THIRD YEAR

Third year can be tough. With so much going on, lots of students end up muddling through the year and exams. The key is to be organised and spread out the workload throughout the year. To help you guys out we’ve compiled this guide. We hope it will help shed some light on what everyone should know before embarking on the epic venture that is third med which may help you feel less like this:

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Rotation

The majority of your year will be spent on rotation. In first term there will be two weeks of lectures at the very beginning, followed by 2 rotations with one week of lectures in between, and then a block of 3 weeks of lectures just before Christmas exams. Then in second term you will have lectures once a week on Thursdays.

Generally people have at least 2 surgical placements (one in Tallaght, one in James’s), at least 2 medical ones (one in Tallaght, one in James’s), everyone does Ophth & ENT and you may be out in one of the peripheral hospitals like Naas, the hospice, the NRH in Dun Laoghaire, Peamount or the Hermitage.

The Tuesday sessions in second year were only a taste of what’s to come! For 2/4 weeks at a time, you will be attached to a ‘team’. A team is made up of a consultant and NCHDs of various grades. This includes interns (just finished final year), SHOs, a registrar, and a SpR (Specialist Registrar). It’s a good idea to introduce yourself to consultants early on in the rotation. Ask about the outline of their typical week. The things you’ll be expected to attend include ward rounds, clinics, MDT meetings, theatre, and journal club. If you appear enthusiastic and get your face out there, they’ll probably be more willing to teach you!

You’re probably used to ‘hospital clothes’ by now. It’s important to dress appropriately. Guys can usually make do with fitting their belongings in their pockets. For the girls, a discreet handbag is ok. Always have your stethoscope with you – but don’t wear it around your neck. Have your hospital ID card on display – you’ll get these when you start in each hospital. Other things that are good to have with you are an Oxford Handbook of Clinical Medicine (good for being productive when you’re waiting around for someone to return your bleep), a tendon hammer, pentorch, pen and paper and your logbook.

Get as many things signed off in your logbook as possible. Any time you perform a clinical skill, see an ECG, hear a reg talking about an acute scenario – these are all opportunities to bulk up your book. It took us a long time to figure out the difference between a long and short case so we’ll try to explain. A long case is a full history and exam, ideally observed by a consultant/reg. In reality, they may not have time to observe you but presenting to them afterwards is ok too. A short case is a short physical exam or inspection, eg auscultating a murmur, palpating hepatomegaly, describing a drain/tube/incision. These can often be signed off at the end of a ward round if you have seen some clinical signs. Some useful things to learn to recognise are hernias, stomas, scars, tubes, drains and ulcers.

If you’ve done basic clinical skills (tutorials on phlebotomy, iv cannula, ng tube etc) and someone on the team asks if you can do something, say yes! Ask them to supervise you the first time to get their feedback. They will step in if you run into difficulty. If you ask them to let you watch them do it first, and then watch you do it, you won’t be doing anything that day. Having said that, if you truly don’t feel comfortable doing whatever they ask, say you would prefer to observe.

This is the year to get really comfortable examining patients so that you appear confident come exam season.

Here’s some helpful advice about specific placements..

Hospice                                Buses 9, 16, 49 and 54a all stop on Dame Street and will bring you to Harold’s Cross. This is a really worthwhile placement which most students got a lot out of. The teaching is great. You’ll get lots of tutorials and there is time dedicated to presenting and getting feedback on your histories. Everyone does a 10 minute PowerPoint presentation on the last day.

NRH                       The journey from town takes about an hour. Get the 46A bus to Baker’s Corner and it’s a 10 minute walk from there. It’s on the outskirts of Dun Laoghaire so avoid the DART as the walk from the station is quite long. There is a dedicated tutor who does a lot of teaching and you may be asked to do a few short presentations. Try to attend some MDT sessions while you’re here.

Peamount           The only way of getting to Peamount (other than driving) is the 68 bus. This takes about an hour from town (it starts at Hawkins Street near College Green) or 45 minutes from South Circular Road just next to the Rialto gate of SJH. To get there for 9 o’clock you need to get the 7.50 bus which goes past SJH at roughly 8.10. Most days though don’t require you to be in that early. Later in the day buses are hourly so try and leave close to the timetable. It’s a respiratory rehabilitation hospital so know the resp exam well and the basics of asthma and COPD before going. Last but not least, look out for the Peamount pig!

