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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!

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!

September 01, 2017

Finals countdown…

After a relaxing two week break I have emerged from my chrysalis as a fully-fledged final year medical student. Do I feel any different? Do I look any different? People certainly seem to be treating me differently, all the focus is now on job applications in October and final exams in February next year. Doctors teaching us in hospitals have high expectations and seeing students from the year above us now working as FY1 Doctors is inspiring fear rather than confidence! I don’t think I have felt this nervous since freshers week, nervous feelings about the task ahead have resurfaced now that my ambition to become a Doctor is almost a reality, with a few final hurdles to overcome.

I embark on my final year by starting on my Acute Medicine block. This block is split between UHCW in Coventry and Warwick hospital. We spend time in the emergency department and the acute medical wards, doing a variety of shifts so we can see as many patients as possible. I’ve spent the first two weeks of the block on the acute medical wards at UHCW. These are interesting places to be as a student as you get to see lots of patients presenting with common medical problems that will come up in finals. Patients are clerked in A&E and once its decided that they are stable and need medical treatment as an inpatient or are waiting the results of investigations they come to the Acute medical ward (AMU) at UHCW. The doctors on AMU then clerk the patient and then arrange or follow up investigations and start treatment. There is a huge variety of patients on AMU at any one time. Patients may have come in with chest pain and shortness of breath so things like heart attack or pulmonary embolism need to be ruled out even if you suspect a chest infection. Some patients may need to be admitted under a particular medical specialty and will move once a bed becomes available and for others they can stay on AMU and leave after a few days of treatment. As a student you can clerk patients, help take bloods, insert cannulas and attend ward rounds and because its AMU, every day there are new patients to figure out.

Another area we have been assigned to is the Medical decisions unit (MDU), where patients are referred in by their GP for tests or treatment only available in hospital. These patients are usually not acutely unwell or unstable but they have presented with a problem that could be serious. For example if a patient presents to their GP with central chest pain that came on after eating a large meal, the GP simply doesn’t have the tests available in the community to rule in or rule out a heart attack even if it sounds like heartburn, that patient needs to come to hospital for further tests but they don’t necessarily need to come in an ambulance and wait for several hours in A&E. In MDU the tests can be done quickly and so patients can either be reassured confidently or brought in for further treatment. MDU is one of my favourite places to be as a medical student and it is great practice for finals. You can take a fresh history and examine the new patients and decide what your differential diagnosis is and what tests you want to do and then present it to one of the junior doctors who will agree (or disagree!) with you and who can organise the appropriate tests. Over the course of your shift you can chase up the results and actually find out if you were right and can decide on the management with the juniors and consultants. It’s a great chance to present cases to seniors and get feedback on your clinical reasoning skills and management.

Aside from getting to grips with the acute block I have also made a revision planner for finals, having the next 20 weeks before my first exam planned out and stuck to my study wall is terrifying! Hopefully when I start my A&E shifts next week that will provide a welcome distraction from my revision planner and the countdown to finals!

August 31, 2017

Care of the Surgical Patient – and the Beginning of Year Four

When I first became a medical student, being a fourth-year student seemed such a distant place to be. Before getting there, we had lectures to sit through, ward rounds to attend, and – who can forget? – exams to pass. I used to look in awe at the fourth-years I knew and think, “Wow – they must know so much. I wonder how I’ll ever learn enough to make it into the fourth year.” Well, odd as it may seem, last week we started our fourth year – it’s a bit anti-climactic, however, as it’s really a continuation of what we’ve been doing in the third year. Nevertheless, it’s hard to believe that I’m in that position now. I certainly don’t feel as confident and knowledgeable as those fourth-years seemed to me, way back when. But maybe I just don’t realise how much I’ve actually learned in the intervening three years. I’ll have to wait and see how I do on finals!

Along with our fourth year of medical school, we have also just started our sixth Specialist Clinical Placement block – this one is the CSP block (Care of the Surgical Patient). I’m thrilled about it for a couple of reasons. First, my clinical partner and I are at the largest of our teaching hospitals. I am taking full advantage of the huge variety of cases and the opportunities for teaching that are sometimes present at smaller hospitals but are definitely routinely present at ours. There’s just so much going on here. Second, I’m teamed up with a vascular-surgery team for most of this block. In previous blocks, I’ve spent time in orthopaedic surgery, colorectal surgery, urological surgery, gynaelogical surgery and loads of other disciplines, but I’ve never actually spent time watching operations on blood vessels, so this is an area entirely new to me.

