MEDS90020: Principles of Clinical Practice 3

This rotation can be quite intense or relaxed depending on where you go. It’s split into Geriatrics (essentially General Medicine), Rehabilitation, Aged Psych and Palliative Care. It can be a rotation with lots of spare time – there isn’t much as much opportunity to speak to patients as they can be delirious, demented, mentally unwell or about to die.

The aged care guide from the university is your bible for this rotation, but it is missing information on Palliative Care. Refer to the eTg guide on palliative care and you’ll be set.

High-yield topics include:
•Orthogeriatrics and Falls Prevention
•Cognitive impairment: Dementia, delirium, depression
•Urinary incontinence
•Rehabilitation
•Polypharmacy
•Cognitive screening tools
•Social support and services (ACAS, respite, TCP, role of allied health)
•End-of-life care (managing symptoms, legal aspects)

Luckily there is no rotation-specific assessment in aged care.

Written examination - PCP3 rotation based (2 x 3 hours), end of semester 1, end of semester 2 (35%)
10x OSCE stations (2 per rotations) end of year (35%)
Mini-CEXs throughout the year (two per rotation, of which the best 8 will contribute to mark) (10%)
Written tasks specific to rotation (e.g. reflective piece in GP, discharge summary in Mental Health), throughout year (10%)
Standardised case-based discussion, end of year (10%)

This was one of my favourite rotations throughout the year. I was fortunate enough to be placed at the Royal Children’s Hospital, which I think is one of the most amazing hospitals to work at! There is a strong culture of teaching amongst the registrars and consultants – for example, at the end of most General Medicine rounds we would often be asked to talk about something we learnt in rounds and research a topic to present on the next round.

The lectures at the beginning of the rotation don’t usually pop up in exams. However, the high yield topics would be vaccinations, fluid management, SUDI/SIDs, non-accidental injury, HEADSSS screen, and physiological/pathological murmurs in children. Looking at the most important and common presentations, I would group them into clusters:

•Seriously unwell child (hypoglycaemia, DKA, meningococcal septicaemia, anaphylaxis, meningitis-encephalitis)
•Child with altered conscious state (afebrile seizures, febrile seizures, mimics)
•Child with changes to breathing (Asthma, bronchiolitis, croup, pertussis, epiglottitis, foreign body)
•Child with vomiting and abdominal pain (both surgical and medical causes)
•Failure to thrive (there are lots of differentials here)
•Child with fever
•Child with rash (infectious and inflammatory causes)
•Child with developmental delay (yes you need to remember your milestones)
•Child with a limp

When thinking about your differentials, it is useful to also group them by age as well, as some conditions are more common in certain age groups.
The RCH guidelines are more than enough to get you through – they’re very comprehensive and most questions are based off the guidelines. You can also find the RCH handbook for complementary information. The RCH Kid’s Info Fact Sheets are very useful as they’re mainly targeted at parents, so you can refer to them when practising how to counsel patients.

The rotation is split into three sub-rotations in ED, a random specialty and General Medicine. I personally found the ED shift to be the highlight of this rotation – we were able to assign ourselves patients and review them independently, after which a registrar would come and find us to present to them. They have seemed to develop a slick, well-oiled system. Shifts are usually 8 hours and split into an 8am-4pm and a 4pm-12am block, but you do not have to stay the whole time! In the morning I would advise coming in at 11am as it’s usually quiet until Fast Track opens at 11. Otherwise, your contact hours for the rest of the rotation are quite variable but I was able to be off by noon on General Medicine at the latest for most days.

You will also be able to attend a special session where you go to a local high school to practise your adolescent interviewing skills under the HEADSSS framework. Near the end of your rotation you will also have a simulation session of Advanced Life Support in paediatrics.

During this rotation you will have two rostered Mini-CEXs and you will have to write weekly reflections on interesting patients you see on the ward. Don’t worry about the reflections – they’re usually marked leniently.

