Final year and FPAS...

Last year I thought the worst of medical school exams was over. But then we finally got told how they were calculating the rankings for FPAS scores and they used every year of exams (except finals) so that left me a bit deflated. Earlier years were a bit hit and miss especially catching up with a non-science background. Never mind. And then we had to sit the SJT *shudders.

Anyhow here is how the figures stack up for getting a foundation job through FPAS...

FPAS scoring:

Academic score + SJT score = x/100 points

Academic score: A( x/43 points for exam results) + B (up to 5 points for previous degree) + C (up to 2 points for national presentation/publication/prize) = x/50 points.

A)They scrapped quartiles and moved to deciles this year. You get 43 points for your medical school exam results. The top 10% get 43, then the second decile get 42 and so on. I guess this will differentiate between students but would have been nice if they told us this earlier... The med schools can decide independently how they calculate your decile too.
B) A phd gets top points, then masters, 1st, 2.1 etc... if you didn't intercalate you start off on the back foot.
C) Only one point for each category so having two presentations is still only worth one point. Extra stuff counts if you apply for the academic programme though...

So that gives you a score out of 50.

And here's the killer, the Situational Judgment Test (SJT), one exam, is worth 50 points too! Surely that's madness! So basically getting your top job may mostly hinge on how you do with this exam. A bad day could wipe out all the deciles of grind.

SJT revision:

There's an official practice paper online http://sjt.foundationprogramme.nhs.uk/ and an entire industry has sprung up flogging courses and books etc. Most of it in my view is a waste of money. The book questions sometimes give conflicting answers to similar questions on the official mock paper. Other sources are worth glancing at to consider topics and how to approach questions but you can't learn the right answer. I'd stick with the official examples and cross your fingers & toes.

That was my approach anyhow, results are out on Monday so I'll soon find out how that went!

Good luck peoples!

                                                 "Damn it I've lost count again..."

Electives overseas

Africa...

Conjures up images of wild, open, barren land and mud huts.
Parts of it are like that, but it can also be incredibly beautiful with its burnt orange sunsets, noisy minivans, patterned cloths and bustling markets. 

I chose to visit Malawi and found the people genuinely warm and welcoming. In general they were fun, honest people who looked on a sometimes challenging life with a mix of optimism and resignation.

Blantyre at dusk...

When to go and objectives...

I spent my last summer holiday as a student on elective (our official elective is only 6 weeks and I wanted the chance to go to more than one interesting destination). I had always wanted to visit Africa and was keen to see how healthcare in a developing country would compare to the UK. My main concern in choosing a developing country for my elective was that I did not want to be unsupervised and "practising" on patients in an unethical way but I did want to have the opportunity to get hands-on experience. A tricky balance.  I was glad I had not gone earlier in my course - I would have learnt less and been far less useful.

Where I went...

I organised the placement myself through the University of Malawi (a LOT cheaper than using an elective company) and was allocated to Obstetrics & Gynaecology at one of the country's main government hospitals - Queen Elizabeth Central Hospital, Blantyre (or "Queens" to the locals).

I was shown around the library and even given my own email address and access to the IT facilities which was unexpected. The team made me welcome from the start and I shadowed various members of staff including nurses, clinical officers and registrars plus attended ward rounds, clinics and theatre. My fears of being asked to crack on with a c-section solo were unfounded - in reality, the department was well supported and staffed most of the time and so I actually had no concerns with being asked to act above my level of competence. However not all my friends working in district hospitals had the same experience - some were left to conduct ward rounds and on-calls alone as if they were a qualified doctor with full prescribing powers. Of course, having the power to give someone a drug out there is not always relevant as shortages are frequent. Even at the main central hospital where I was based it was common to run out of basic drugs and so patients' families were sent on errands to try to source them. 

Empty shelves at the city chemists...

When I tried to buy dexamethasone for the labour ward there was ONE vial in the entire of Blantyre.

The hospital grounds are well maintained but the infrastructure needs some TLC. As I was leaving one of the wings was being upgraded but even the areas that have been recently built with international help could do with better planning. There are rooms set aside for facilities that don't exist - in my view a waste of space and money when some wards have patients on mattresses on the floor due to lack of beds.