So far, it’s been really interesting. I thought a lot of vascular surgery was occupied with conducting bypass operations, but there’s so much more to it than that! A lot of the patients we’re treating are elderly people who have diabetes and/or a smoking history, as these are two of the many risk factors for peripheral vascular disease. The issues that the surgery team deal with are much more varied than I expected: there are lots of bypass operations, some toe/limb amputations, a lot of wound debridement (removing dead tissue from wounds that have not healed fully) and lots of other things that you probably wouldn’t discuss over the dinner table with your mother – unless she is a vascular surgeon. Let’s just say there’s more gangrene than I expected.

And of course, although we’ve had our fair share of shadowing operations (I even got to make a stitch the other day!), there’s much more to the CSP block than just time spent in theatre. We have post-take ward rounds, clinics and lots and lots of teaching around surgery-related topics. We’ve had anaesthetics sessions, suturing workshops, teaching on wound dressing and care, and many other topics. I wasn’t too keen on a career in surgery before coming into this block, but who knows? There’s still time to change my mind!

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August 10, 2017

End of third year…

If I close my eyes I can still picture the second year exam pass list, seeing my name there and relief flooding over me, it feels like only yesterday. Since then I’ve started and completed a research project (student selected component 2), had a refresher course of hospital life (advanced cases 2) and had five of my speciality clinical placements. So far I’ve completed 6 week blocks in General practice, Child health, Obstetrics and Gynaecology, Care of the Medical patient and Care of the Surgical patient. There are no exams in third year (phew!) so the main thing to worry about is making sure you have submitted all the correct forms and assessments for every block on your e-portfolio.

It’s been a busy year since we started our speciality placements in January and I’m really looking forward to a break, every block has had its good and bad points, but all have been enjoyable and interesting in different ways. In General practice it was a great confidence boost to be able to conduct entire consultations on our own for the first time. In both child health and O&G we were exposed to a lot of intense emotions from both the patients and staff, helping care for sick children is about reassuring and supporting parents as well as providing medical care for their child and in O&G caring for the same patient over the course of a long labour is stressful for everyone involved. Care of the medical patient wasn’t just about the theory, our consultant always made us think about the person behind the disease and the effect on their life. Care of the surgical patient has been about when not to operate just as much as any of the surgical procedures, something which surprised me!

Learning when to intervene or not is a huge part of medicine but I suppose in surgery it is vital to ensure that if an operation is performed it is for the right reasons. The last two weeks of my surgery block at George Elliot hospital have been with a Breast Surgeon. The breast clinic is a one-stop clinic, patients are examined and can also have a mammogram and ultrasound of the breast and get the results on the same day. This means lots of patients can be reassured and others can be referred quickly for further investigations. A lot of the results are then discussed at the breast surgery multidisciplinary team meeting where histo-pathologists, oncologists and surgeons, radiologists and nurses all decide together the best course of treatment for patients. In some cases it could be a simple benign lump that needs no further treatment, or in others it could involve deciding what type of surgery or systemic treatment is required for a cancer. It’s great to see how these complex decisions are made as a medical student, I’ve certainly learnt not to believe everything I watch in Greys Anatomy!

Following our break I come back to the acute medicine block. I’ll be working evenings and nights in A&E as part of the team. This will be followed by the Psychiatry and Musculoskeletal blocks. During this time I will also apply for my foundation doctor jobs (i.e. decide where I want to live!) and sit the situational judgement test, which plays a huge part in what job I will get. It’s going to be a busy autumn for me but what’s important now is that I have 2 weeks off, time to relax, ready to come back as a final year medical student.


August 08, 2017

Time flies…

Now that we've finished the Care of the Medical Patient block, our fifth six-week block in a row in 2017, we finally have a couple of weeks off to relax and re-charge our batteries. This is our official Summer Vacation. I worked for many years in the private sector before coming to medical school, but this thirty-week stretch in Phase III with only (three) bank holidays off is the longest I have ever done without a break in my professional life. I really hope that it's worth it in the end! I'm relaxing and not doing much and in between the lie-ins and catching up with old friends, I'm taking my time filling in the gaps in my notes from some of the earlier blocks. I'd rather do it now than spending time panicking over Christmas.