General comments
MD3 has been the best year of medical school so far for me. This is your advanced specialty year, where you will rotate between Child and Adolescent Health, OB/GYN, Aged Care, General Practice and Psychiatry. You will shuffle through many different hospitals and clinics during the year, so make sure you have a private car available. Otherwise, the teaching in each rotation was great and all of my teams made an effort to include me as much as they could.

I found the year less time-intensive than earlier years, but this is variable depending on how much you want to stay back. You get more responsibility as you begin to help admitting patients into the ward, reviewing patients as needed, and finishing some mundane paperwork/scutwork. As usual, there will still be lots of free time spent observing on the wards however. When there was nothing interesting happening, my teams were always happy for me to leave early and study. Compared to MD2, you will find yourself with much more free time (and not clerk patients because you have no more long cases to do).

Lectures are usually front-loaded into the first week of rotation so that 90% of your time on subsequent weeks were devoted to your placement. I found that this worked quite well as I wouldn’t be completely clueless on my team, so to get the best value out of being on placement, study the material beforehand! Each rotation emphasises different parts of history and examination (e.g. birth, growth, immunisation, feeding, HEADSS for paeds, and forensic, developmental and psych history for mental health) so make sure you are familiar with these during your rotation.
Refer to the presentations and conditions in your study guides to get an idea of what you should be studying. Throughout the year, most questions expand past taking only a history + examination, but now you’ll need to discuss how you would address a patient’s concerns and most importantly, counsel them on their options.

I would strongly advise writing rotation-specific notes before you start that rotation, as you won’t be completely clueless when you start out. This was how I organised my year:
•CAH term: Finish CAH notes by Week 4, begin WH notes (which is by far the heaviest in terms of content)
•WH term: Finish WH notes by Week 4, revise for mid-year written exam
•AC term: Finish AC notes by Week 2, begin writing GP notes (which I knew would be the heaviest in semester two)
•GP term: Finish GP notes by Week 3, begin writing MH notes, begin OSCE practise
•MH term: Finish MH notes by Week 2, spend the rest of the term refining previous notes and revising

As for how to write your notes, I’m a huge fan of tableception. Compartmentalising similar things allows you to build up your own structure when answering questions.



Rotation-specific advice + study resources

On our very last day of OSCEs, one of our coordinators congratulated us for finally becoming “pretty much doctors now”. We all scoffed, but it’s great seeing the light at the end of the tunnel…and also dreading the light from the incoming train that is internship. Make sure that you have at least two references for the PMCV match in the next year – my suggestion would be to ask your GP supervisor and a consultant you’ve developed a good rapport with in clinic.

This year was by far the most interesting year of medicine for me – take as many opportunities to help out on the ward as you can, because I found that there was usually more than enough time to study throughout the year. That being said, you can always leave if you find that your time could be better spent doing something else. The end-of-year examinations are a major slog, with your assessments being scattered over two weeks, but you'll finally be able to rejoice as these will be the final examinations in medical school that count towards your Z-score!

This is the most highly variable rotation. There are two extremes – either your GP will make you sit in the corner and observe, or you’ll be independently consulting every patient you see. I would HIGHLY recommend that you go rurally for this rotation as you will have a higher chance of parallel consulting (e.g. independently seeing a patient and offering a management plan before calling the supervisor in to double-check). In my practice, patients would book to see me and I was expected to print off scripts, pathology requests, and write patient notes and referrals. If I was unsure about anything I could call my supervisor to come in, so you won’t be left to flounder. I had many great, memorable experiences – seeing a walk-in patient with renal colic in the setting of a solitary kidney, and another patient with ?PE, and I was able to call and handover to the nearest ED service for these patients. I was also thrown into some difficult encounters – such as talking to patients who had been sexually assaulted or were severely depressed, at times suicidal. It’s a good idea to reflect on the patients who leave a strong impression on you.

Many students in more affluent metro areas were essentially passive observers for their rotation, which is not ideal for learning. While it is intimidating at first, you will find that your clinical skills improve immensely by reviewing patients by yourself, and it’s great seeing how much you’ve learnt during your clinical years.