I spent some time in the Emergency Department too where there was a cracking US consultant who was great at teaching and passing on practical skills and also enthusiastic about flagging interesting cases to students and other staff. It was a fast paced and challenging environment and I heard that there were some terrible RTAs that presented. Patients often turn up in the back of a truck as there is no reliable ambulance service and people cannot afford other private means of transport. Practical procedures there are unavoidable so great if you want to be a real member of the team.   

There were many challenges:

• Seeing patients die from eclampsia.
• C-sections that proved complex and resulted in hysterectomy.
• Pregnant women with meningitis and malaria
• Lack of privacy - intimate examinations often carried out in full view of the entire team (this could be 12 people) without drawing curtains
• No theatre one day because key staff had gone for interviews and there was nobody available to cover.
• Late presentations of treatable disease because of the lack of access to effective primary care.
• Sinks but no hand washing... aaaargh!

But I was impressed by:

• Dedicated midwives, working long hours for less than $10 a day. Not a terrible wage in context but they could have left to work abroad and chose to stay where they would be needed.
• Staff persevering with malfunctioning equipment and faced with acute shortages of key drugs.
• Patients who were dignified and rarely complained - this gave me an interesting insight into womens' health in a different cultural context but I was also aware that there was under-reporting of pain as a result.
• Staff make the best of everything and one of the main things I learned was an appreciation for clinical evaluation without reliance on imaging and creativity with limited kit. Surgeons managed with one size of gloves and three suture types. 
• Caring relatives. Patients bring their own chitembe or sarongs that they use as sheets - the hospital doesn't provide any. In stark contrast to the UK relatives set up camp in hospital grounds in order to provide care and meals for the patient. So, whilst other aspects are clearly lacking, care and attention for the patient is evident.

TOP TIPS FOR BLANTYRE

Kabula Lodge - lovely place but not safe to walk to and from town even in the day as tourists are known to reside there and have been targeted frequently (sometimes violently) in recent months. (Yep, one was me). You will need to factor in taxis to your budget for staying there. I was told that sometimes you are followed from ATMs after taking out money so always get a pre booked taxi home again.

Doogles - loud but friendly. The staff are great fun and they will store your bag for you if you go away at weekends. Not great for meeting long term visitors as people tend to be more transitory here.

Vege Delight - best place to eat even if you aren't a vegetarian! quirky food and friendly owner. 

Heritage Cafe - near QECH and Beit Cure just off the roundabout. Great buffet lunch and super cheap.

National Bank had a bureau for foreign exchange - great rates August 2012 and friendly staff who even changed a small amount of currency for me when I ran short on my last day. Highly recommended.

Don't let the crime put you off - in general Malawi is a very safe place and theft is culturally completely unacceptable but with the huge contrast in wealth tourists will always be a potential target. You could just as easily be mugged at home.  Just be sure to minimise what valuables you carry and take taxis after dark. Blantyre is not a very pretty city but it has character and I loved the markets. At the weekends it is easy to get away and see other brilliant areas of the country just never get public minibuses after dark  - the roads are dangerous enough in day and potentially lethal at night given the potholes, lack of working headlights and no seatbelts. Do get minibuses in the day - its fun and a great insight into everyday Malawian life - try to grab the second row on the right, the seats are fixed and wont tip you off and avoid the backseat as this is often where they squish 7 people...

Outside of the hospital I explored the country and tried out horse riding in Zomba, kayaking at Lake Malawi and trekking in Mulanje. 

An intense but rewarding trip to a lovely country with warm people. 

So if you are thinking of going, buy your plane 

ticket early (££££ ouch), learn some 

of the local language if you can and

 consider bringing supplies for the 

hospital as they will be appreciated.

Stethoscopes and OSCEs

So the written exam is all over and it feels like the summer holidays should be starting except there are still the dreaded OSCEs to go...These are the practical exams - the bit where you have to actually know how to use the stethoscope dangling round your neck.