Naas                     While students may not initially be very excited about going to Naas, in the end most people were really glad they were there. The teaching is fantastic. You have the opportunity to take free accommodation in a house right across the road from the hospital which is very handy.

Surgery               

  • You can go to theatre whenever your team are operating, provided it’s ok with them. If there’s more than 2-3 students assigned to a team, it’s a good idea to divide up the theatre time because often 2 is the maximum number of students allowed in at a time. Theatre lists generally start around 9.
  • You’ll need your hospital IDs to get into theatre and in James’s and the Eye & Ear you’ll also have to sign in.
  • In James’s, there are scrub machines which you can use once you ask at theatre reception for your card to be registered. When you’re finished with your scrubs, use your card in the machine in the corridor outside the changing rooms to return them. In Tallaght and the Eye & Ear: scrubs are in the changing rooms!
  • You need to wear your scrubs, a theatre cap and make sure your ID badge can be seen. Caps are in boxes in the changing rooms. If you know you’re going to be in theatre that day, you should bring a pair of runners or crocs (if you have a pair of those sexy shoes!) or something. Sometimes you’ll need to borrow a pair of clogs from the changing room. Grab a mask from the equipment room before going into the operating room.
  • You shouldn’t leave valuables in the changing rooms. When you’re going into theatre you can bring your phone, a small notebook, money with you in your pocket (basically: small things!). You can’t bring bags or stethoscopes or anything else in. We don’t have access to lockers in the main hospital buildings, so really if you have anything valuable with you that day, it’s best to leave it over in the locker room in the Trinity Centre.
  • Find whatever theatre your team are operating in (it’s on the noticeboard). Then you should hopefully find someone from your team that you recognise and ask them if it’s ok for you to be there for the next operation. Teams are generally quite happy to have you there. If you’re not scrubbing in, just stand back a little bit and DON’T TOUCH ANYTHING GREEN!

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  • The surgeon may ask you if you’d like to scrub in. If you’ve never done this before, ask a theatre nurse to teach you. It’s really important that everyone who is scrubbed in has done it properly, so if you don’t know what you’re up to, no one will mind if you ask for help. If you want an idea of what’s involved, just watch a few videos on YouTube.

Modules & Exams

Laboratory & Investigative Medicine

This is examined at Michaelmas and Hilary and, along with Pharmacology, comprises the majority of formal lectures. It is a combined Pathology and Microbiology module with a bit of Chemical Pathology and Immunology thrown in for good measure. The material is pretty interesting and it finally feels like you’re learning ‘medicine’. However, it’s a mammoth course and it’s a difficult task to comprehensively cover every aspect of pathology and microbiology in a single year. Our best advice is to work consistently throughout the year and be sure to attend all revision tutorial/lecture opportunities.

You will have a LabMed paper at Christmas worth 35% of your overall mark and another at summer worth 50%. At Christmas, the paper is entirely MCQ. It will consist of single best fit questions, which include Clinical Vignettes, and extended matching questions. The summer paper has the same layout with the addition of short answer questions where you will have to answer 10 out of a choice of 14. There is no negative marking in either of the papers. Some people will have a LabMed viva (pass/fail or honours). The material covered in the first term is carried over and examined again at summer. The final 15% of your overall mark is made up by a 3000 word essay that is usually due around the start of April. You choose your essay from a list of titles and it will either be Path of Micro.

The lecture notes are great for study, some people didn’t use anything else. A lot of the MCQs are made up from small details on the slides. If you prefer to use books, we liked Kumar & Clark and Robbins (some used big Robbins, others used baby Robbins). If you need to consult a book for microbiology ‘Clinical Microbiology Made Ridiculously Simple’ is excellent. Of note, many of the EMQs require a bit of clinical knowledge – it’s a good idea to know the signs and symptoms of common diseases even if they are not specifically mentioned in the lectures.

 

Pharmacology and Therapeutics

Like Lab Med this is examined at Michaelmas and Hilary with material carrying over. You’ll be happy to hear that most people find third med pharmacology easier than second med. It builds on your second year foundation and makes it a bit more clinical. This means less new esoteric drug names to memorise!

