I've just started my clinical years and after reading through the awesome threads by Benjamin on here and the Clinical Years thread on PD over the past few years, I've found it really insightful to hear from those who are further ahead than me in their medical careers. I'm aiming to write about / reflect on my various experiences as a clinical student on here pretty regularly and perhaps provide some advice on "what I wish I knew before I started clinical" too. Hopefully others can weigh in on their own experiences as well!
So, it's very early days for me but I have to say it's been an amazing experience so far. I am loving my time in the hospital and the learning is just immensely greater than what you could ever get from the traditional on-campus lecture/PBL model that forms the basis of the preclinical years. Don't get me wrong, I loved my first two years and certainly learned a lot, but truly nothing can compare to the real deal. Seeing real patients managed by doctors in real time (unsurprisingly) is such a high-yield way to learn and everything seems to so readily stick into my head and make a lot more sense than it ever did when I learned about it in a theoretical sense.
It's come as no surprise to me that you really need to be an independent learner, seek opportunities whenever they come and put up your hand every time to get the most out of the clinical years. I've definitely been one to shy away from certain opportunities in the past for fear of embarrassing/humiliating myself and I've been making a very active effort to overcome this since I've started the year. The reality is that nobody expects anything special from you as a student who has only just set foot in a hospital. The worst that can happen is that you fail in a safe environment, learn from your mistakes and will be better for it the next time it comes around. It's always going to be better for that to happen now, when the expectations are very low, than when you're a junior doctor and still can't competently perform x skill because you were too scared to learn it as a student.
Currently a typical day for me will involve a variety of shadowing doctors / occasionally nursing staff, clerking my own patients and handing over to a senior (underlining this as it is honestly the best learning I've ever had in medicine!), writing patient notes or referral letters (these are obviously checked and critiqued by the supervising doctor!) / doing various procedural skills (most of which I'm currently hopeless at). The distribution of the day really depends on a variety of factors and this comes down to which staff are working at the time, how keen they are to involve you in their work (tip: ask to observe the doctor or see your own patients and report back - the worst that can happen is that the doctor is too busy and you can't do it today but you've demonstrated that you're keen for when they may have spare time or a good opportunity for you) and how busy the day is.
It's honestly really awesome learning to essentially pretend to be the doctor, work up a patient and propose a management plan but have the full safety net of senior supervision and an opt-out / send for help card whenever I need to. Knowing what my reg/consultant would do differently after I’ve reviewed the patient myself highlights the key mistakes that I’m making, things I’m missing and the topics I need to study in my own time - really no other method of learning compares for me. I really intend to make the most of my time as a student where I know I'll get to do this and it really does feel like such a privilege to be in this position.
I find it really surprising just how many times I've heard/read about students going home early or not showing up at all so they can study at home.... I just can't really imagine a situation where you'd learn more at home in a book as opposed to being in the hospital and getting the direct experience. Obviously if there's absolutely nothing for you to do and you've been sent home early that's a different story, but I'm finding that there's rarely a time when there is NOTHING to do and students skipping days / going home super early every day just rings alarm bells for me. There's a reason you spend the clinical years in the clinical environment and not at home.
Some other lessons/take-homes I've gained over the past fortnight:
When working with undifferentiated illness, imagine what the worst possible case could be for that patient and rule it out. I've found it's easy to fall into a trap of "x patient has a classical presentation of [insert relatively benign condition]" and then when I hand back over to my seniors with a comment to that effect it is met with "how do you know it's not [insert much more concerning condition]?" and "did you ask about x history or do y examination to exclude/check...."? for which I have a tail-in-my-legs response or "I can't believe I didn't think of that at the time!" because of course, I didn't ask that crucial question. What I've found that works for my current level of (extreme) inexperience is to think of anything bad that could possibly going on, or if there's a possibility of an adverse/avoidable outcome if I just make sure to exclude certain factors in the history/exam/investigations and have this in mind while I see a patient.
