MED5091: Advanced clinical practice 1

- Pre-Intern Appraisals (PIA) (hurdle): there are five of these that need to be filled out by a supervising consultant doctor, one for each rotation (none for the elective rotation) and each worth 18% of Year 5
- Clinical Knowledge Test (CKT): the only exam for the year, is MCQ/EMQ format and is done at the end of the year, not a hurdle to pass but a hurdle to attend (which is unusual), worth 10% of Year 5
- Modules: a variety of paper, online, and in-person module tasks aimed to supplement clinical learning, many of which are hurdles, for each rotation; the sites and supervisors choose how exactly they want these done (more on this later), none of these count towards the final Year 5 score
- Attendance: a very strict expectation of 100% attendance, although technically the lower bound is 80%

These units are code for a "pre-internship" year. In my opinion, I found this to be the best year of medicine, but undoubtedly, it comes with many challenges. I'll try to order my comments here in a logical fashion.

Structure of the year
So Year 5, of which these units account for the vast majority of (so I'll use them synonymously with 'Year 5' for my ease), is divided into 6 rotations, each 6 weeks long, with a week of lectures (and the CKT) at the end of the year. There is a three week gap after the first three rotations, for reasons that will become apparent later in this review, I wouldn't call these a holidays. There is only the weekend in between each of the other rotations.

The six rotations are:
1. Medicine
2. Surgery
3. Emergency
4. Aged care
5. Specialty
6. Elective

Obviously, these rotations are not necessarily in this order. Speaking of which, it's worth touching upon how you get to choose your rotations and what my tips and tricks are. The Faculty sends out an email with your rotation allocations towards the middle of Year 4, this will be a generic email saying that you got your Medicine rotation (for example) at Rotation 5 and so forth. These rotations are not set in stone, and you can swap them. My tip is to NOT have your elective in the first two rotations of the year, and ideally not in the first half of the year. This is because, internships, which I'll touch upon towards the end of my review, need referees and these need to be from Australia (preferably: Victoria) so best to have some Victorian rotations before those intern applications are due.

After this initial allocation you are allowed to preference for individual rotations, which occurs towards the end of Year 4. The exact process has escaped my memory, but I think you get to preference 10 rotations for each allocation, but only a maximum of two rotations from the one site. So for example, you can only preference The Alfred twice for a medical rotation. As with any preference system, the highest one should be the one you want the most. The specialty rotation I'll talk about later, but it's essentially a mix of the more obscure medical specialties, surgical specialties, and other specialties (including the weird and wonderful such as a rotation at the Victorian Institute of Forensic Medicine). The Elective rotation is left for later,and can essentially be done anywhere that offers a 6 week rotation with a single supervisor.

The only caveat with rotations for domestic students to be aware of, is that if you haven't done a rural year in Years 3 or 4, then you have to do a least one 6 week rotation in a rural area. What I'd advise is, choose which of the 5 rotations you would want to do in a rural area, and for preferencing in that rotation, ONLY list rural sites. For the other 4 rotations, list NO rural sites unless you want to do more time rurally. The rule of thumb is: if you preference it rural anywhere in your list, you'll get it, so be aware of this. Personally, I chose to do my Surgical rotation in rural Mildura to escape early wake-ups and Melbourne winter, and I also did my Aged care rotation in Bendigo in the brand new hospital - I loved both rotations and would therefore recommend rural rotations to everyone.

As for what preferences most people got, I think I got four first preferences, and one that was somewhere else on my list. Most people probably aren't so lucky, but generally do get at least one top preference in their final allocation. These final allocations are revealed to you via email in late September.

Before starting each individual rotation, it's worth checking the handover sheet. This is a Google spreadsheet that students are encouraged to fill out once they have completed a rotation, and provides tips and tricks about the rotation. Ideally, every student would fill this out, but in reality it's probably less than 25% per rotation, which is a real shame. Regardless, hopefully you find that some decent soul has filled in something for your upcoming rotation, so you know what you're heading into.


Medical rotation
Medical rotations are my love, so I thoroughly enjoyed my rotation. I was fortunate enough to do a rotation at one of the large tertiary networks in an area that I am super interested in, and I tried to make the most of it. Obviously detailing my rotation would be of very limited use to most of the people in the degree, so here is my general advice:
- This is a rotation where you can really hone in on your intern skills. There will be plenty of opportunities to make the intern's life easier by doing procedures on the ward, doing discharge summaries, writing the ward notes, making referrals, etc. Try and do as much of this as possible as you'll inevitably have to do a Gen Med rotation next year where all of this is bread and butter. Should be noted, that anything you do should be run by your intern and should be checked by your intern, especially official hospital documentation. Technically, you should not be writing on drug charts or writing scripts, but definitely try and get some exposure to them.
- Just to reinforce this: for all the above, it's unlikely you'll have an intern who will hand you these opportunities on a platter. You have to seek them out, you have to be keen. I promise you that it will pay dividends for not only your transition into next year, but also how the consultants are registrars will view you. You want to be viewed as a member of the team, not another medical student. This is the key. I tended to stay doing jobs until 7pm some days, and as a result I had an amazing rapport with the team and was always invited to join out-of-hours rounds on interesting cases, Friday evening beers, extra clinics, and so forth. Be keen and helpful, and you'll learn way more.
- With that said... you are still a student. So don't be a slave. You're there to learn, not do all the boring work while your intern deals with the fun stuff. It's a fine balance between pulling your weight and learning. One way to make sure you get enough of the latter is to do what med students do: see patients. Try and be at the admissions (or do them yourself!), report back cases to your registrars when they have time, and ask questions. This is the last time you have to ask questions without feeling too stupid, so make the most of it!
- Do your pre-readings. It should be obvious, but if you're entering a rotation on Lung Transplants, and you haven't got a clue what they're about, you should really smash out some readings on the weekend before. UpToDate is my personal fav for seeking out information in a rush, so that's what I'll recommend. But seriously, you'll look like an idiot if you can't answer the basic questions you may be asked, and you'll also be lost for a good chunk of the rotation which negatively impacts on your learning opportunities.
- Onto something particular: discharge summaries. These are something that I wasn't taught how to approach, and it really took me reading a lot of summaries and doing heaps myself until I developed a format which I found to be reproducible across simple and complex patients in multiple medical and surgical specialties. Here's how I like to go about tackling these pesky beasts:

Many, depending on the series of lecture

Yes there is a practice CKT available from the Faculty.

5/5

Yes.

This is a year where textbooks should be utilised only if you really need to, as most of the learning should be occurring during working hours and not at the desk (unlike Year 4!). Personally, I'd strongly recommend at least having a look at the Australian version of "Marshall & Ruedy's On Call: Principles & Protocols", as it is a relatively succinct text on everything practical than an intern will be doing for patients on the ward (minus the paperwork!). As for other resources, as per my reviews of previous units and years, I'd also recommend utilising UpToDate, eTG, and http://radiopaedia.org/ as much as possible.

Varies between rotations and sites, but expect to be at your site the same hours as your intern or junior doctor. That generally means 8am - 5+pm for medical rotations, 7am - 5+pm for surgical rotations, and 8-10 hour shift rotations if in the emergency department.

Semester 1 and 2, 2017