfully they’re behind me and my cohort now. I think (and truly hope) that as long as each of us has kept up with our work throughout the year and has maintained a consistent stream of work over each block, we should hopefully be OK when it comes time to put pen to paper for the Phase III exams.

We have already sat the Safe Prescribing Assessment, a Warwick requirement to graduate (although not, as I understand it, a GMC requirement). Now it’s just a matter of waiting for results and dealing with the consequences, whatever they may be. The prescribing exam tests our ability to interpret instructions given to us by using the British National Formulary (a huge compendium manual covering basically every single drug available to be legally prescribed by healthcare professionals in the UK) and transcribing them onto mock drug kardexes (they resemble drug charts for patients in hospital) and discharge letters. It sounds straightforward but it’s a lot more complicated than one would initially expect. I know that many people, including me, found the exam really tricky.

It’s really important that we med students also look after our physical and mental health. It’s really easy to get in the habit of burying our nose in a book for 12-15 hours per day. But I have been forcing myself to do things like swim and take walks around the neighbourhood. I find it much more efficient to work after I’ve cleared my head, and swimming also helps me sleep better at night so that I’m less sluggish during the day. Is it a winning formula? I’ll know the answer to that in a couple of short months!


January 03, 2018

The End of The Block…

After what feels like the longest year that most of us can remember, we are finally done with our last block of the Specialist Clinical Placements. It’s hard to believe that from now on, it’s all going to be revision and clinical apprenticeships (presuming finals success…). I’m glad that we ended with the Psychiatry block, however, as it allowed us to focus on an area of medicine that we don’t see very much of outside of psychiatry, and hopefully having this block so late will keep the information fresh for our upcoming exams.

Our last week of Psychiatry involved more time spent in an acute-ward setting, and enabled us to see far more presentations of common psychiatric conditions, including Emotionally Unstable Personality Disorder, severe Generalised Anxiety Disorder and many other fascinating presentations. We were also able to see another assessment under the Mental Health Act, something which is taken very seriously (for obvious reasons) and is very thorough and complete. I’m glad that so much effort is put in place to safeguard patients who might not be in a safe mental state to manage their own mental-health conditions, and it’s good that the process is so robust and observed so closely. There really is a lot of legal scrutiny for the process of detaining patients in hospital, and every professional I have worked with has agreed that this is entirely appropriate.

Looking back on 2017, it’s really amazing to think of how much ground we have actually covered; there is so much that I didn’t know at the start of the year but have picked up throughout the course of the year through many different means: we’ve had large-group teaching, small-group teaching, one-on-one teaching, ward-based exposure and of course loads of self-study. My notes, however, are a complete horror show and I could easily spend the majority of the next two months just reorganising and getting everything into shape! But of course we don’t have time for that right now. It’s all about accessing, revising and hopefully committing to memory all of the information that we’ve learned over the past three-and-a-half years. The task is daunting, but I think we’ve climbed steeper hills (first year, I’m looking at you). My main goal for the first day of revision is to at least get everything on one disk drive!

Now that we are done with our last Specialist Clinical Placement, most of our cohort are now off on Christmas break – which will be nice, but of course we will have the additional spectre of upcoming final exams looming over our heads. I’m looking forward to leaving the UK for a couple of weeks – Coventry is lovely, but I think I need a change of scenery to keep from going mad – and hopefully some slightly warmer weather and creature comforts will be the perfect environment to start my revision.


December 22, 2017


In my last blog I spoke about the change of pace when I started the Psychiatry block. There is certainly less urgency about the psychiatry block but the days are no less intense and most days at the end of placement I’m just as exhausted as any of the shifts I worked in A&E.

My clinical partner and I are currently assigned to a male adult inpatient psychiatric ward. Like any other ward most days there is a ward round, however instead of a group of people peering at a patient from the end of the bed, there is a ward round room where patients come to speak to the team about their care. Sometimes the doctors or nurses may request to see someone, other times there are prescheduled appointments. Some of these meetings can be brief, patients who have improved a lot who are discussing spending more time at home and are nearly ready for discharge. In contrast, some of the patients may be seen for over an hour, taking a complex history from a newly admitted patient, as well as a collateral history from family, followed by time to discuss the plan among the clinical team. In other areas of medicine while patient centred care and involvement of family and friends is preached, it isn’t always practiced. However, in psychiatry every consultation starts with the same, important question: how are you feeling? Often patients don’t know how to answer this, but their response is key. Key to knowing if they are ready for discharge, if their home leave was a success, or if their new medication is having side effects or if their symptoms have improved. The involvement of family and friends is strongly encouraged and where these are lacking other means of social support are utilised in the form of community psychiatric teams and social services as well as other members of the MDT or multidisciplinary team (a key buzzword for exam purposes!).

