Third Year Guide

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THIRD YEAR GUIDE

Introduction
Congratulations and welcome to Phase 2!! You have officially survived your first 2 years of medical school and have endured the many lectures, tutorials and assessments of Phase 1. You should be proud of yourself! It’s now time to put all that fresh scientific knowledge and your rudimentary clinical skills to the test in the hospital. It’s fair to say that starting third year is one of the biggest changes you will encounter in medical school. Having to quickly adjust to a new environment, plus develop a new way of learning makes third year perhaps more challenging than your previous 2 years at BSMS. You are bound to be nervous about this change, but just remember all your peers will be feeling exactly the same. Most students worry about whether they will be able to acquire the sheer amount of knowledge thrown at them during third year. Although there is undeniably a lot to learn, you must remember that the aim of third year is to have a breadth of knowledge not depth of knowledge! Despite the nerves, third year will come as a long-awaited breath of fresh air for many students. It’s the pivotal moment where you really start to feel like a doctor…so embrace every minute and enjoy it!

  • General Tips - Be organised from day one of your first rotation (placement block) - Gone are the days where you can rely on your mates to tell you what is happening in the week! Unlike Phase 1, each student pretty much has a unique set of timetables for the different modules of year 3. Some of your friends may be on different rotations or wards to you, therefore it is important to be organised yourself. The best way to do this is to buy a diary and make a note of where you are meant to be during the week. By writing your own master timetable which brings together all your modules, you avoid having to look at several documents at once which can make things confusing. At the start of each rotation spend some time in the library looking for books that may help you with that rotation. There is no point getting books for future rotations…you will only make life harder and more stressful for yourself!
  • Prioritise your workload - From essays to organising group presentations, you will always have something to do when you return home from the hospital! It is very easy to spend an evening relaxing and going over a couple of lectures from the comfort of your bed after a long day in the hospital instead of starting that dreaded SBM essay; however, it’s important to do assignments with deadlines early, as leaving things to the last minute will interfere with preparation for your CbDs (see below) or your summer exams. Going through the notes that you have taken whilst in the hospital, reading books, or going through lecture slides may not always be a top priority!
  • Don’t be afraid to ask for help - There will come a time during the year when you may be unsure about something you hear on the wards or in a lecture. Whether you are sitting in clinic or attending a ward round, it is best to clarify something you don’t understand sooner rather than later. You are more likely to remember the consultant’s explanation of a procedure or a condition when you are in the clinical situation. It may not always be possible to get the consultant you are shadowing to explain everything to you, especially if it is a busy clinic or a long morning ward round. Therefore, try making a note of your question and ask other members of the clinical team such as the junior doctors or nurses to help you. It is also worth going through difficult concepts with your friends. Additionally, your Clinical Academic Tutor (CAT), module leaders and the student support team can help you with issues that may not just be work related. Remember you are only a third year student…no one expects you to know everything. Never suffer in silence!
  • Be professional - You are essentially a part of the clinical team once you start on the wards. This means it is important to behave well around patients and other members of staff. Being polite and treating everyone equally is vital and will not go unnoticed.
  • Every day is a new day - Year 3 is a roller-coaster ride. There will be days where you will tell yourself “why did I ever consider doing medicine!” and there will be days where you feel absolutely amazing and see how rewarding medicine can be. Take every experience as a learning experience and take on board any form of criticism. You are at medical school to learn so don’t let the bad experiences bring you down.
  • Get enough sleep - The key to staying sane during third year is to know when to stop working. It is important to have some kind of interest outside of medicine that you can turn to when things are getting too overwhelming. It is natural to feel exhausted after a particularly long day, so you shouldn’t attempt to work excessively in the evening when you are feeling tired…let your body rest. If you need to sleep you should sleep! Try and get enough sleep in the evening otherwise you will struggle to concentrate the following day; also falling asleep on a ward round is just a little bit embarrassing! You should take it easy for most of the year…especially at the start of each rotation, otherwise you will burnout!

