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Clinics - Making the most of it

Written by James Wong · Friday 21st March 2014

Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it?

The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed.

Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history.

Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors.

So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take.

Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck.

This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.