As for the content, you’ll need to revise common presentations from MD2, but there is added emphasis on preventative medicine. You should know about:
•All national screening programs (e.g. breast, prostate, colorectal, cervical screening, CV and diabetes risk, CKD, etc).
•The top 30 common presentations in RACGP (https://www.racgp.org.au/afp/2013/januaryfebruary/common-general-practice-presentations/)
•ALL of the content covered in the workshops and online modules – often appear on past examinations
•Motivational interviewing (e.g. smoking and alcohol cessation)

For the rotation-specific assessment, you’ll need to write a 1000 word reflective piece on a patient you’ve seen in clinic.

No

Clinical site-dependent

If you’re keen on a specific project, you can ask any potential supervisor whether they have a research project that is suitable for a medical student. Otherwise, wait for the SONIA database to open in April with a list of available projects. You’ll need to attend interviews with potential supervisors – make sure you come armed with questions about not only the project itself, but the working environment, how much work you’re expected to do, and what support you will receive. After projects have been finalised, you’ll need to submit a draft research proposal followed by your draft literature review. Since your supervisor is the one who assesses these, make sure you email working drafts to them with enough time so they can give you feedback before you submit.

There are two written exams in each semester: a WH/CAH, and MH/AC/GP. They usually consist of around 45 MCQs and 6 SAQs worth 20 marks each.

There is not much room for study before both exams. Your exams will be the week after you finish your placements for each semester, so you absolutely cannot leave study for the last minute. Studying and making notes ahead of each rotation will not only lighten your load coming into exams, but you’ll also be able to get more advanced teaching and feedback from your team if you understand what is happening on the ward.
Collaborating with others is a must before your written exams. To minimise your study workload, “divide and conquer” – upload past exam recalls onto a Google document and assign people questions to answer and present at each study session. It’s great for making sure you’re all on the same page, and I found it useful to hear answers that I had never thought of.

For the OSCEs, unfortunately, anything can be examined – even procedures. Start revising the whole year extremely early. Most people will begin to do some form of OSCE practise by August, three whole months before the end-of-year OSCEs. You’ll have two stations per rotation, so don’t neglect revising material from earlier in the year. Don’t just focus on your rotation-specific histories and examinations, but focus on the communicative stations as well. These can involve medication counselling, explaining a procedure to a patient, answering questions, breaking bad news, explaining results and negotiating a plan with the patient – the list goes on. Cover as many different types of stations as possible, because the medical school will throw you stations you’ve never practised before. It is imperative that you’ve practised enough so that you have a good structure and approach to each different type of OSCE station. As always, practise with others, see what they do differently, and keep refining how you’ll handle the stations. With an unexpected station, it’s important that you fall back to a structure to work your way through, but at the same time don’t misread the stem.

You don’t need to stress too much over the Standardised Case Based Discussion. You’ll be shown a video of an incomplete history that lasts for 4-5 minutes. Then you will tell the examiner what else you would like to ask, what you’d examine for, what investigations you’d like and how you would manage the patient. It’s very similar to a CSL, except you only have 15 minutes. Make sure to spend most time on history, but don’t run out of time. Practise how you will organise your notes from the example video they give you, and that should be enough.

A hugely important rotation with lots of spare time. Mental illness is incredibly common amongst the population and quite debilitating, so I would encourage you not to dismiss it right away – which a lot of medical students unfortunately do as it’s less concrete than other fields of medicine. It’s an under-resourced field and doesn’t get the appropriate amount of funding given the impact it has on society.

During your rotation you’ll be sent around to many different private clinics, inpatient units and other mental health services (e.g. Crisis Assessment Team). The patient demographics at each service is different. The Crisis Assessment Team, for example, reviews patients they feel are “high-risk” in an outpatient setting. Private clinics admit voluntary patients and refuse to admit involuntary ones, who are sent to public inpatient units. Therefore, those at public inpatient units are usually quite unwell and agitated. It can be quite confronting. You have to remember that these patients are being held against their will (which will frustrate anybody, especially if they don’t think they have a mental illness) and some attempt to abscond. Unfortunately, a lot tend not to improve either – non-compliance rates are higher compared to other fields as many don’t think they’re unwell anyway.