Clinical Foundation Course (CFC)

Year 3 starts with a 5 week course introducing you to clinical medicine as it is practised in secondary care. If you have ever had any previous work experience in secondary care, be prepared to be bombarded with those classic induction talks on fire safety, manual handling and infection control. You will also build on your clinical skills during this time, especially with regards to resuscitation and life support. Although there is no formal assessment in the form of a written exam at the end of the CFC, you will be expected to pass a 10 minute resuscitation scenario, for which you will receive lots of practice opportunities beforehand. The best way to prepare for the test is to go through one or two mock scenarios with your housemates the night before. It is also a good idea to get in touch with the phlebotomy team during the CFC. This is a great opportunity for you to practice venepuncture on actual patients several times in a supervised environment. This will give you the confidence to start taking blood on the wards within the first few weeks of your first rotation. You will have a lot of free time during the 5 weeks so enjoy it!! However, that 80% attendance rule applies…so avoid the lie-ins. The CFC continues with additional sessions on Wednesday and Friday afternoons during your first clinical rotation, with attendance being monitored at these sessions too.

Scientific Basis of Medicine

Every Wednesday morning is SBM day. It is the only day of the week where the whole year is together. The purpose of the SBM module is for you to build on your scientific knowledge from Phase 1. You will revisit a lot of the central themes that you learnt in first and second year, but in slightly more detail. SBM is taught in the form of lectures, so the best way to approach this module is to do whatever worked well for you in Phase 1. SBM can be broken down into four different parts - research methodology, immunology and genetics, pathology, and pharmacology and therapeutics. The module is assessed through three bits of coursework (i.e. three 2000 word scientific essays) and a short answer question paper which you will sit in summer. You will be required to write the 3 essays over the course of the year. Essay titles are based loosely around the topics taught during the SBM lectures. You will have the opportunity to select a title that interests you out of a choice of around 10 titles. It is worth choosing a topic you find both interesting and useful in terms of revising for the final SBM exam. You should aim to score above 12 in all your essays as this will take some pressure of the final SBM exam. The SBM short answer question paper consists of 30 x 3-mark compulsory questions based on any of the lectures taught on Wednesdays. It is therefore a good idea to dedicate one day of the week to go over the lectures covered during that week in order to stay on top of things!

Medicine

The medicine rotation lasts 10 weeks with teaching taking place daily, from Monday to Friday, excluding Wednesday mornings. The module is delivered in the Royal Sussex County Hospital (RSCH) and Princess Royal Hospital, Haywards Heath (PRH), with lectures and symposia based in the education centres of the two hospitals. During the rotation you will be required to attend several sessions which are outlined in your module logbook. Sessions will include morning ward rounds, outpatient clinics and carrying out histories/examinations in a supervised environment. Within the medicine rotation you will be allocated to a specific firm where you will spend the majority of your time. This for example may be a respiratory ward or an endocrine ward. The most important skill to refine during this rotation is your systems examinations (cardio, respiratory and GI). Practice these whenever you get the opportunity as it will put you in a better position when it comes to the OSCE. You should also become familiar with the red flag history taking questions to ask for common medical presenting complaints such as chest pain, shortness of breath, jaundice etc. Practice asking these questions to patients a bit every day as it will help you tremendously for the OSCE…seriously it will!! You will quickly notice your history taking develop to the standard required of year 3. A good time to take histories from scratch is during your allocated weekend on-take with the junior doctor. During this rotation you will also receive specific diabetes teaching. Diabetes is an important topic to get your head around, so make sure you attend your allocated sessions! In the final week of the rotation you are assessed in the form of a CbD (see below). You will also be required to submit your attendance and skills logbook. Medicine is a good rotation to refresh your knowledge from modules 103 and 104! In terms of reading material, the ‘Crash Course: General Medicine’ book will be helpful, along with the ‘Oxford Handbook of Clinical Medicine’. BMJ Best Practice is also a good resource…especially for CbD preparation.