At Christmas you’ll have 50 T/F questions, 0.5 negative marking. At summer you’ll have 50 more T/F questions, 10 SAQs and 2 out of 4 essays. Last year the Christmas exam was worth 20%, the summer exam worth 60% and everybody had a viva worth 20% which also acted as a pass/fail or honours viva for those who were borderline.

The viva is nothing to be afraid of. You’ll be given a patient’s drug chart to work through describing each drug, drug interactions and errors on the kardex (these vary from a missing prescriber signature to incorrect doses of common drugs to drug contraindications etc.). You’re also asked for your impression of the patient’s condition(s). This exam is actually a lot less intimidating than it might sound; there are Kardex tutorials throughout the year in which they cover cases that are very similar/identical to those that come up in the exam. If it’s a pass/fail or honours viva you may also be asked additional questions related to your written exam.

The lecture notes for pharmacology are generally quite good and you can definitely do well with them alone. Take heed if you hear the words ‘That would make a nice MCQ, wouldn’t it?’! A BNF is also really useful. A new one is published every 6 months so if you ask the hospital pharmacy very nicely, they might let you take an old one. Just don’t all go at once! We found it useful to draw out the flowcharts for treatment plans, e.g. heart failure, anxiety, community/hospital-acquired pneumonia; and know the doses for the ‘big’ drugs, e.g. low-dose aspirin, heparin, antidotes.

 

Principles of Medical/Surgical Practice

This module pertains to placement, including clinical tutorials during attachments and radiology tutorials etc. There are 4 components to the assessment for this module:

  • Medicine/Surgery MCQ paper – 35%
  • Short case Assessment – 10%
  • Medicine/Surgery OSCE – 50%
  • Logbook review – 5%

Don’t be too deterred by the vagueness of the exam title and complete lack of past papers… The medicine/surgery MCQ paper is actually not bad. You have it at the end of the year along with your other summer exams. It’s primarily based on tutorials held during placement and the radiology tutorials given during the year. Unfortunately not everyone has the same clinical tutorials/placements. It is a good idea to ask your friends what material was stressed by their tutors in the peripheral centres. Nonetheless this exam is not hard and it’s actually nice knowing you can’t really prepare (read: cram) for it. There’s a fair bit of crossover with Lab Med.

The short case exam is enough to strike fear into the heart of even the most competent medical student. Fortunately it’s really not as bad as it seems! It involves doing a quick physical exam on a real patient and presenting your findings/answering the examiner’s questions on the case. You can also talk to the patient while you’re conducting the exam which can help you get a better clinical picture. Most of the examiners are very nice and really don’t expect too much from you. Don’t worry if you can’t come up with a diagnosis. They just want to see that you have some basic knowledge, you have a logical approach and that you’re safe. Don’t forget to wash your hands!! Don’t make anything up, eg don’t pretend you hear a murmur if you don’t. The examiners will prompt/guide you along if needs be. As long as you have your systems exams down you’ll be flying. Sites like http://www.geekymedics.com and http://www.surgicalnotes.co.uk (this is for postgrad exams but you can use it selectively) are very useful. This exam is good preparation for final med where there are short cases as part of both medicine and surgery. This usually takes place around March and then you will have 2 more short case assessments , 1 Medicine and 1 Surgery, as part of your OSCE in June.

The log book review is done as a station at your clinical skills OSCE in March. You sit down with one of the clinical tutors who looks through your logbook (some skim through, some go through in meticulous detail – it really depends who you get). They then give you’re logbook a mark out of 100 depending on how much of it is filled out at this stage. You then have another logbook review as part of your MedSurg OSCE in June.