One of the things I really like about Psychiatry is that it takes a truly holistic approach to patient care. While a patient’s main reason for being in hospital may be their psychiatric condition the doctors know that treatment of this alone won’t solve the issue. Another key buzzword for medical school exams is treating patients using the “bio-psych-social model”. You need all three to treat any condition effectively, this applies to any medical condition but it is particularly pertinent in psychiatry. A psychiatric illness may require medication or even ECT treatment (the biological approach), but a patient may also benefit enormously from psychological support. The social approach can be very complex in psychiatric patients, patients may need help with housing if they are homeless or may not know how to claim all the benefits they are entitled too. They may need help finding a job or gaining work experience. These are things the doctors and nurses discuss at ward round with the patients, finding out what their hopes and ambitions are for when they are discharged.

Mental health services may be severely under pressure and underfunded, but it’s great to see the psychiatric team help a patient with every aspect of their lives to achieve the best management of their psychiatric illness. Perhaps psychiatry is where all the MDT and Bio-psycho-social magic really does happen!

The Acute Block… the Pressure Mounts

We’ve recently started our acute-medicine block, which is a very descriptive title. This block has us students at the very thin end of the wedge as far as treatment and patient management goes, and the block also has the reputation for being one of the most enjoyable of all specialist clinical placements. I can see why – it’s fast-paced, exciting and the timetable is laid out really, really well. Our opportunities are wide and varied and all of the doctors whom we work with are willing to help and get us involved. It’s a very collegial and inclusive atmosphere, at least from what I’ve seen so far. This is a branch of medicine that I could really see myself liking a lot.

The people designing the timetables have worked hard to give us exposure to a huge variety of disciplines at both a large hospital and a smaller one. We have rotations in the Intensive Treatment Unit (ITU), in the ‘majors’ and ‘minors’ departments of both large and small hospitals, a couple of shifts on the resuscitation wards, and a whole lot of other things as well. It’s really interesting. I feel like we are also being taken very seriously as medical students finally – perhaps when you reach the final year, doctors know that you’re more experienced and are happy to supervise you in your role but give you less guidance – which is exactly what we’ll need as F1s. On several shifts, I have been given the opportunity to clerk patients (conduct an initial history and examination) and present my summary along with differential diagnoses and a management plan to the doctor in charge, and I have always got useful and worthwhile feedback afterward.

I recently spent some time on the resuscitation ward within the larger of our two hospitals, and loved every minute of it. It was an evening shift – this is so that we can see patients at the busiest time of the day – and there were loads of interesting presentations. The purpose of resus is to stabilise each patient and make sure that all life-threatening conditions are neutralised before they are transferred to more appropriate care – which usually means another ward within the hospital. On my most recent resus shift, we saw several people with complicated fractures – treating these involved taking x-rays, putting on emergency plaster casts and sometimes re-applying the cast if the subsequent x-rays weren’t showing what the doctors wanted to see. I got to hold lots of legs in place for stability whilst wet slabs of plaster were slapped on and wrapped up. All I can say is: thank goodness for aprons!

Our time on the ITU was a little more sedate, although still very interesting. We saw patients who had usually come from A&E (although not always) and had usually suffered severe injury, several of which were to the brain. Several patients were in induced comas whilst their serious medical issues were treated. It took a little bit of getting used to, but once we were stuck in, it was really very exciting. We still have four weeks left of the acute block, and I’m really excited for what we have yet to see – watch this space!

Getting Stuck into the Acute Block

We’re in the middle of the acute block and it is really living up to its vaunted reputation. I am having a great time and learning a lot, and it seems like everyone in my rotation is having similar experiences. My clinical partner and I are lucky because most of our teaching and shadowing sessions are at a very large regional hospital; this appears to mean that we see lots of injuries and presentations that wouldn’t normally go to a regional hospital. There is a lot of trauma and some fairly serious acute medical presentations, and we get to see a lot of very interesting and cool things.

I’ve found that we are really encouraged to get involved once we tell the A&E staff that we are students, and this is a huge advantage of the acute block and being so far advanced in our careers as students. When we’ve been observing/helping out in A&E, most of our time is split between A&E minors (where people present with not-very-acute conditions) A&E majors (where people come for acute and serious but not life-threatening presentations) and A&E resus, which is geared toward stabilising patients, saving their lives and initiating immediate management before passing them along to more appropriate parts of the hospital.