Slightly more alarming is the fact that we're now the oldest cohort at Warwick Medical School. When did this happen? It feels like we had our induction week just last month, but now we're just weeks away from yet another cohort starting. And the people who have been just one year ahead of us the whole way through the course have now got their degrees and are now actual, real-life F1s in hospitals up and down the country. It's wonderful, inspiring and more than a little daunting that this will almost certainly be us in a year's time. I have faith that we'll be fine, though. The environment for junior doctors to learn is very supportive, and the medical school has trained us well in what to expect.

When we start back, we'll be on the Care of the Surgical Patient block, which is intended to teach us as medical students everything we need to know for a firm basis in surgery and anaesthetics. I'm actually really excited - it's not a part of medicine I know much about from a practical standpoint. We've observed lots of operations and procedures but our (minimal) involvement up to this point has been on an ad hoc basis from consultants who kindly ask us to scrub in; this is rare. I hope in this block we will get a much better, hands-on view of what surgery actually entails. I believe that every foundation doctor is required to do at least one surgical rotation (although don't quote me) so this will be excellent practical backing.

For the rest of my break, however, I'm going to concentrate a little more heavily on the 'life' part of my work-life balance. This will be the last time before final exams that I get to relax and have a lie-in occasionally (or frequently)! I'd be lying, however, if I said that I wasn't revising a little bit at times. There is so much information to learn, and I cannot afford to forget any of it. But maybe I'll think more about it after I wake up from my nap!


July 31, 2017

Perks of the job…

Being a graduate entry medical student is pretty tough, hours are long and the work never really ends so feelings of guilt are always present, having said that studying medicine is a real privilege and there are some excellent perks…you just have to know where to look for them! One of the perks of being a medical student is the opportunity to go to conferences. There are always bursaries and prizes available for medical students to attend conferences. At the start of third year all students must complete a research project and lots of my colleagues have been able to present their work at conferences. Some around the UK, to exotic places like Newcastle, and others have gone a bit further afield to present at conferences in Canada! Presenting an oral or poster presentation at a conference not only looks great on your CV but is a great opportunity to network with other students and doctors who share your interests.

This year I’ve had the chance to present my work on a medical education course for students at a regional medical education conference. This was not only great practice at delivering oral presentations but I got to meet lots of people interested in medical education. Many of the attendees were clinicians who also worked in medical education, I was able to quiz them about their jobs and how they got into their roles over coffee. I was also able to get to know senior members of the medical school better and understand what it’s like to work in management roles within a large medical school. The most recent conference I had the opportunity to attend was the International Congress for the Royal College of Psychiatrists which took place in Edinburgh. Although I wasn’t presenting at this conference I was able to attend fully funded as I had successfully applied for a fellowship from the RCPSYCH that supports students interested in psychiatry for 3 years, and as part of this you can go to the annual conference for the duration of your award! Being able to attend such a large conference was really exciting but also quite daunting. I took the opportunity to attend sessions on topics that I’m particularly interested in such as perinatal mental health, getting into research and improving medical education and recruitment to psychiatry. In between sessions I met lots of other medical students as well as psychiatry trainees in a special refreshment area reserved for Students and Trainees- a very friendly and welcoming place to enjoy the free conference food!  I was introduced to the Chair of the Psychiatry Trainees committee and learnt about opportunities to get involved in this in the future. I also made contacts with people in Warwickshire who I could get additional clinical experience with in sub specialities like Forensic psychiatry.

I’m looking forward to attending the conference again in the future and been able to present some of my work that my fellowship is supporting me with as part of my elective project. The medical student elective is another major perk of medicine-6 weeks to go and experience medicine in any part of the world! Our elective takes place after final exams in March/April and I’m hoping to go to Ethiopia and conduct a research project in perinatal mental health. We had to submit our proposals for approval last week so fingers crossed it will all be approved and I’ll be off to Africa! Medicine isn’t all that bad after all!


July 27, 2017

Coming to the End of Year Three

Starting the Care of the Medical Patient block felt like staring into the great unknown – how could we possibly cover all of this information in just six weeks?! – but it’s actually been great, if hard work. I’ve seen so much – it feels like all of medicine compressed into one six-week period and it’s hard to believe it’s almost over. It feels like a whirlwind tour!

Despite the time constraints of the block, however, our tutors have put a lot of thought into our timetable and, whilst it’s very broad in its focus, sometimes it feels like we’re jumping around a lot. I guess this is what being an F1 on A&E feels like! For instance, it’s not rare at all to spend the morning on an endocrine ward, have haematology teaching at lunchtime and then spend the afternoon in a neurology clinic! But thankfully we have developed a very strong base on core medicine in the second year – our hard work in Core Clinical Education is paying off – and so this block is allowing us to build on that.