If you want to recommend investigations, be able to justify why you're doing them. In PBL we are taught to come up with every possible differential diagnosis and suggest every possible test under the sun to rule various conditions in/out. In reality this is incredibly unrealistic for quite a number of reasons; financial constraints are the main thing that spring to mind, but availability of imaging technology / radiographers / radiology staff / pathology staff / patient-specific roadblocks to certain investigations are a few others. I've been asked many times already what investigations I'd order to diagnose/track the progress of patients and it's easy to list off every test I can think of that might be vaguely relevant to the patient's condition. When I've been asked why I'd order certain tests, however, I've realised that often there's no reason for them. The key lesson I've learned here is that you need to be able to answer the question of "how will this investigation alter the management plan?". If the answer is that it won't, then you shouldn't be ordering that investigation. In hindsight it's obvious, but I think it's a great litmus test!
Different doctors like things done differently. Get used to thinking you've nailed something down to an artform, only for a different doctor to see what you've done and explain why it's wrong or how they like it a completely different way for one reason or another.
Not everyone will treat you with kindness and excitement. Obviously you can expect this, but the hospital isn't an education building. It doesn't exist purely for students so you can't expect that everyone will be bending over backwards to find you opportunities and take hours out of their day to teach you.
Ask for opportunities! This advice is repeated everywhere but it really is so true. If you're standing around twiddling your thumbs (which admittedly is an inevitable component of being a student - your teachers are very busy people who aren't always going to be available at your beck and call) then you can't expect someone to approach you and hand you cool opportunities on a silver platter. Always ask if you can tag along to observe your reg/consultant take a history or examine the patient, or ask if you can attempt that cannula/catheterization/suturing/hold the ultrasound probe etc etc. You probably won't get the chance if you don't. If you put in the work early of asking for opportunities and showing that you're keen, you are far more likely for someone to ask you to be involved when something else cool shows up later on. Keep in mind that the reg and consultant aren't the only people you can learn from either. The allied health and nursing staff are fantastic at my hospital and I've found that being nice and demonstrating that you're keen to them will at a minimum get you lots of procedural skill practice if you've got them on your side!
This has probably been very haphazardly written so hopefully it's made some form of sense! It's been a huge week in my defence. Keen to hear any and all thoughts!
So, it's very early days for me but I have to say it's been an amazing experience so far. I am loving my time in the hospital and the learning is just immensely greater than what you could ever get from the traditional on-campus lecture/PBL model that forms the basis of the preclinical years. Don't get me wrong, I loved my first two years and certainly learned a lot, but truly nothing can compare to the real deal. Seeing real patients managed by doctors in real time (unsurprisingly) is such a high-yield way to learn and everything seems to so readily stick into my head and make a lot more sense than it ever did when I learned about it in a theoretical sense.
It's come as no surprise to me that you really need to be an independent learner, seek opportunities whenever they come and put up your hand every time to get the most out of the clinical years. I've definitely been one to shy away from certain opportunities in the past for fear of embarrassing/humiliating myself and I've been making a very active effort to overcome this since I've started the year. The reality is that nobody expects anything special from you as a student who has only just set foot in a hospital. The worst that can happen is that you fail in a safe environment, learn from your mistakes and will be better for it the next time it comes around. It's always going to be better for that to happen now, when the expectations are very low, than when you're a junior doctor and still can't competently perform x skill because you were too scared to learn it as a student.
Currently a typical day for me will involve a variety of shadowing doctors / occasionally nursing staff, clerking my own patients and handing over to a senior (underlining this as it is honestly the best learning I've ever had in medicine!), writing patient notes or referral letters (these are obviously checked and critiqued by the supervising doctor!) / doing various procedural skills (most of which I'm currently hopeless at). The distribution of the day really depends on a variety of factors and this comes down to which staff are working at the time, how keen they are to involve you in their work (tip: ask to observe the doctor or see your own patients and report back - the worst that can happen is that the doctor is too busy and you can't do it today but you've demonstrated that you're keen for when they may have spare time or a good opportunity for you) and how busy the day is.
