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Having spent two years in hours of lectures and being drowned in dissertation, starting clinical blocks couldn’t have come sooner for me - it was definitely about time! That doesn’t mean to say that it didn’t take time to adjust and get into the swing of things during clinicals, though. It was quite a bewildering experience to start with; the masses we still had to learn became very apparent very quickly - but being involved in a practical environment was still a welcome change.
Clinical medicine is a really different kettle of fish compared to what we are used to and comfortable with in pre-clinicals. Over your clinical years, you will be sitting in on outpatient clinics, helping the junior doctors on the wards, taking histories and examining in-patients, practising clinical skills, sitting in teaching sessions (like lectures) and scrubbing up to observe and assist in theatres. It does take some time getting into and it’s okay to spend the first few weeks just getting used to it all - don’t worry if you feel like this is a slow process.
You will likely be given a timetable by your site coordinator of everything that is going on in that department on a weekly basis, listing all the possible ward rounds, clinics, teachings and theatre sessions that you could possibly go to. I found this really daunting at the start because we are so used to being spoon-fed specific timetables during pre-clinical lectures; where we were always told when and where to go!
It took a while to establish that it definitely is more of a self-learning experience where you can ‘make’ your timetable by going to a variety of different sessions in that department per week. You may have to may a minimum of a certain number of clinics or theatre sessions so make sure you know what’s expected of you. You’ll also have some lectures, ward-based teaching and clinical skills sessions that will be timetabled in for you. You’ll be assigned a consultant who has overall responsibility for signing you off; it helps to meet with them (with the help of their secretary) at the start of the placement to introduce yourself and do some expectation-setting, some consultants expect you to be shadowing their every move whereas most are more than accepting that you have other teachings and sessions on your plate and are happy to see you in their clinics and theatres when you get the chance. Google Calendar is a godsend.
For your first year of clinicals the most important thing is probably to get used to the process of history taking and getting comfortable talking to patients. I used to find that when I took my first few histories I was spending so much brain power trying to remember what question comes next that I would often end up forgetting what the patient had already said and found it hard to actually listen. Learn the structure of your history (PC, HPC, PMH, PSH, DH, FH, SH) off by heart and practice writing the headings out on a grid time and time again so that you’re not wasting time thinking about the structure. Have some ‘exploding symptoms’ in your mind; e.g. if they complain of cough explode this: what type of cough, what brings it on, is it dry or wet, do they bring up mucus, what colour, is there any blood, any associated symptoms? After a few, it will become second nature. Your second year of clinicals can then focus more on practical skills, thinking of investigations for your differentials and focussing more on what the doctor actually does and why.
The wards can be an initially intimidating place. It helps to go on in pairs to begin with and introduce yourself to the nurses who are often great at helping you feel welcome and will show you to the doctors office where you can introduce yourself to the junior doctors. They were in your shoes once and remember what it’s like. Ask them for patients who would be willing to have a chat with you about how they ended up in hospital and practice taking a proper structured history and examining. The important thing is to make sure you practice presenting that history - it’s a skill in itself and isn’t to be underestimated!
It takes a while to figure out how to get the most out of a ward round. Once you’ve tagged along on a few (and felt utterly and completely lost with all the medical jargon, running around and drowning in abbreviations), you will eventually get the hang of what’s going on and can offer to help the junior doctor update the patients’ notes as you’re going along. At the end of the ward round, hang about and ask the junior doctor if there are any jobs you can help with e.g. taking blood or cannulas (if you’ve practised on a model a few times it helps to actively seek out opportunities to practice these on real patients under close supervision).
It’s easy to feel like a bit of a spare part on the wards or if they are extremely busy, it might be hard to find the opportunity to break into your team to ask for things to do, jobs or teaching. If the wards aren’t giving you too much to do, you can always wander down to outpatients clinic and see if there are any free for you to sit in on. You can often build a good rapport with the consultant and their junior and clinics are sometimes good opportunities to observe communication skills and explanation skills of that particular specialty.
If you are keen on the surgical environment, heading down to theatre will provide you with some good experiences to get involved. Head down to theatre reception the day before to get the list of patients of that specialty for the next day, ask which pre-op ward the patients will be coming into in the morning and note down the operations. Have a quick read up on them and the relevant anatomy that evening, then head to the pre-op ward the following morning to have a quick chat to the patients to consent and take a brief history. Then head down to theatres, get changed and introduce yourself to the scrub nurses, anaesthetists and surgeons. Theatre can be a formidable environment but if you are keen and ask questions politely at appropriate times most staff are more than happy to help. After observing for a while, someone helpful may show you how to get scrubbed and you’ll be able to get a closer view and even assist in some cases.
In the often very chaotic and disorganised world of clinical medicine, it helps to have some structure of your own. If you know you need cannulas and bloods for your logbook, go out on the wards looking for them. If you know you need 6 clinics during the block for a sign off, plan these out. For each specialty/placement, know what you are expected to know. Your medical school will probably provide you with a list of learning objectives. Plan these out according to the weeks of your placement so that you have something on your mind to focus on during the block in terms of studying. Good resources include pathophysiology videos on YouTube for some basic understanding of conditions, then textbooks like ‘Crash Course’ or the ‘At a Glance’ series which are brilliant for being concise; all you need to do is annotate them with the knowledge you’ve gained from clinicals that day and this can replace the need to spend hours and hours making your own notes.
Clinicals are often relentlessly long days and definitely require big snackage… and that ten extra minutes you save making your lunch the night before are so much more precious the next morning!
Good luck for your clinical placements!
For study advice: check out my top ten tips out here [https://www.bma.org.uk/connecting-doctors/community_focus/f/51/t/1713]
Deputy Chair BMA Medical Students Committee (welfare lead)
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Do you have any tips for making notes when on clinical placements? I am a physiotherapist in training so a slightly different profession. I find myself sitting in the clinic observing mostly with a note pad. If I have questions I jot them down but apart from this I find that my use of the pen and paper tool is not being used to its full potential.
How should I structure my notes best so that when I look back at them after the placement they will be useful and make sense?
Hi, in answer to your question I can suggest using flash cards whilst on clinical placement. E.g. when in a respiratory clinic, make a flash card (anonymised) on each new patient you see walking in with their presenting complaint and any new learning points. By the end of the clinic you will have a few flash cards on each condition that you can then file away with your respiratory notes. I hope that helps;
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