Putting that bit of kit on when you start the clinical placements is terrifying. If your hospital has no scrub uniform for doctors they all just wear smart clothes so a stethoscope = doctor to many patients and often to other staff. If you are a grad student with a few extra wrinkles its not uncommon to be mistaken for a registrar or even (horror of horrors) a consultant... So after one placement of nurses constantly asking you to assess breathless patients or to amend drug charts you'll see quite a few students hiding their stethoscope in bags and pockets! To begin with I wasn't really sure when I would need one anyhow and although it seems obvious to me now I do recall bringing one to a plastic hand surgery outpatient clinic. They must have thought I was a total idiot :) In order to help you avoid a similar embarassing fate here are some tips:

Stethoscope Rules

1. Bring if its Respiratory, Cardiac, General Medicine, Acute Medicine, General Practice, Pre Surgical Assessment (for those pesky new heart murmurs), Care of the Elderly (virtually everyone has COPD or pneumonia)...
2. Don't bring if you are going to Surgery, Outpatient clinics unrelated to Cardio or Resp, Psychiatry...
3. If you need one unexpectedly there will virtually always be one with the doctor or on an obs trolley
4. Do get your own! Buy the best model you can afford - cheap ones are usually still £60 or so but if you can afford a bit more I'd say it helps. I was fortunate enough to get an expensive one as a gift and I have found that I can hear murmurs etc more clearly with it. Sometimes other people ask to borrow mine because the sound quality is better so its not just me! Of course it doesn't help you interpret what you hear - that's all down to the user!
5. If you have an expensive stethoscope you will look more stupid when you can't use it. Murphy's Law.

So, assuming you've survived the clinics and wards and actually got to practice using your shiny new toy the big moment really comes when you have to demonstrate it...

Of course stethoscopes are only a small part of the examinations you will do. They do get used in abdominal exams, as well as the obvious respiratory and cardiac stations. Plus blood pressure of course... and if you do get a BP station don't be surprised to find a terrifying double headed stethoscope with the examiner able to listen in so there's no faking what you hear...(not that you would ever do that of course...)

                                                         Scary like Medusa...

OSCEs

OSCEs  fall into three main categories - (i) practical physical examinations, (ii) history taking/information giving/advising "chatty" stations and (iii) procedures like taking blood etc.

"Stations" refers to the OSCE task and usually last 10 - 15 minutes.

In my experience the usual set up is a mock ward with cubicles with curtains drawn. There is a chair outside every station with an instruction card face down. Everyone lines up outside their start cubicle...

BUUUUUUZZZZ!

The alarm sounds, your heart pounds, you snatch up the instruction card and try to read. You have one minute to grasp what the station task is about.

BUUUUUUZZZZ!

You yank back the curtain and rush in trying to look casual. You begin your introduction to the patient and start trying to follow through the task. This can be easy or awful.  Chatty stations can be a gift or a nightmare depending on your inter-personal skills and whether or not your simulated patient is meant to be psychotic.

BUUUUUUZZZZ!

Times up and you have to stop what you are doing and move to the next cubicle.

And it all starts again....

Top tips for OSCEs

1. Practice your skills well in advance. You can't rock up on the day and hope to wing them all. Its a recipe for disaster. 

2. Confidence is key. If you think you have heard something or seen something on an xray, say so! Present your finding fluidly and concisely using proper language and you will look professional. Saying "um, the xray has a cloudy bit on it over at the edge" is not going to win you many marks whereas "loss of the right costophrenic angle and a meniscus suggest the patient has an effusion" comes across much better. You've seen the same thing but a lot of it is in how you get the information across.  Caveat to this is NEVER make stuff up. If you don't know something admit it rather than lie or say something like "I'm not sure of the detail of that so I think its something best checked with my senior colleague". That's honesty not failure and you can probably still pass the station if you have done everything else properly. Lying is a sure way to fail...

3. Always introduce yourself to the patient, explain what you are doing and get permission. Don't say you are a student and that the examination is for your learning unless it says that on the scenario instructions!

4. Get a group of friends and write OSCE scenarios for each other. That way you will be examining each other and can get feedback and see how you cope when you don't know what the scenario is in advance.