Surgery

The surgery rotation is also 10 weeks long. You will be allocated to two surgical firms headed by a named consultant; one vascular firm and the other a digestive diseases firm. You will also spend some time in urology. Like medicine, you will take part in the day to day activity on the wards and in outpatients. You will also have the opportunity to watch and assist in surgery…take these opportunities when they come. It is also a good idea to try and assist in the surgery for your CbD patient if you can, as this will come across as a sign of genuine interest in the eyes of the examiners. Surgery is a great rotation to perform history taking on new admissions. You will also become familiar with the common surgical presentations very quickly if you attend all your allocated ward rounds. By knowing the common conditions you will be able to revise for the summer knowledge test more efficiently. One way to make the most out of the surgery module is to follow patients through from arriving at the theatre (or even from when they are on the ward, if you can) to leaving the department after the operation is complete. Again in terms of books, the ‘Crash Course: Surgery’ book is helpful. It is also worth learning all the symposia/lectures delivered during this module at some point, particularly the ones on pre- and post-operative complications, fluids/nutrition, and acute abdominal pain. These are popular topics that are always tested in some form i.e. during your CbD or in the knowledge test.

Elderly Medicine & Mental Health

Elderly medicine and mental health is split into 2 x 5 week blocks. The module will usually start with a block of lectures which cover most of the important conditions you will see during the module. Topics such as falls, stroke, delirium, Parkinson’s disease, heart failure, arrhythmias, and polypharmacy are areas you should know well in elderly medicine. For psychiatry, you should know about the mental health act, psychotic disorders, mood disorders, anxiety disorders, personality disorders, substance/alcohol misuse, and psycho-pharmacology in a fair amount of detail. The tricky part of psychiatry is that you are unlikely to come across a variety of conditions during your time at the mental health hospital. Therefore you should try and do a lot of reading outside of placement to make up for this. Mental health also plays quite a big role in the OSCE, as there are several possible stations that can come up. Being empathetic and non-judgemental is even more important in these stations!!

SSC

You will have 2 SSC’s in rotations 2 and 3 which will either be on a Wednesday or a Friday afternoon. This is a great chance to do something you are genuinely interested in. If you are thinking of intercalating, consider choosing something related to your desired course as this will strengthen your application. Like Phase 1, the SSC will most likely be assessed through an oral presentation or an essay. In addition to producing an assessed piece at the end of each SSC, you will also have to design a poster on ONE of your SSCs and present it at a ‘poster conference’ in the medical school towards the end of the year. You should aim to present your poster for approximately half of your 15 minute allocated slot in order to allow time for the examiners to ask you questions and confer. Practice presenting your poster with your housemates.

Case Based Discussion (CbD) Assessment

At the end of each rotation, you have a CbD assessment (two if you have done the elderly medicine and mental health module). This is where you present your OWN history and relevant examinations of a patient you have clerked during the rotation, as well as talk about the differential diagnoses, investigations and management plan. For your CbD, it is necessary to know your case inside-out, particularly when it comes to justifying the differential diagnoses you have made. When selecting your case for the CbD, try to choose something simple but interesting. Picking a patient with a complex rare disease is likely to be associated with unusual investigations and treatments which will make your justifications for differential diagnoses difficult. It’s also likely that patients with rare disease will be those that the consultant who will be examining you has been to see and will know the case well. This means, you cannot make a single mistake unless you wish your marks to suffer. Picking a simple/common condition is also helpful in terms of revising for your OSCE and KTs. However, If possible try to find a case with a bit of a twist as this will keep the examiners on their toes during your presentation.