Each area has its positives: the minors area is the least hectic and stressful of the three, which means that when we see patients here, we can spend more time focusing on their presenting complaint without the added pressure of it becoming urgent very quickly. In the majors area, the energy level is really high, and there are loads of doctors around, so as students we get support as soon as we need it and clinical contact all the time. And the resus area gives us the opportunity to see the bare face of medicine, where people’s lives need to be saved immediately. Both my clinical partner and I have seen some really eye-opening trauma in resus – let’s just say that I am absolutely never, ever getting on a motorbike in my life.

I feel that we’re lucky because our acute block is coming rather late in Phase III (much luckier than had it been our first rotation, for instance). It being so late has equipped us to consolidate a lot of the medical knowledge that we’ve built over the phase and indeed over the preceding years, and we also have a lot more confidence speaking to patients and getting straight to the point about what information needs to be uncovered. Unlike lots of other degrees, basically everything that we’ve learned throughout our time in medical school (especially a lot of the anatomy and physiology from Phase I) is relevant at all parts. The vocational nature of the degree means that everything is applicable at all times – we were quizzed the other day on the mechanism of action of bronchodilators, which we learned in November of our first year! In any event, the acute block has exceeded my expectations, and I am seriously considering a career in emergency medicine because of it

December 18, 2017

Fingers and toes crossed…

Well that’s it, I have officially completed my final specialist clinical placement as a final year medical student. I will be back in hospital in January for my revision block and then next stop finals!

I cannot believe how fast this year has gone, it feels like only yesterday I was checking my emails as a 3rd year student to see where my first specialist placement would be and it doesn’t seem that long ago I was in the lecture theatres in first year. The amount I have learnt in such a short space of time is quite staggering, however it is equally alarming how much I need to learn and remember over the next 8 weeks!

The last two weeks of my musculoskeletal block have mostly been focused on rheumatology and our end of block assessments. I presented a patient case about Psoriatic arthritis (a condition that affects the skin and joints) to our consultant and was then quizzed about my knowledge of the case and of the disease, which was quite nerve wracking but good practice for our clinical exams. We also had our end of block clinical exam which is run exactly like our finals will be. Mine was in fracture clinic with a patient presenting with hip pain. He was such a lovely person and he was still in very good spirits when I saw him despite him already seeing another medical student due to a lack of patients. He was less impressed with my examination technique which involved making him manoeuvre quite awkwardly around the couch which would have been tricky even if his hip didn’t hurt! I certainly still have some way to go before my examinations are slick enough for finals!

In our last week my clinical partner and I were invited by our rheumatology consultant to attend a special clinic conducted by a Professor visiting from London. This professor specialises in a rare disease called scleroderma, a disease where the body’s immune system attacks different tissues in the body resulting in skin disease and various problems with other organs which can be life threatening. This is an incurable condition and it can be very difficult to treat, many of the patients in the area with this condition travel to London for treatment but once a year this professor visits Coventry to see particularly difficult cases and offer advice to the rheumatology team at UHCW. It was interesting to observe the UHCW consultants presenting cases (getting tips for my own exams!) and see how this world-famous Professor was still so down to earth and friendly with the patients. While medical students are often told not to worry too much about rare diseases, when you are in final year and preparing for clinical exams you start to believe all the rumours about some of the tougher clinical cases, with scleroderma rumoured to be one of them I wasn’t going to miss the opportunity to attend this specialist clinic!

Keep your fingers and toes crossed me and hopefully the next time I’m writing my blog it will be on the right side of finals!

December 13, 2017

Psychiatry and Beyond

As 2017 draws to a close, it’s amazing to think of how much ground we have covered and how much we have learned since the start. We are now coming to the end of our eighth Specialist Clinical Placement this year, and once again it’s been a fascinating tour through a part of medicine that we’ve not had much exposure to up till now.

After spending the first three weeks of the block on a community psychiatric placement, we have spent the past two weeks learning about old age and acute psychiatry. Most of the care that we have had in these two sections has been ward-based, and we have had the opportunity to see some very interesting presentations of a more acute nature. These tend to be patients who have been asked to remain confined to a ward for their own good, as they pose a danger to themselves or other people and are in clear need of treatment. The legal process that doctors are required to go through in order to detain someone are very robust, and I think that this process is crucial to a beneficial and defensible medical service.

It’s easy to think of medicine in discrete blocks: a patient with a heart problem is only a heart problem, a patient with bipolar disorder is only bipolar disorder, etc. But what we have seen a lot of in this block is patients with multiple mental-health and physical-health comorbidities presenting at the same time. We have been able to see why psychiatry requires a strong foundation in physical medicine – doctors need an in-depth knowledge of physiology in order to understand side-effects of drugs and physical causes of mental ill-health, among many other things. Although my stethoscope isn’t getting much exposure during this block, the potential to use it is always there. Next week is our final week on psychiatry (and actually on Specialist Clinical Placements altogether!) and I’m really looking forward to what it will bring.