5. Rope in friends and family to be your mock patients. Many will find it quite fun (for a while anyway!)

6. Practice your skills with the real patients you see everyday - this is the closest thing to an OSCE - they have real signs and are often happy to help you learn.

7. Offer to do the ward jobs. When you have to do a mock ABG in the exam you will ace it because you have done it lots of times for real!

8. Know the kit. I've heard people say they had to put a speculum together and they had no idea how that was done... 

9. Try to keep calm. If you totally mess up one station push the feelings and memory of it into your inner box of doom and move on. You can agonise over it later...

10. Expect the unexpected. Examiners seem to throw in the odd scary station to differentiate the best students. Try to think logically and work your way through it the best you can!

Then cross all your fingers and toes and wait for the results!

____________

 Choosing a stethoscope 

Lots of people I know chose Littmann for their stethoscope, we are like sheep: http://solutions.3m.co.uk/wps/portal/3M/en_GB/Littmann/stethoscope/products/buyers-guide/

Desperately seeking DOPS...

Anyone in a London medical school can probably tell you about the horror that is the DOP system. 

Essentially these are "directly observed clinical procedures". Note the words 'directly observed' - oh yes, this means you not only have to find the procedure that needs doing (often trickier than it sounds) but also find some lovely member of staff and persuade them to:

a) let you do it,

b) watch you do it, and 

c) fill in a form.

Sometimes this is easy because seniors are helpful and encouraging. Equally it can be an absolute nightmare when everyone is busy and you suddenly spot an elusive DOP that you have been waiting to do all year. Obviously its very important that we should all be competent at basic procedures but sometimes the chance to do things just doesn't arise in your particular ward or clinic setting. The scary part is that you can fail for not getting these done. Its a high risk strategy to leave them till the end of the year. Its the only reason I can think of that students are insanely keen to do rectal examinations when the opportunity arises. The chorus of "Oooh, please, please can you let me do that" is unthinkable otherwise...

THE BASIC DOP

This one is really embarassing. For those of you who have never seen a pulse oximeter - its basically a plastic gadget that clips on someone's finger and tells you what their oxygen saturations are via a handy monitor reading. Simples. Its pretty much impossible to feck up. Which means trying to find a nurse who will fill in the form is a tad tricky. When I waved my form apologetically, the sister called all the nurses together, made me repeat what it was for and then they all laughed. A lot. I like to think they were sniggering at the form, not me, but you never can tell... Somebody asked why on earth we had to get a form signed for it given that we were supposed to be bright enough to be at university. Which was a fair point although of course just because you can do organic chemistry doesn't mean you can do up your shirt buttons. Technically speaking, you can go into a big discussion of the importance of O2 sats but in reality none of the nursing staff want to listen to a medical student witter on about this when they are busy.

Even worse than that one is the bit where you have to get someone to sign a form when you observe them giving an infusion. People look at you in confusion. 'But it says "Directly Observed Procedure"' they say. And we say 'Yes, you observe us observing you'. Hmmm. And then they have to fill in the boxes saying what we could do better and what we did well or the DOP gets rejected. I'm still not sure how you can watch someone badly. Unless perhaps you shut your eyes or fall asleep.

THE IMPOSSIBLE DOP

At the other end of the scale is the rare DOP. These ones are like gold dust. I've spent months asking people if anyone needs an intramuscular injection or a nasogastric tube. Inevitably you just missed an opportunity or you get told to get someone to write a letter to some secretary to see if another admin person might possibly get you into a clinic where such things are done. Given the glacial speed of admin I decided that was an unviable option. Fortunately for me two came along in one day right in the nick of time. Like buses. But that was after days spent desperately wandering the wards, theatre and A&E in search of a signature on my precious DOP forms. You know things are desperate when you ask if its allowed to IM yourself in the thigh for a DOP...

So my top tip is extremely dull: BE SUPER ORGANISED AND GET THIS STUFF DONE EARLY!

Time for a celebratory Kimberley!

http://www.nicecupofteaandasitdown.com/biscuits/previous.php3?item=22 

Fortune Telling...