I spent some time last week in an oncology clinic. I’d somehow never been to one before and it was really interesting. All of the patients were follow-up patients, so I was not present for any new diagnosis or any situations in which bad news was broken – but of course that’s not all that medicine is about. We spoke a lot about follow-ups and ongoing treatment and how different upper-GI cancers can present. I got to hear about a really uncommon presentation over the phone (as my consultant was also on call) and we saw the patient’s scans on the internal imaging system. The patient’s superior vena cava had been almost completely occluded by an undetected growth just under the sternum, which was detected incidentally after imaging for a different problem – this is apparently very rare and everyone got very excited by this. How interesting to see!

One of the other timetabled sessions last week gave us the opportunity to follow the Diabetes Specialist Nurses around the hospital. As med students and future junior doctors we don’t interact much with Specialist Nurses on a day-to-day basis (at least at the hospital where I am, they tend to move between wards), so this was a great opportunity to see healthcare from the shoes of people whose roles were slightly different to ours. We went on a massive, great ward round around the entire hospital, seeing diabetic patients and making sure that they were all supported in their needs. Some were newly diagnosed and some had lived with the condition for years, but the Specialist Nurses gave them excellent support; I was really amazed how well-versed they were and the strength of the rapport they had built up with their patients across the entire hospital.

We’ve not got much time left but I feel like we’ve got loads out of this block. And even though we had CCE in the second half of year two, all of the knowledge from that 30-week chunk has created a very strong base for this block. I’m really glad we did it as we did. And when this block ends, so will our third year! I just cannot believe that we’re almost fourth-years. This sounds so terrifyingly old. In the meantime, I’ll just concentrate on enjoying my summer vacation.


July 21, 2017

Scrubbed up…

It’s now Specialist placement 5, the last block of year 3, and for me it’s my care of the surgical patient block. Despite all those years watching Grey’s Anatomy I’m not particularly interested in surgery and have spent most of my time in theatres so far thinking about lunch or how much my feet hurt! At the start of the surgical block I was definitely less than enthused and thinking more about my upcoming holiday in august than the anatomy of the abdominal wall, but I must say I have been pleasantly surprised!

I’m based at George Elliot, which is a small district hospital. Over the 6 weeks we rotate round 3 different surgical specialities: Urology, Colorectal and Breast Surgery. I’ve been with urology for my first 2 weeks, learning about different types of disease that can affect the prostate, bladder or kidneys that may require surgical intervention rather than medical intervention from the nephrologists. Clinics in urology are really varied; there is some overlap with gynaecology in women suffering from incontinence due to pelvic floor damage and there are lots of patients referred through the fast track system for worrying symptoms such as blood in the urine. Learning about the different investigations for these patients was something we covered last year but this year there is more focus on learning about the surgical management options, and how you decide which is best. Being able to get scrubbed up in surgeries means you can get much closer to the action and see the anatomical structures, and really appreciate the complexity of some of the operations. One operation to remove a patients kidney that had a tumour, lasted 6 hours, watching the surgeons avoid major blood vessels and control bleeding as they dissected the large tumour was fascinating. In contrast, another operation I observed was to remove a bladder tumour, which took less than half an hour-but to the patient these are both major, life saving operations.

As well as spending time in clinic and in theatres with the surgeons and anaesthetists we have also spent time with the junior members of the team while they are on call. The surgical senior house officer (not an FY1 but not a registrar yet) carries a bleep and sees all new patients that come into A&E or are referred by GP’s who may need to see a surgeon. This was a great opportunity for my clinical partner and I to take the history, examine the patient, come up with our differential diagnosis and decide what investigations we would want. The SHO was brilliant and gave us really useful feedback and helped us understand things we might have missed and importantly asked us to justify our investigations, something we have to do in our exams!

So 2 weeks in and I fairly sure I still won’t ever be a surgeon but so far I’ve learnt lots, which is always good with the prospect of 4th year approaching, and as an added bonus I haven’t fainted in theatres (yet)-win win!


The Broad Church of the CMP Block

It’s hard to believe, but we have passed the halfway point in our Specialist Clinical Placement (SCP) blocks, although I wouldn’t yet say that the end is in sight yet! Our fifth, and current, block is called “Care of the Medical Patient” (CMP) and is the block with the broadest focus yet. The purpose of this block seems to be to cover the general-medicine topics that we don’t see in a lot of our other blocks. For instance, we’ve already had blocks covering musculoskeletal health, paediatrics and obstetrics & gynaecology, all of which are very focused in nature. This block is much broader in approach, and the hospital where we are working has done a very good job of distributing us very widely across multiple disciplines.