Along with several thousand other hopeful final-year medical students around the country, we sat our Situational Judgement Test exams last Friday. This is a relatively new assessment (in the past five or so years), which plays a large role in determining where we will go for our foundation-programme placements. We were presented with dozens of ethical scenarios and asked to respond to each, and even though Warwick Medical School do a really good job of preparing us for the exam (as much as they can), I think it’s fair to say that there’s no more preparation I could have done to have performed better or worse. It’s just so tough to prepare for this exam – I guess that’s the point, though! We’re expected to react instinctively and be evaluated based on this judgement. We won’t know the outcome until early March when we are given our foundation-programme placements.

And very soon our Specialist Clinical Placement blocks will draw to an end entirely, leaving us in the run-up for finals. It’s been a long road and a very busy year, but I’m looking forward to seeing what the next chapter brings!

December 04, 2017

One exam down…only a gazillion more to go

First exam done! All Warwick students sat the national Situational Judgement Test (SJT) last week. This is an exam that makes up 50% of our total score for our Foundation job applications so while it doesn’t test your medical knowledge it’s still very important! The SJT focuses more on the qualities expected of a doctor and how you handle difficult situations that we will be faced with such as confidentiality issues, explaining mistakes to patients and prioritising our workload. It’s a tricky test to prepare for so I’m glad it’s out of the way.

Apart from SJT practice I’ve still been enjoying my musculoskeletal block, we’ve been in the plaster room practicing putting casts on each other and I’ve also been in the trauma theatres. A day with the trauma team starts early with the 7.30am trauma meeting where all the traumas that came in the previous day are discussed and operations planned and prioritised. The team on call then head off to fracture clinic and the junior doctors respond to any trauma bleeps from A&E. The following day the same team then is in the trauma operating theatre doing any operations that are required on trauma patients that have come in over the previous few days. The day that I was in theatres we had a huge variety of different hip fractures, an unusual fracture in a teenager and then more common types of hip fractures that occur in the elderly. When we first learnt about falls in the elderly and hip fractures in second year I could not believe how much they cost the NHS with some studies suggesting they cost £1 billion per year, they are also a significant cause of mortality with a significant proportion of elderly patients not surviving even just 1 month after a hip fracture. All the studies show that if you treat a hip fracture quickly the mortality goes down no matter what the age of the patient is. For that reason, we had patients in their 90s on the trauma list to fix their hip fracture to preserve their mobility so they don’t become unwell and suffer any further complications.

Operations to fix hip fractures aren’t the most pleasant to watch and there is an awful lot of hammering and banging that makes you appreciate why people are so sore after their operation. I don’t have the best track record when it comes to fainting in theatres so I was slightly apprehensive about attending trauma theatres. So far during medical school I’ve hit the deck on a ward during a chest drain insertion as well as in theatre during a C-section, both times staff were lovely and understanding but both times I was completely mortified so I ate the biggest breakfast I could manage before heading into theatres. I must admit then when I was scrubbed up and quite close to the action I did feel quite queasy but I managed to stay standing! Hopefully I’ll have plenty of opportunities to further desensitise myself during our assistantship so I don’t continue to be a falls risk!

November 27, 2017

Community Psychiatry and the SJT

All of us Phase-III students are now in the third week of our final Specialist Clinical Placement rotation. It’s hard to believe but we’re almost at the end of this year’s formal medical instruction. We’ve all been working really hard and I hope something comes out of it. 2017 has just flown by

We’re about halfway done with our Psychiatry block, and it’s proven fascinating thus far. Of the six-week block, three weeks are meant to be spent in the community, one spent with an old-age consultant, and two on acute care. Our community placement has been in a lovely clinical practice in the community (i.e., not at a hospital) with several psychiatrists (including consultants and registrars), psychologists, and care coordinators all working together for each patient’s wellbeing. I gather that most patients won’t be seen by a psychiatrist unless they are referred by a medical professional or a police officer, depending on the circumstances. We’ve seen lots of varying presentations in the clinics, including severe depression, emotionally unstable personality disorder, paranoid schizophrenia and many other things. And we’ve seen patients at various stages of treatment as well, including new-onset, follow-ups after initial therapy, and some patients who’ve been under treatment for decades and have come in for medication reviews. It’s fascinating to see all of these presentations at once, after having read about them for so long.