Today I had the loveliest patients arrive in via A&E. They were elderly patients who were confused and unwell and I was able to spend some time holding hands and giving a bit of comfort as well as finding out what had brought them in. You know that was one of the loveliest days as a result. Even now, when I still have a lot to learn I get a chance to be kind to people and do simple things to make them feel better and it gives me a lot of happiness. Much better than yelling at another lawyer down the phone! I'm only worried that when I'm actually a doctor there will be more time pressure and I won't be able to do this as well as I can now.

As one of the students with the on-call team I got to go clerk our new patients and do all the examinations for the admitting registrar. Basically this means getting to find out the history and carrying out lots of examinations and checking basic obs (heart rate, respiration rate, blood pressure, oxygen saturations etc). Naturally as the student its a given that everyone is going to do this all again to check you did things properly but its good to get a chance to see someone without a clear diagnosis so you can have a go working out what is wrong with them and seeing if you are on the right lines. There's always plenty to learn if you get it wrong and if you are correct it makes you feel a bit excited that something from all the reading has finally sunk in...

 

"Hmmm...UTI you have"

I remember the first diagnosis I ever made was in a setting like this and I had seen a patient with shortness of breath, peripheral oedema and chest crackles at the bases. I was suddenly there thinking "heart failure" and was just so relieved that all the things I had seen fit a pattern and meant something! I still had no idea whether it was right or left sided but at least I had made a start on the right path! My greatest fear in the first two years was writing all the symptoms and history down neatly and still having no idea what was going on...

One particular patient was quite interesting because they had a set of symptoms somewhere between pneumonia, heart failure and asthma exacerbation. Definitely one of those times when you get grateful for imaging and blood tests.

I don't know how everyone managed in the days before all these investigations. It would be like trying to drive to Scotland with signs pointing in different directions whilst you are running out of petrol...

Exam revision aids...

Its that dreaded time of year when exams are round the corner. Your brain is fried and you still need to cram in a whole year of work.  

 

So, I thought I'd mention some of the resources I like to use for revision...

 

 

PasTest

One of the online aids that has a bank of over a thousand questions and other video and text resources although I think the latter are rather variable in quality.

It has a good selection of questions and you can tailor your revision to particular topics, select mock exams and timed revision. They have lots of question styles but I tend to limit it to answering single best answer (SBA) questions because that's how they test us in our exams.

They send you updates of how you are doing but to be honest its all a bit pointless unless you are the sort of person who will be doing lots of the questions over a sustained period of time whereas I tend to cram and do loads just before exams. 

MMAM Rating: 8/10
http://www.pastest.co.uk/product/medical-student-online?gclid=COO0wZK81bACFUdlfAodFx5A1w

 

Pass Medicine 

I used this one last year but I didn't like it quite as much. Having said that I think the explanations of the answers are a bit more in depth than PasTest and I think its cheaper too...(hurrah)
MMAM Rating 7/10
http://www.passmedicine.com/

 

Kumar & Clark Pocket Essentials Clinical Medicine

There's a great selection of SBA questions at the back of the book although I think online testing is better because you can get the answer immediately without having to flip back and forth and without risking seeing the answer to the next question. Its a neat book with lots of topics and very useful as a third/fourth year revision tool in itself so worth buying. I know that it helped me get at least ten questions right last year :D

MMAM Rating 8/10
http://www.amazon.co.uk/Pocket-Essentials-Clinical-Medicine-Ballinger/dp/0702028304

 

Oxford Handbook Assess& Progress

Lots of people have used this and say its great. I couldnt get one from the library for love and I had no money so I didn't buy it. Might be worth borrowing though if you can track it down...

MMAM Rating ?
http://www.amazon.co.uk/Clinical-Medicine-Oxford-Assess-Progress/dp/0199562121

Mobile apps

The revision websites have downloadable apps and there are also a few other question banks you could try. I quite like the Prognosis app which is available on Android...The scenarios get you thinking about investigations and management not just diagnosis which is particularly important once you get to 4th year!

