How do you study during clinical years?

I feel like this depends in large part on the teaching style of your uni and the resources they provide. My uni gives you pretty regular lectures and e-lectures all through clinical years, so I've based all of my studying off of going through them, as they form the 'core knowledge' for each year. I rarely crack open a textbook as I find they invariably go into too much detail. A quick google or the oxford handbook is usually enough.

Honestly the way my studying has changed the most during clinical years is realising that I should actually study less. Yes you need spend a certain amount of time in the library, but that is not the focus of clinical years at all. You learn the most by really being there. Hanging out on the wards and seeing patients cements knowledge into your head in a way that books never can.

And for exams I'm a fan of MCQ pratice books. Considering signing up to passmedicine or a similar service for this yewar, but undecided as yet.

It's worth sitting down at the beginning of each rotation (with your consultant if possible but otherwise with a good book/syllabus) and work out what you need to gain from the rotation. In general, you need to know about emergencies for real life and stable patients that could feasibly appear in an OSCE station for finals. Then make a plan for how you can achieve each goal. Taking cardiology as an example:

Finals
Assess a patient or actor with chest pain / palpitations / shortness of breath / oedema - find talkative patients on the cardio ward, in A&E (if you are feeling brave), or just another medical student.
Recognise common murmurs - cardiothoracic pre-op area for patients with aortic stenosis before having an aortic valve replacement. You don't have to take a full history if you are in the way - just read about aortic stenosis and then track down a couple of patients to lay your stethoscopes on... Spend a morning going around different wards and be brutal about what you need (not "do you have any interesting patients?" but "do you have any patients with murmurs?". There will be at least one on every ward - even in orthopaedics.

Real life
Investigation of chest pain and management of different acute coronary syndromes (stable angina, unstable angina, NSTEMI, STEMI) - the cardio ward will be full of these but sometimes it's helpful to see them "fresh" (i.e. without all the investigations to hand and the consultant telling you the diagnosis). You could either follow the on-call medical FY1/SHO who will see a few chest pains during a shift or the on-call cardiology SpR. That way you can see when a troponin is ordered, when it's repeated, who gets an echo, etc.
Recognise common arrhythmias on an ECG - books are fine but this is something you learn by doing. Look at the ECGs for every patient you see on the cardio ward round, go to coronary care and just sit looking through ECGs. A lot of coronary care units will have a library (e.g. for training the cardiac nurses) of interesting ECGs - S1Q3T3, hyperkalaemia, STEMI, etc.

Remember that you don't have enough time to rotate through all specialties at medical school. Your "general medicine" rotation might be with a cardiologist but you could be expected to cover endocrine/neuro/resp/gi/geris/etc during that time as well. When you strip a specialty to its bare bones (as above), you can see that a week is probably enough time to get out everything you need!

Equally don't stick with the consultant to which you are assigned. They'll very rarely be concerned at your "absence" if you tell them where you are going or run through your plan at the beginning of the rotation. If anything they'll think you are amazingly proactive and be secretly delighted that you aren't going to sit through their sleep apnoea clinic twice a week for the whole rotation...

Sorry for the long post but I thought an example of how to "work smart" might help!

I like what you wrote there. Can you advice me on how to manage an orthopaedics rotation beforehand? And I'm uncertain what to prepare but I would really distaste the idea of starring blankly into space when I'm asked a question I don't know an answer for.

Ortho is a little atypical as it is really lots of specialties rolled into one. My thoughts are:

Finals
Spine: Back pain history and examination - maybe do one spine clinic but make sure that your history and examination are flawless. If you can find back pain patients (look for a list of spine injections) then great, but use other students if necessary. Back pain is a great actor OSCE case because they can easily identify "passable" students by whether or not they asked all the appropriate red flag questions. Memorise a perfect history/examination routine as if you were rehearsing for a play!

Hip/knee/shoulder: Try and get to at least one general clinic for each of these. Your aim should be to examine as many patients as possible, ideally those with clinical signs, e.g. positive drawer test. Try and pick up some examination tips from consultants in clinic and then practice on each other until you can perform a “perfect” routine (timed to 5 minutes or whatever you are allowed in medical school finals). OSCE cases are usually OA (hip), meniscal tear (knee), rotator cuff tear or impingement (shoulder). If your hospital has an acute knee clinic, go there to find a few ACL/PCL ruptures.

Hand: Carpal tunnel syndrome history/exam and rheumatoid hand exam. Hands are “high yield” because lots of general OSCE patients will have hand signs: Heberden's nodes, Bouchard's nodes, the constellation of deformities seen in advanced rheumatoid, and Dupuytren's contracture. There are some good RA hand examination videos on YouTube - again practice with colleagues.

There are not many orthopaedic emergencies but make sure you read around (and are clear about) septic arthritis, open fractures, cauda equina syndrome, compartment syndrome, non-accidental injury, and the limping child (septic arthritis again but other important differentials include slipped capital femoral epiphysis, Perthes’ disease, etc). These are all reasonably rare but could be pass/fail issues if tested in OSCEs and/or written exams.

Real life
Most of the common musculoskeletal issues you might encounter (e.g. as a GP) are included above. In addition, you could think about:

Your approach to the inpatient that falls on a ward. You will get lots of calls about this out of hours as an FY1. Maybe talk to a junior doctor about how you should assess these patients, what needs to be documented, etc.

Looking at x-rays – in the falls patient above, you’re most likely to need to interpret a hip x-ray as most other things can wait until someone more senior is immediately available the next day. You could attend some early morning fracture meetings and/or look through all the x-rays for the current orthopaedic inpatients – pre-op, intra-op, post-op. That will help you get “tuned in” to seeing obvious and subtle fractures on x-ray.