Most patients have been really open with me and my clinical partner when we ask them questions about their conditions, including symptoms, duration and treatment of their condition – and it’s great when they are able to help us learn. Elements of the psychiatric history can be quite personal, as they involve intimate details about a patient’s upbringing and social life, and so sometimes it takes some effort to get comfortable posing them, but when you realise that you need to handle an intimate psychiatric exam the same way you’d handle an intimate physical exam – with sensitivity and professionalism at all times, focusing on the patient’s wellbeing – it becomes easier with practice.

Over the next few weeks, we have old-age and acute psychiatric placements. I’m really looking forward to them, especially the acute part. About a year and a half ago, we had an introductory week on a psychiatric intensive-care ward and it was absolutely brilliant. Now that we have gained a lot more medical knowledge, and in particular have spent the past few weeks bolstering our knowledge of psychiatric conditions and how to treat them, I hope it will be that much better and more useful.

Very shortly, members of our cohort will also be sitting the SJT, or the Situational Judgement Test. This is a test that all final-year medical students are required to take before entering the foundation programme, which is hopefully at the end of summer 2018 after graduation. The SJT is designed to assess students’ ethical judgement through asking us to respond to various realistic scenarios. One common scenario presents us with a fictional but realistic hospital situation and asks us to rank, in order of appropriateness, the options on how to proceed. Although you cannot officially revise for this exam, its administrators issue official practice tests, and there is no shortage of revision courses and materials to help us get through. WMS have even included sample SJT questions at the end of our CBL cases as well, which has been very helpful. I’m looking forward to seeing what the exam contains, but more importantly, I’m looking forward to it being behind me!

November 21, 2017

To study or not to study…

Two weeks into my final block and my fellow students and I are counting the days, not until Christmas, but to our exams! I’m already a week behind on my revision timetable and I seem to spend more time thinking about all the time I’ve wasted rather than getting on with my revision!

My last block is the musculoskeletal block. Our year group is split into 7 groups and each one has done the blocks in a slightly different order, so everyone is finishing on something different. Some students are happy they are finishing on General Practice so they can practice and revise almost every subject, other people are glad they are doing Paediatrics or Obstetrics and Gynaecology so that all the information covered in those blocks stays fresh in their mind for exams. Musculoskeletal isn’t a bad block to finish on, this block covers rheumatological conditions which are a favourite of medical school clinical exams and covers orthopaedic surgery so we are seeing lots of patients with osteoarthritis and painful joints, which also come up a lot in our exams. Many rheumatological conditions don’t just affect the joints but have effects on other areas of the body so it’s actually very good revision for other organ systems as well as ensuring my anatomy hasn’t been completely forgotten.

One of our teaching sessions can be slightly nerve-wracking with a consultant who likes to sit in the middle of a circle of nervous students and swivel on his chair and directing questions at us about almost any subject in medicine and surgery! Trying to think of another side effect of steroids when all the ones I remember have been said already or been asked to name 4 causes of clubbing (a clinical sign of disease in the nails) is quite exhausting but it’s also helpful! Our consultant helps us if we are struggling with a range of comedic actions and facial expressions and we all leave with a smile on our face knowing that while we got some answers right, it didn’t matter which ones we got wrong as now we know which areas of medicine we need to work on!

We are also spending time with the orthopaedic team in fracture clinic, seeing new patients as they are sent round from A&E with a variety of injuries. We are getting lots of practice with our history and examination as well as getting the chance to look at some painful looking X rays!

Aside from our MSK block and revision I am also trying to fit in some revision time for the Situational Judgement test, a national exam that will determine 50% of the score I get for job application to the foundation programme. Fingers crossed for the start of exam season!

November 10, 2017

High security….

With just one 6 week block to go before my last Christmas holiday of medical school its all getting a bit scary. My fellow final year students are all getting a bit jittery at the mere mention of exams and some of us are still in denial that exams are happening at all. Helping at my final societies fayre a few weeks ago it felt strange to be asked what my plans were after graduation, how I had found the course and if I had any tips from eager first years when it doesn’t seem that long ago that I was in their shoes! It was great fun welcoming new students and handing over to the new president of the Psychiatry Society, a society that I’ve enjoyed been part of since I started medical school. I’ve been involved in organising some great events, increasing the size of the society and getting the chance to promote a speciality I feel passionate about. I’ve also met lots of people that will hopefully help in future job applications-perhaps I’m getting a little ahead of myself but its preferable to thinking about exams!