There is a logbook for mental health which will require you to interview patients, but there isn’t much opportunity to as you’ll mainly be relegated to being an observer. Make the most out of these by practising doing a Mental State Examination and then present to your registrar afterwards. If you get the opportunity to interview a patient do it – patients can be much more difficult to build a rapport with in a mental health setting, so this will help you be more comfortable asking difficult questions, using correct language in sensitive topics, and negotiating with patients who you can’t establish a rapport with.

If you can, attend a Mental Health Tribunal. These are independent hearings that review whether a person should still receive involuntary treatment. The treating team will present their case for involuntary treatment to a lawyer, consultant psychiatrist and community member. Patients may also represent themselves at the hearing, which can at times fracture their relationship with the treating team. No doubt will you be exposed to many interesting ethical dilemmas.

The amount of content in mental health is smaller compared to other rotations. The DSMV contains enough detail to get you through. Focus your studies on:
•Mood-affective disorders (major depression and bipolar disorder)
•Anxiety disorders (GAD, OCD)
•Psychotic disorders
•Panic disorders

The rotation-specific assessment requires you to write a letter to an imaginary GP updating them on a real patient you’ve seen. Follow the sample letters on MDConnect to have a good idea of how you should formulate your letter.

This is the most time-intensive and content-heavy rotation of the year. The first week of lectures is an absolute marathon, but it does provide around 85% of what you need to know. Otherwise, other resources include the Permezel textbook and the guidelines from PROMPT and RANZCOG. These should adequately cover what you need to know.

What makes this rotation so time-consuming is the much feared logbook, but each clinical site is lenient in its own way. You need to tick off a certain number of births, clinics, reviews and certain major procedures. While it’s a lot to look at, most people usually have no problem signing everything off by the latter end of the rotation – if this is your rotation before exams, try sign off everything as soon as possible so you have as much time to study as you can.

The great thing about obstetrics is that most women are healthy and well. Attending your first few births is quite a surreal experience – new parents literally crying with joy, unable to put babies in jumpers because they can’t stop their hands shaking – I had a dad literally grin and pat me on the back after waiting 14 hours for a baby to come out. It’s a time to cherish.

It’s different in each site, but you will usually be allocated a midwife to essentially shadow. Birth shifts entail a lot of waiting and observation, which can be quite boring for medical students. I would advise going on obstetric ward rounds with the doctors if possible and following them around, while letting your midwife know where you’ll be. This means that you’ll be able to attend to emergency Caesareans as they arise. Finally, if you’re able to, try and be allocated to a multiparous patient as labour is usually much shorter.

On birth shifts, most medical students will stand and observe but I would recommend you get as involved as you can. Palpate for the foetus and offer to insert catheters after each epidural. Nothing beats being the accouecher as well – try and see if you could catch the baby with the patient and midwife’s permission (because it is incredibly rewarding!)

The rest of your obstetrics term will entail clinic visits and a few random items here and there (e.g. US, pregnancy day assessments). As always, ask if you can see the patients independently if there are rooms available!

There are also lots of opportunities to get involved in surgeries. I'm not interested in surgery in the least, but it's still fun to ask if you can scrub up for most procedures. However, in gynae you’ll be usually relegated to the infamous job of holding the uterus up (which to be honest can get quite exhausting).

As for what’s important to study: every single lecture. I’m not kidding, but the good thing is that EVERYTHING will be reinforced on the wards. All of the material in Women’s Health is high-yield.

As for your assessment, you’ll need to write two case commentaries (one in obstetrics, one in gynaecology) based on patients you see. You will need references for each case so you should try and refer to guidelines. They can be marked quite harshly – so prepare yourself for it.

Recalls available on UMMSS

5 out of 5

Will outline rotation-specific study material below.
Although I never had it, "The Unofficial Guide to Passing OSCEs" is a great textbook to refer to.

Varies depending on rotation.

2018

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