MMAM Rating 6/10
http://www.prognosisapp.com/

I don't have any links to any of these companies so this is my unbiased view! I'm sure there are lots of other great sources for revision. Feel free to comment and add any you think should be on the list...

Good luck...

Ps. For anyone who is looking for revision aids for GAMSAT there is now a book! I've only had a flip through but it looked pretty reasonable in content though rather horrific in terms of price... One to find in a library somewhere if the coalition government don't close them all...

http://www.amazon.co.uk/Standard-GAMSAT-Preparation-Online-Ireland/dp/0986691526/ref=sr_1_1?ie=UTF8&qid=1339944372&sr=8-1

First Crash Call

WARD ROUND - the team are lovely and I am lulled into a false sense of security...

8.35am: Slept through my alarm but made it in just on time. Luckily the consultant isn't in and nobody has mentioned my tardy arrival. Result!

10.30am: Its been 2 hours and the fact I missed breakfast is starting to reveal itself in loud rumbling noises. I look innocent and pretend its a patient.

10.35am:  Everyone is about to move on to see the patient I have clerked - my moment of glory/fear to present the details and suggest a management plan. 

Suddenly the patient in the next cubicle starts going downhill at a rate of knots and everything falls into dissaray. The team rush over to see what is happening.

Its rapidly heading towards an emergency situation. Its noisy and smelly and sad. I feel my heart rate go up...

The SHO calmly asks for someone to:

1. help hold the patient's sick bowl
2. get the ECG machine 
3. get cannula equipment 
4. check patient's blood results from the morning

The medical students all look at each other and freeze. Nobody is sure who is supposed to do what...

I rush off to find an ECG machine. I've done an ECG once before. Well, twice but the first time didn't count because it was on my friend and her underwire bra made the trace come out crazy. Plus it took me half an hour... I find a machine with a faded sticker barely legible that says ECG but it looks weird. I cant see the clips that I think should be there. It seems to have lots of plugs. I panic. I stare at the various trolleys. But there's no time so I lug it over and announce meekly that the ECG machine has arrived. Everyone ignores me. Someone has magicked a tiny one from somewhere. Then someone else eventually moves the lumbering hulk of a machine back to the corner I dragged it from. I am so embarassed. I'm still not sure how it works or whether it is a relic that was on the way to the recycling bin.  

 

Somehow everything is done and the SHO is so calm she impresses me. But then I remember that she's seen this before. We are all flustered and trying our best not to get in the way but its our first time. The surgical team is called to assess the patient urgently. They discuss the options but don't seem sure its possible. Meanwhile we think things are stable; there's access with cannulas and the nurses are keeping the patient comfortable. 

CRASH CALL...

All of a sudden its a crash call. Last time this happened on my ward it was a false alarm and the patient recovered but this time its different. Suddenly there seem to be hoards of people around the cubicle. Neighbouring patients are gawking while we try to pull all the curtains and one of them loudly complains and asks if the patient is dead yet. I feel sick. A small female doctor is doing CPR. Gusto is the wrong word but she's really going for it. I feel terrified thinking that in the not so distant future that's going to be me trying to bring someone back... As students we just stand there helpless trying to follow what's happening, fetch anything people need and understand what we will be expected to do in future. Machines are beeping importantly. Its not a shockable rhythm. People move in and out at high speed asking calmly but urgently for drugs and charts and delivering kit and generally being efficient and useful.

It goes on for over half an hour. Everyone looks drained. It is unsuccessful and that is sad although its likely that the patient would have been for palliative care at some stage soon. Our patient was lovely and I'm just sorry that's how things ended. This job really is nothing at all like its portrayed on TV. There is no glamour. I have just seen someone vomit faeces. But the team did their best. 

The first crash call I've seen is over and I'm hoping there won't be another for a very long time. But just in case, the first thing I'm doing is to find the crash trolley, make sure I know how to use all the kit and revise ECGs... 

How to do CPR: http://www.nhs.uk/conditions/accidents-and-first-aid/pages/cpr.aspx

ECGs: http://www.patient.co.uk/doctor/ECG-A-Methodical-Approach.htm