You will be asked to have written your clerking (history and examination findings) and differential diagnoses on hospital paper. You should break up your history into the standardised format of basic demographics, presenting complaint, history of presenting complaint, past medical and surgical history, drug and allergy history, family history, and social history (format will slightly differ for mental health). You will usually have to present your case for 15-20 minutes (8 minutes for the double module) and then answer several questions from your examiners for the remaining time. As you’re presenting your case, act confident as if you were the FY1 doctor who saw the patient first. Try to use medical terminology as it shows that you have been turning up to hospital. Speaking clearly and looking at your examiners whilst presenting as opposed to reading of your notes comes across well…if you can, try memorising some of your history! The best time to find a case for medicine and surgery is during your on-take sessions or during the weekend. It is recommended that you find something suitable around weeks 4-6 of your rotation. You should then spend a good week and a half learning your case and the associated knowledge. Remember anything you write on your notes or anything you mention in your presentation is fair game for the examiners to ask questions on. The key to doing well in your CbDs is to know your case and to be able to justify everything you say accurately. Practice your CbD under exam conditions with your housemates and get them to ask you questions. Also, if you have time go over your CbD with one of the junior doctors on the ward.

Revision and Summer Exams (KTs & OSCE)
Studying medicine is not difficult with regards to the complexity of the subject matter; its difficulty lies in managing to learn the volume of information that is needed to become a safe and competent doctor. Thus in order to do well in the year 3 knowledge tests, revision should ideally start from the very first day of your first rotation with collating your notes on different diagnoses. Consider making a table for each condition you see in the hospital. Your table could include column headings such as epidemiology, aetiology, pathophysiology, clinical features, investigations, differential diagnoses, and management. Knowing this type of information is crucial in order to diagnose conditions, so the earlier you get into the habit of learning like this, the better you will perform in the KTs. Each of the KTs is solely assessed through multiple choice questions. These are just like the questions you had in Phase 1. Questions in the KTs are patient-based, in that they will describe the important findings of a history or examination and you will have to give the diagnosis. You may also get asked some questions on what you would do next (e.g. which investigation would you like to perform?) or even what you would do to manage the patient, but these will not be covered in as much detail as you will need to know in years 4 and 5. Try doing lots and lots of practice questions in the weeks leading up to the exams. Good resources are BMJ OnExamination and PasTest. Some of the questions from these sites are very similar to the actual KT questions! Also rather than reading hefty books days before you sit the exams, try finding a small revision book from the library which you can quickly read through (e.g. Surgery on the Move - Jenna Morgan).

If there is one exam during third year that you should truly focus on it is the OSCE!! One big difference for the third year OSCE compared to the other OSCEs you’ve done is the type of knowledge required. Each station is still 5 minutes long but they will test clinical knowledge including investigations. With respect to history taking stations, you need to know what questions to ask in order to rule a particular diagnosis in or out. The history taking stations will also test whether you are a safe doctor; therefore it is vital that you ask certain red flag questions when it is appropriate to do so. You are more likely to encounter history taking stations in the year 3 OSCE as opposed to clinical examinations, so spend time practicing different presenting complaints with your friends. Try to get hold of an OSCE book from the library with some mock scenarios. You could then get together with two other friends and have someone being a patient, someone being the student, and someone being the examiner. In terms of examinations, cardiovascular, respiratory, GI and peripheral vascular examinations are most likely to be tested in some form. Remember practice, practice, practice…examiners can easily tell if you have been spending time in the hospital or not!
In terms of when to start revising properly, consider sacrificing a month or two before the final exams (maybe more for the OSCE) and you should be in a good position to do well. This is obviously just a rough time-frame; you should work at your own pace and decide when it is best for you to start. You should also try to attend as many of the AMECS revision sessions run by year 4 and 5 students. These sessions range from mock OSCEs to CbD practice and will make things less stressful when it comes to your actual exams. Getting through third year is a big achievement, so work-hard and never give up…it will be worth it in the end!

Good luck!!

Contriubuted by Ishpal Singh Moonga

BSMS MedSoc is the Medical Society of Brighton and Sussex Medical School.

Website built by Dom Lowcock, December 2015. Check out Ihsan, too.

Photographs courtesy of Sam Cross, Hannah Cockle, Freddie Sweeting, and Lucy Thorn.