Overall, I’ve really enjoyed my psychiatry block, I’m even more keen to pursue it as a future career and being interested in the subject makes it that bit easier to study! For the last two weeks we have been assigned to a community psychiatrist who specialises in psychosis. It was interesting to be in these clinics where the focus wasn’t on treating every single symptom but on improving their level of functioning so they could remain in the community. To my surprise this often meant that patients had untreated delusions or hallucinations but as the consultant pointed out if the patient is safe and is not distressed by these symptoms then is it worth the risk of unpleasant side effects? On one occasion, a patient presented to clinic acutely unwell and was very agitated, I must admit I was quite nervous and unsure if I should pull my personal alarm (to call for help) but the consultant was able to calm the patient down an arranged to follow them up at home with the rest of his team. I was glad I hadn’t called for help unnecessarily in contrast to the previous week when I accidently set my alarm off and only realised when several people burst into the room!

Dealing with difficult patients is a vital skill in all branches of medicine but especially important in psychiatry, and particularly in forensic facilities. A great thing about the psychiatry block is that we can organise additional placements within different subspecialties, I organised time with the eating disorders team, the perinatal psychiatry team and also arranged a 1 day placement at a local Medium secure hospital. Secure units aren’t just for people who have committed crimes that require psychiatric treatment, some have challenging behaviour that is difficult to manage in normal inpatient settings and there may be a high risk of criminal behaviours. Apart from additional security within the building the ward environment wasn’t very different. Forensic services are different in that patients tend to remain in hospital for longer periods of time and continuity of care is highly valued with the same consultant responsible for their care when they leave hospital as an outpatient. Following up patients over the course of their illness and see someone literally get their life back on track must be very rewarding and wasn’t something I expected to think after visiting a secure unit!

I’m sad to see my 6 weeks of psychiatry come to an end but time marches on-so off I go to my final block, musculoskeletal medicine here I come!

Psychiatry: the Last Frontier

Our cohort is in the first week of our last specialist clinical placement, and there is a certain feeling of conclusion in the air. For the vast majority of our group, this is the last medical rotation we will do at Warwick Medical School. It’s hard to believe that we’re so close to being done (well, there’s just that small matter of final exams…), but at the same time it feels like we’ve been learning for a very long time (actually, we have!) and so the fact that the end is in sight is a bit of a relief. We’re very much looking forward to progressing onto the next phase of our lives and careers.

My clinical partner and I have Psychiatry as our last rotation, and it’s proving to be very interesting and eye-opening. This is a branch of medicine about which I know very little, and so seeing the different presentations and the sheer variety on offer is really interesting. It’s also the one rotation that’s probably got the least to do with any other speciality, and so we really have to concentrate if we want to follow everything. Back in Phase II, we had a week’s exposure to the psychiatry speciality via a placement on a secure ward: it was interesting, but that placement was slightly more intense as it was psychiatric intensive care, whereas our current placement is almost wholly community-based. In any event, we’re seeing loads of very interesting presentations and the staff we work with are all very supportive and friendly, and they want to make sure that we learn as much as we can.

We’ve had lectures at many points in our medical-school career about the various types of psychiatric presentations, and like most of medicine, most of them are little more than words on a page until we see them in the flesh. However, up till now we have tended not to focus on a patient’s psychiatric co-morbidities if he or she is on a regular medical ward with a more pressing physical problem. For that reason, we haven’t usually been focusing on many psychiatric presentations until now, when it is the specific focus of our block. That’s why this block is helping us to see lots of new and exciting cases of conditions we’ve read about – it’s been a long time since a new branch of medicine was opened up to us like this!

We’re only a few days into it, but so far we have seen patients with schizophrenia, emotionally unstable personality disorder, severe depression and many other conditions that we’ve only read about up to now. It’s really a different flavour of medicine entirely. There is a lot of pharmacology (and with this come LOADS of contraindications and side-effects to learn), a lot of psychological therapies (mainly CBT, or cognitive behavioural therapy, typically administered by psychologists) and plenty of other therapies that we don’t see much of outside of psychiatry. I’m really excited by the potential, and I’m sure this block will live up to the excitement.

October 24, 2017

Lesson’s to be learnt…

Open any newspaper and you will be greeted with headlines telling of a “social care crisis”, of “bed blockers” and a “dementia time-bomb”. While many of the headlines are misleading and not helpful, the issue of an increasingly aging population and the increasing rates dementia are very real. As a medical student, we witness the problems increasing rates of dementia causes in the NHS on all our placements. On the Care of the elderly wards many patients were “medical fit for discharge” but remained in hospital due to social care issues, many patients with dementia can become aggressive and upset when they are confused and can be difficult for staff to manage and also upsetting for other patients. Observing the challenges dementia places on the healthcare system is no different in the psychiatry block. We spend some of our time in Old age psychiatry where most of the work focuses on dementia but also other mental illnesses that have presented in old age.