It's honestly really awesome learning to essentially pretend to be the doctor, work up a patient and propose a management plan but have the full safety net of senior supervision and an opt-out / send for help card whenever I need to. Knowing what my reg/consultant would do differently after I’ve reviewed the patient myself highlights the key mistakes that I’m making, things I’m missing and the topics I need to study in my own time - really no other method of learning compares for me. I really intend to make the most of my time as a student where I know I'll get to do this and it really does feel like such a privilege to be in this position.
I find it really surprising just how many times I've heard/read about students going home early or not showing up at all so they can study at home.... I just can't really imagine a situation where you'd learn more at home in a book as opposed to being in the hospital and getting the direct experience. Obviously if there's absolutely nothing for you to do and you've been sent home early that's a different story, but I'm finding that there's rarely a time when there is NOTHING to do and students skipping days / going home super early every day just rings alarm bells for me. There's a reason you spend the clinical years in the clinical environment and not at home.
Some other lessons/take-homes I've gained over the past fortnight:
When working with undifferentiated illness, imagine what the worst possible case could be for that patient and rule it out. I've found it's easy to fall into a trap of "x patient has a classical presentation of [insert relatively benign condition]" and then when I hand back over to my seniors with a comment to that effect it is met with "how do you know it's not [insert much more concerning condition]?" and "did you ask about x history or do y examination to exclude/check...."? for which I have a tail-in-my-legs response or "I can't believe I didn't think of that at the time!" because of course, I didn't ask that crucial question. What I've found that works for my current level of (extreme) inexperience is to think of anything bad that could possibly going on, or if there's a possibility of an adverse/avoidable outcome if I just make sure to exclude certain factors in the history/exam/investigations and have this in mind while I see a patient.
If you want to recommend investigations, be able to justify why you're doing them. In PBL we are taught to come up with every possible differential diagnosis and suggest every possible test under the sun to rule various conditions in/out. In reality this is incredibly unrealistic for quite a number of reasons; financial constraints are the main thing that spring to mind, but availability of imaging technology / radiographers / radiology staff / pathology staff / patient-specific roadblocks to certain investigations are a few others. I've been asked many times already what investigations I'd order to diagnose/track the progress of patients and it's easy to list off every test I can think of that might be vaguely relevant to the patient's condition. When I've been asked why I'd order certain tests, however, I've realised that often there's no reason for them. The key lesson I've learned here is that you need to be able to answer the question of "how will this investigation alter the management plan?". If the answer is that it won't, then you shouldn't be ordering that investigation. In hindsight it's obvious, but I think it's a great litmus test!
Different doctors like things done differently. Get used to thinking you've nailed something down to an artform, only for a different doctor to see what you've done and explain why it's wrong or how they like it a completely different way for one reason or another.
Not everyone will treat you with kindness and excitement. Obviously you can expect this, but the hospital isn't an education building. It doesn't exist purely for students so you can't expect that everyone will be bending over backwards to find you opportunities and take hours out of their day to teach you.
Ask for opportunities! This advice is repeated everywhere but it really is so true. If you're standing around twiddling your thumbs (which admittedly is an inevitable component of being a student - your teachers are very busy people who aren't always going to be available at your beck and call) then you can't expect someone to approach you and hand you cool opportunities on a silver platter. Always ask if you can tag along to observe your reg/consultant take a history or examine the patient, or ask if you can attempt that cannula/catheterization/suturing/hold the ultrasound probe etc etc. You probably won't get the chance if you don't. If you put in the work early of asking for opportunities and showing that you're keen, you are far more likely for someone to ask you to be involved when something else cool shows up later on. Keep in mind that the reg and consultant aren't the only people you can learn from either. The allied health and nursing staff are fantastic at my hospital and I've found that being nice and demonstrating that you're keen to them will at a minimum get you lots of procedural skill practice if you've got them on your side!
This has probably been very haphazardly written so hopefully it's made some form of sense! It's been a huge week in my defence. Keen to hear any and all thoughts!
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