What I’m really liking about this block is that we are exposed to a lot of topics in more detail than we ever were in Core Clinical Education (the latter two-thirds of Phase II). It’s great, and I’m really glad that (finally) so much of my work in Phase II seems to be bearing fruit. For instance, we are getting focused haematology teaching for the first time – so we are learning about lymphomas and leukaemias, factor deficiencies and all sorts of stuff that we briefly skimmed over last year. And the best part is that now we get to go to clinics and see patients in the flesh who live with these conditions. I learn best when there is an actual human being with whom I can associate a particular condition. It just helps tremendously when I can picture a patient in my mind to recall presentation, examination and treatment. As a case in point, I feel much more comfortable with lymphomas and leukaemias than I did before starting this block.

For my first placement in the first CCE block of Phase II, I spent about ten weeks on a respiratory ward at a local hospital. At this point, I had been a medical student for about fifteen months. It seems so very long ago now! This was probably my favourite placement, and I really felt at home in this learning environment. I was lucky enough to spend another day in a respiratory ward again just this past week, and it reminded me of how much I liked it. The presentations were fairly common (exacerbations of COPD, advanced pneumonia, bronchial carcinoma, etc.) but it was great to come back to a respiratory setting with a lot more experience under my belt. I felt much more comfortable working with the doctors and nurses and also felt much more comfortable understanding which investigations were being done and way. I hope to see more respiratory medicine in the future.

I have also spent some time observing neurology clinics for the first time; this was another area in which I had read a great deal but had seen hardly any patients. Now I can confidently say that I have seen and can hopefully recognise cases of myasthenia gravis, epilepsy, early-stage Parkinson’s disease, multiple sclerosis and many other common neurological conditions. Attending neurology clinics definitely brought more than one flashback to Block 3 of Year 1 (Brain and Behaviour), especially the direct and indirect pathways for movement regulation and how they can become inhibited. Thankfully I didn’t have to worry much about the various tracts that go up and down the spinal cord – that’s a headache for another day!


July 05, 2017

Fly on the wall

As a medical student, I spend a lot of my time hovering awkwardly behind consultants and other doctors as they see patients on the ward. In clinics, myself and my clinical partner are also squeezed into the room, often sat across from the patient, it feels like a follow up appointment in the form of a panel interview! I am always so grateful to patients and their relatives who are happy to put up with a committee of people on ward rounds and very crowded clinic rooms all so we can learn. I have been even more grateful over the last few weeks during my care of the medical patient block to patients and their families who have allowed me to sit in on clinics where doctors are regularly breaking bad news: the oncology clinics.

Cancer biology was not my strongest subject during my biomedical science undergraduate degree but in medicine it’s not just the underlying cellular and molecular biology that’s important, we need to know all the clinical manifestations so we can diagnose cancer, when to refer and what investigations are needed. So, in this block I decided to make a concerted effort to try and improve my clinical knowledge of both the diagnosis and investigation of cancer and of oncology as a speciality.

One of the clinics I attended was a fast track clinic for suspected lung cancer. GP’s can refer patients with symptoms or signs indicative of lung cancer and they will be seen in hospital within 2 weeks. Patients attending this clinic have often had a chest X ray and in some cases a CT scan before they attend so the consultant can in either reassure the patient or show the patient where the problem is that they need additional information from, perhaps in the form of a biopsy or a different scan. What struck me most in this clinic was the number of patients who were told that they had a suspicious mass in their lung but decided not to have further investigations, many were elderly and were quite clear that they didn’t want to undergo any further procedures. Having these conversations requires a very sensitive and perceptive type of doctor and is a very different type of medicine to what medical students probably envisioned before medical school.

Attending the oncology clinics, patients already knew they had a diagnosis of cancer but often didn’t know what treatment if any was available. These appointments lasted up to an hour and the doctors were clear that the appointment lasted until the patient wanted to leave, they encouraged questions from the patient and their family, and took the time to explain things multiple times. They comforted patients and relatives as they cried at the prognosis and then did it all again for the next patient.

All the time I’m sat in the room, a fly on the wall, observing how the doctor handles the different consultations, learning how they manage these complex patients, but all the while I’m trying my best to not get emotional too and reminding myself that it is a real privilege to be invited into people’s lives to experience their best and their worst times.