Spending time in the community memory clinics I saw patients presenting with a variety of memory problems. The memory clinic is designed to help improve detection rates of dementia and ensure patients receives the best medical treatment and social support. For example, if a patient is diagnosed early with vascular dementia, there is an opportunity to ensure they are on the best treatment for their high blood pressure and diabetes which could help reduce the decline in their memory. Slowing the memory decline can allow people to live independently for much longer and have a higher quality of life. Alongside the medical interventions, psychological interventions in the form of support groups for patients and carers can help maintain good mental health and help families cope in these difficult situations. Providing the right social support can also help patients stay at home longer with their families. Observing how the medical and nursing team all worked together to help these patients was interesting and it was great to see the positive impact the team had.

Treatment of dementia is focused on community care but sometimes it isn’t safe for patients to be at home or even in care homes if they have complex behavioural needs. As part of our placement we also spent time on the inpatient dementia wards. In contrast to any other ward I’ve been on, every patient had a completely individualised care plan that had been formulated through careful observation. Even though many of the patients had severe dementia, staff had spent time with them to find out what their interests were, what music did they like, what activities or food were there favourites? Spending the time getting to know the patient meant that staff could engage the patients in activities that they actually enjoyed and find out what was possibly upsetting them or causing anxiety. One patient that had previously been violent and aggressive was now calm and ready for discharge, no medication had been given, just time.

While I’m panicking about my prescribing exam it’s good to know that the answer isn’t always medication and that getting to know all of our patients, no matter what their condition, can make a huge difference. That’s certainly a lesson that will stick with me and I hope will make me a better doctor.

September 27, 2017

The End of the Surgical Block and the Passage of Time

Our sixth block, officially known as Care of the Surgical Patient, is coming to a close already. I swear it just started the other day, and yet it’s already almost over. Like lots of specialist-placement blocks, it’s been a very self-motivated learning experience. This is something I wasn’t quite expecting about the course: as a student, we are given a framework of learning opportunities and then, depending on the block, we are expected to fill in some portion of our timetables by ourselves. This requires a very proactive student who isn’t afraid to get stuck in and talk to the right people, but can also take some getting used to as well.

I spent the first few weeks of the surgery block really enjoying vascular surgery (really, it’s very cool!) but then branched out to learning about other forms of surgery in the last couple of weeks. You really have to do this in the trust where we did our surgery block. I spent some time with colorectal teams and going to lots of follow-up clinics in other areas – breast surgery, urology, even the ENT (ear, nose and throat) clinic for an afternoon. It was absolutely fascinating to spend time in underexposed parts of medicine and surgery, and I’m acutely aware that these might be the last opportunities for a long time that any of us students get to see such a wide variety of disciplines.

One big surprise of this block was that, interestingly, it contains a lot less exposure to actual operations than I initially expected. This kind of makes sense, however. I guess that a lot of what we as students and foundation doctors have to know has far less to do with actual surgery and far more with knowing about conditions that would cause an operation to be necessary (and there are plenty), how to assess a patient immediately before an operation, how to treat them afterwards, and of course the anaesthesia care before, during and after as well. I don’t think foundation-year doctors even make it into theatre for operations, so that realm is basically reserved for registrars and consultants. Even though I found surgery really interesting to watch, I’m glad to have had the opportunity to gain knowledge in other related areas too as it feels much more relevant to our education at this level.

Soon we will be starting the acute block, which means that our seventh – and penultimate – block will begin. A new cohort of medical students (I remember when we were that young and excited!) will be starting and we’ll now be top of the heap. I’ve been interested in emergency medicine for a while, so this block is really exciting to me. Although we have our fair share of overnight and odd-hours shifts, I think it will be really accurate and a good opportunity for us to understand what emergency medicine is like – plus I want to see if it really is like 24 Hours in A&E! I am very excited about this next block and anticipate a lot of excitement.

September 21, 2017

Spending time in clinics!

Well, the pace of the fourth year hasn’t slackened at all, and things have picked right back up after our summer break. I’m still really enjoying the Care of the Surgical Patient block and am learning loads at the same time. I’m not only spending time in the theatres and on ward rounds, but also attend my fair share of clinics. A clinic is (usually) a half-day session where the doctor has appointments to meet patients alone in a treatment room and discuss their condition. Clinic appointments can be either new referrals or follow-ups; the nature of the follow-up appointments varies depending on the discipline. Some people with lifelong chronic conditions will check in with their doctor every six months or every year or something. But others, for instance after surgery or a broken bone, will come in for a meeting just to make sure that everything is OK before being discharged.