The MedSurg OSCE takes place at the very end of the year in June. It consists of 3 written stations, a history taking station, 2 short case stations, a logbook review and a rest station. Each station lasts for 6 minutes. The written stations include a radiology station, an ECG station and a data interpretation station. In these stations you will be given an example of an ECG or an X-ray or blood test results and asked a few short questions on each. The history station is essentially an extension of the history done for the second med OSCE. You have 6 minutes to obtain the history (from an actor), present it to the examiner and formulate some semblance of a differential diagnosis. Most of the cases are simple enough and it shouldn’t be too hard to diagnose the patient’s condition. The logbook review is similar to the one you will have had at March except this time you select 4 /long cases (2 medical and 2 surgical) from your logbook and the examiner chooses one case for you to present. You can’t bring any notes about the case in with you but don’t worry about knowing the details off by heart. They’ll listen to a brief presentation and then ask you some questions about the case, eg imagine you’re an intern who has just taken this history. What would your differential be? What investigations would you do? What are the possible treatments? These are cases you will have taken throughout the year so there’s plenty of time to prepare these answers. The short case stations will be the same as the short case assessment you will have had earlier in the year, with one being medical and the other surgical. The same advice still stands for these. They just want to see that you have some basic knowledge, you have a logical approach and that you’re safe!

 

Ophthalmology & ENT

Everyone will spend 2 weeks on Ophthalmology and 2 weeks on ENT in the Royal Victoria Eye & Ear Hospital.

Ophthalmology includes a written paper and a practical exam. For us the practical exam took place during our rotation and involved doing a standard eye exam. You’ll be taught this during placement and there is also a video available on the TCD ophthalmology website. Preparing for this will serve you well in the long run as there are easy marks to pick up. The written exam in June is made up of 50 MCQs and 4 SAQs where they show you a photo of an eye and you have to come up with the most likely diagnosis, talk about what investigations you would do, the treatment and also the complications. Definitely know the self-assessment lecture (on the Ophth website) for these. The website also has podcasts by Prof Cassidy which are a great learning resource. Her book ‘Ophthalmology at a Glance’ can supplement these.

ENT is a written exam only. You’ll have 5 SAQs to do in an hour. Teaching is given during your rotation in ENT in the tutorials by Emma Cashman. These tutorials are usually all you need to know for the exam. There is also a straightforward exam at the end of your ENT placement which doesn’t count towards your final grade and is again based mainly on material given in the tutorials.

Of note these exams count towards your final med grade in Surgery, 0.5% each.

 

Advanced Clinical & Professional Practice

For this module your clinical skills OSCE will make up 40% of your mark. The OSCE is similar in structure to the second med OSCE, being a slight step up in terms of difficulty. Clinical skills are taught during medical and surgical rotations both in SJH and AMNCH. The best advice is to attend your scheduled clinical skills tutorials and take any opportunities you have to practice. The tutors are usually very receptive to you coming to practice outside of your timetabled tutorials and clinical skills can provide some respite from rotation or is an option when all members of your team seem to have vanished from the hospital (and it will happen…).

There are a number of other components and assessments which make up this module. These include Global Determinants of Health and Development, Psychology and Psychiatry Applied to Medicine (PPAM), Medical Ethics and Inter-professional Learning (IPL). Global Health week took place during the 3 week block of lectures before Christmas. During this week you’ll have lots of great speakers, it’s quite eye-opening. For the assessment you’ll be assigned into groups and given a topic that you must make a poster presentation on. You’ll also have two weeks of PPAM lectures in second term. This builds on some of the stuff you covered in HDBS in first year and helps prepare you for your Psychiatry rotation in fourth year. You’ll have a choice of assignment – one option is a 2 day personality workshop. In your logbook there will be a page for you to fill out your ethical reflection on a scenario that you encountered during your time on placement. Near the end of the year a member of the ethics team will meet with you to discuss and assess your reflection. The final component of this month is 3 mornings of IPL that also take place in the 3 weeks of lectures before Christmas. This is like PBL with students from Nursing, OT, Physio, SLT and Dietetics. You have a very short assignment or reflection to complete at the end of this. Try to get these small projects and assignments done as soon as you can so they don’t build up.

Evidence-Based Medicine

You have lectures about evidence-based medicine (EBM) throughout the year and before Christmas you’ll write an EBM paper as a group. This is a very small module that is also assessed by your elective report after your 3rd year elective in summer.

 

SUMMARY

In summary guys, it can be a tough year so pace yourselves, try stay on top of everything but don’t take it too seriously – its the last year that doesn’t really matter. Enjoy the weekends, come to all Biosoc events, turn up to placement hungover and don’t feel too bad when you ‘accidentally’ sleep in.

After all that it’s still legitimate to feel like this when asked by a caring relative: What specialty do you want to do?

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