And just a note about theatre
Lots of students waste their time standing at the back of the operating theatre without any real idea of what's going on. Unless your consultant feels differently (ask him/her!), I would focus on a small number of core operations. If you know that you are there to see *one* total hip replacement, you can pay attention and engage with the case much more effectively than if you think you're stuck for a day watching five THRs. My initial thoughts are to tick off total hip replacement, total knee replacement, carpal tunnel decompression, some kind of injection under fluoroscopy (hip or spine), intramedullary nailing of a fracture, plate fixation of a fracture, and dynamic hip screw. Just try to understand the principles – intramedullary fracture fixation is more or less the same for humerus/tibia/femur/etc.

Try to plan the case, e.g. if there is a THR later in the week, read around the subject (www.orthobullets.com more than enough!) beforehand. If the consultant/SpR are available in the theatre coffee room beforehand (they usually are) then ask whether they can summarise the steps of the operation before they start. You ideally want to be able to follow what’s going on. In theatre, ask the surgeon and scrub sister if you can be there, then introduce yourself to everyone. Surgeons love it when students make an effort to “own” the case – e.g. see the patient pre-op, watch the operation, and then see the patient again afterwards.

I’m afraid ortho is a little like paediatrics… it’s surprisingly broad… but you need to make sure you get a broad overview and focus on important/common things. Don’t stay with the same consultant the whole time otherwise you’ll become an expert on patellofemoral joint resurfacing but know nothing else…!

Hi varn1x,

When I was studying for my finals I spent as much time as possible in hospitals. I'm a very visual and kinaesthetic, so seeing things in happen made a huge difference to my revision!

I'd have a think about how you like to learn. There are some great resources out there - Feather Does Finals (http://fdf.smd.qmul.ac.uk/videos.html) has some great tutorials on core medical topics. If you're more auditory, Medisense as a long-case-themed podcast you could try! (http://www.medisense.org.uk/#!/hear/moslercast).

I always found studying with colleagues really useful - you can gauge where you are with your knowledge and talking about everything always relieved a lot of stress for me.

Ortho is a little atypical as it is really lots of specialties rolled into one. My thoughts are:

Finals
Spine: Back pain history and examination - maybe do one spine clinic but make sure that your history and examination are flawless. If you can find back pain patients (look for a list of spine injections) then great, but use other students if necessary. Back pain is a great actor OSCE case because they can easily identify "passable" students by whether or not they asked all the appropriate red flag questions. Memorise a perfect history/examination routine as if you were rehearsing for a play!

Hip/knee/shoulder: Try and get to at least one general clinic for each of these. Your aim should be to examine as many patients as possible, ideally those with clinical signs, e.g. positive drawer test. Try and pick up some examination tips from consultants in clinic and then practice on each other until you can perform a “perfect” routine (timed to 5 minutes or whatever you are allowed in medical school finals). OSCE cases are usually OA (hip), meniscal tear (knee), rotator cuff tear or impingement (shoulder). If your hospital has an acute knee clinic, go there to find a few ACL/PCL ruptures.

Hand: Carpal tunnel syndrome history/exam and rheumatoid hand exam. Hands are “high yield” because lots of general OSCE patients will have hand signs: Heberden's nodes, Bouchard's nodes, the constellation of deformities seen in advanced rheumatoid, and Dupuytren's contracture. There are some good RA hand examination videos on YouTube - again practice with colleagues.

There are not many orthopaedic emergencies but make sure you read around (and are clear about) septic arthritis, open fractures, cauda equina syndrome, compartment syndrome, non-accidental injury, and the limping child (septic arthritis again but other important differentials include slipped capital femoral epiphysis, Perthes’ disease, etc). These are all reasonably rare but could be pass/fail issues if tested in OSCEs and/or written exams.

Real life
Most of the common musculoskeletal issues you might encounter (e.g. as a GP) are included above. In addition, you could think about:

Your approach to the inpatient that falls on a ward. You will get lots of calls about this out of hours as an FY1. Maybe talk to a junior doctor about how you should assess these patients, what needs to be documented, etc.

Looking at x-rays – in the falls patient above, you’re most likely to need to interpret a hip x-ray as most other things can wait until someone more senior is immediately available the next day. You could attend some early morning fracture meetings and/or look through all the x-rays for the current orthopaedic inpatients – pre-op, intra-op, post-op. That will help you get “tuned in” to seeing obvious and subtle fractures on x-ray.

And just a note about theatre
Lots of students waste their time standing at the back of the operating theatre without any real idea of what's going on. Unless your consultant feels differently (ask him/her!), I would focus on a small number of core operations. If you know that you are there to see *one* total hip replacement, you can pay attention and engage with the case much more effectively than if you think you're stuck for a day watching five THRs. My initial thoughts are to tick off total hip replacement, total knee replacement, carpal tunnel decompression, some kind of injection under fluoroscopy (hip or spine), intramedullary nailing of a fracture, plate fixation of a fracture, and dynamic hip screw. Just try to understand the principles – intramedullary fracture fixation is more or less the same for humerus/tibia/femur/etc.

Try to plan the case, e.g. if there is a THR later in the week, read around the subject (www.orthobullets.com more than enough!) beforehand. If the consultant/SpR are available in the theatre coffee room beforehand (they usually are) then ask whether they can summarise the steps of the operation before they start. You ideally want to be able to follow what’s going on. In theatre, ask the surgeon and scrub sister if you can be there, then introduce yourself to everyone. Surgeons love it when students make an effort to “own” the case – e.g. see the patient pre-op, watch the operation, and then see the patient again afterwards.

I’m afraid ortho is a little like paediatrics… it’s surprisingly broad… but you need to make sure you get a broad overview and focus on important/common things. Don’t stay with the same consultant the whole time otherwise you’ll become an expert on patellofemoral joint resurfacing but know nothing else…!