I like the nature of clinics and find them very useful to attend. It’s much easier for me to remember details of a condition when I can attach a person’s name and face to it. I can almost walk through the consultation in my head after the fact, which helps me remember investigations and management. You’re not guaranteed to see everything in a clinic, but you’ll definitely see more by attending than if you don’t go at all, and that’s what I like about them. In this block, we have the opportunity to attend a great deal of post-surgery clinics and some pre-surgery clinics as well – including vascular clinics (lots of foot ulcers and artery blockage), colorectal clinics, ENT (ear, nose and throat) clinics, breast clinics, urology clinics and more. It’s great that the organisers of the block are giving us so much of an opportunity to take advantage of what our huge hospital has to offer.

In addition to a main surgical consultant, we are also assigned to an anaesthetist (or two…) for the block and are given a lot of anaesthetics training and tutorials. I have had the privilege of spending some time in theatre with my assigned anaesthetist and have learned a great deal about the science of anaesthetics and how a lot of our physiology needs to be taken into account when anaesthetists do their jobs. It’s not all about making people unconscious and then waking them back up – so many things need to be monitored and kept within safe ranges whilst a patient is being operated on. The list of things to monitor and that can go wrong is really endless.

I recently saw an operation on a patient who was having an adrenal tumour removed; an excess level of adrenaline and related hormones were being released by the adrenal gland directly into the patient’s bloodstream. So before the gland was removed, the anaesthetist had to administer drugs to counteract the effects of the adrenaline: the patient’s heart rate and blood pressure had to be brought down and kept within safe ranges to avoid the effects of high blood pressure. But – and this is where teamwork with the surgeons comes in – as soon as the gland was removed (and ideally a few minutes before), supplementary adrenaline had to be given for a while to counteract for the sudden deficit that the patient’s body was now experiencing. Watching the physiology literally in action was absolutely fascinating and an extremely worthwhile use of my time. I cannot wait to see more!

September 12, 2017

In Demand…

Having started my acute block on the acute medical wards, clerking relatively stable patients, I have spent the last two weeks on the Intensive care unit (ITU) and in A&E where stable is not a word used to describe many of the patients!

The ward round in ITU was one of most fascinating ward rounds I’ve been on as a medical student, many of the conditions you read about as a medical student thinking you will never actually see were there, as well as patients recovering from major traumas with multiple injuries. On ITU patients conditions aren’t just identified and treated, patients are only on ITU if one or more of their organ systems need support. That might be blood pressure supporting drugs in the case of a patient with life threatening sepsis or in more severe cases patients may require multi-organ support, for example, dialysis for kidney failure as well as mechanical ventilation to allow them to breathe. Patients in ITU have 1:1 nursing and are constantly monitored, as such a stay on ITU is very expensive and there are only so many beds, dictated by the number of staff available. ITU beds are in high demand; deteriorating patients around the hospital are referred to the ITU registrar who can then discuss potential new admissions with the consultant. In addition as UHCW is a major trauma centre there is also the possibility of a major trauma arriving that may require admission. Deciding who to admit to ITU is a murky area with no strict rules; does the patient need organ support right now, are they likely to survive even with ITU support? Unfortunately using a crystal ball isn’t an option.

Patients often get referred to ITU from A&E and while it’s much easier for patients to get through the doors of A&E, demand is so high that getting a cubicle to actually assess a patient is not so easy. In just a handful of A&E shifts I’ve seen queues of patients on ambulance trolleys, paramedics waiting to handover their patients to the nurse in charge while the nurse is frantically trying to find a space. Reading about this in the newspapers is disheartening but actually seeing it is shocking. Demand is so high and while some A&E attendances are inappropriate the vast majority aren’t and need to be seen. It was nice to feel useful as a medical student in A&E by helping the doctors clerk patients, take bloods and insert cannulas (my success rate has now improved to 50:50-good for me, maybe not so good for the poor patients!). Seeing a wide variety of presenting complaints was really interesting and used lots of different skills. In Minors I saw lively children injured in various trampolining /climbing incidents, a few sports injuries ranging from badly sprained ankles to fractured bones and even a builder with a chemical injury to the eye. In majors I saw first-hand what happens when social care fails our elderly patients, patients discharged from hospital one day and then back again the next. I was able to observe the treatment of an acute asthma attack, something which can be quite scary but didn’t seem to fluster the experienced A&E consultant. I was also excited to be asked to see a patient had been referred urgently by their GP for a possible stroke, which I correctly identified as Bell’s palsy-a relatively benign condition that will improve in time on its own.

I don’t think there is ever a dull shift in A&E and despite some of the problems with the system it was inspiring to see the Nurses and Doctors in A&E working as a team-and actually feeling like I was a contributing member of that team! I have more A&E shifts over the final two weeks of this block, here’s hoping my cannula success rate improves!