A Pocket Guide for Medical Students: From Enrollment to Job Interviews 3031273419, 9783031273414

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A Pocket Guide for Medical Students From Enrollment to Job Interviews Sarah Cuschieri

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A Pocket Guide for Medical Students

Sarah Cuschieri

A Pocket Guide for Medical Students From Enrollment to Job Interviews

Sarah Cuschieri Faculty of Medicine & Surgery University of Malta Msida, Malta

ISBN 978-3-031-27341-4    ISBN 978-3-031-27342-1 (eBook) https://doi.org/10.1007/978-3-031-27342-1 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my beloved husband who is my rock and has shown great moral support and love throughout my professional career

Preface

Enrolling into medical school is a prestigious venture in anyone’s life but few really appreciate what it embodies until one is neck deep in the system, which may be too late for some. As a former medical student and now resident academic teaching future medical students, I have first-hand experience of this torturous journey that students face. While some flourish, others struggle as they try to find their way and reach their target. Unfortunately, some do not make it and drop out before completing the whole degree course, a tragic episode that might be preventable if prospective students are better informed and equipped with what medical school truly entails. The book is targeted at future and enrolled medical students with the main aim to help them get to grips with what the medical degree is all about, what are the different phases encountered as well as how to survive them. The book will also venture on what to expect once graduated as a doctor. Msida, Malta

Sarah Cuschieri

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Acknowledgment

My sincere gratitude goes to Elizabeth Grech, my former student and now a dear friend who inspired me to write this book.

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Introduction

Medical student, a golden status that many dream of. Achieving this status comes with great responsibility and should not be taken lightly. Yet, few medical students know what is to come as they enter medical school. Studying hard is just the proverbial tip of the iceberg as several “hidden issues” lie dormant until you come face to face with them. Indeed, no one will tell you unless they have been through the experience themselves. This book is intended to go over the A–Z of a medical student’s experience, expectations, and requisites as they enter medical school and then graduate. It features personal experiences both as a medical student and a resident academic, covering what is expected out of medical students by the institution. The experiences shared are based on a UK-based system; however, most features and issues are shared by all medical students across the globe. This is a unique feature that will enable medical students to understand that they are not alone, others have experienced their fears, desires, hardship yet there is hope. The book will provide tips of how to survive the course, how to deal with arising issues and understand how to balance studying and living a life. It intends to also outline the importance of research during medical school and how to go about it as well as how to prepare for the job interview for a medical doctor (foundation doctor) post including formulating a CV and finally provide an insight of life beyond being a medical doctor.

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Contents

1 W  hy Medical School and How to Enrol?��������������������  1 1.1 Introduction����������������������������������������������������������  1 1.2 Reasons to Enrol or Opt Out of Medical School ����������������������������������������������������  2 Reasons for Opting to Enrol into Medical School ����������������������������������������������������  2 Reasons for Opting Out from Enrolling into Medical School����������������������������������������������  4 1.3 The Process to Enrol into a Medical School��������  5 Applying for a Medical School in the UK������������  6 Applying for a Medical School in the USA����������  6 Applying for a Medical School in Europe������������  7 1.4 Practical Points to be Aware of Before Enrolling into Medical School������������������������������  7 Further Reading �������������������������������������������������������������� 11 2 C  ongratulations on Making It to Medschool: Now What? �������������������������������������������������������������������� 13 2.1 Introduction���������������������������������������������������������� 13 2.2 Preparing for the Big Day: The First Day at Medical School�������������������������� 14 2.3 What Is the Difference Between Preclinical and Clinical Medical School Years?������ 18 2.4 Help! How to Survive First Year? ������������������������ 20 2.5 An Insight into the Preclinical Students’ Life������ 23 Further Reading �������������������������������������������������������������� 25

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Contents

3 I s It All Study and No Fun?������������������������������������������ 27 3.1 Introduction���������������������������������������������������������� 27 3.2 Extra-Curricular Activities������������������������������������ 28 3.3 Engaging in Student Associations������������������������ 29 3.4 Clinical and Research Exchanges ������������������������ 30 3.5 Study-Life Balance ���������������������������������������������� 31 3.6 Relationships�������������������������������������������������������� 32 Further Reading �������������������������������������������������������������� 33 4 T  he Clinical Years���������������������������������������������������������� 35 4.1 Introduction���������������������������������������������������������� 35 4.2 The Expectations of Clinicians Out of Clinical Students���������������������������������������� 36 Surgical Theatre Expectations������������������������������ 39 4.3 Surviving the Clinical Years���������������������������������� 41 4.4 An Insight into the Clinical Students’ Life�������������������������������������������������������� 46 4.5 Harassment������������������������������������������������������������ 49 Bullying���������������������������������������������������������������� 50 Discrimination������������������������������������������������������ 51 Sexual Harassment������������������������������������������������ 51 4.6 The Final Clinical Exam �������������������������������������� 52 What Is a Clinical Viva Examination?������������������ 53 Tips to Surviving the Clinical Stations and the Cross-Examination ���������������������������������� 54 Preparation for the Exam�������������������������������������� 55 Further Reading �������������������������������������������������������������� 57 5 R  esearch During Med School��������������������������������������� 59 5.1 Introduction���������������������������������������������������������� 59 5.2 What Is Research and Should I Engage?�������������� 60 5.3 I Am a Student. What Research Can I Do?���������� 61 5.4 All there Is to Know to Kick Start a Research Project������������������������������������������������ 63 Literature Review�������������������������������������������������� 64 Study Design�������������������������������������������������������� 65 Permissions ���������������������������������������������������������� 66 Data Collection ��������������������������������������������������  66

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5.5 How to Write a Scientific Article as a Student ���������������������������������������������� 67 The Methods Section�������������������������������������������� 67 The Results Section���������������������������������������������� 69 The Discussion Section���������������������������������������� 69 The Introduction Section�������������������������������������� 71 The Abstract and Keywords���������������������������������� 71 5.6 How to Publish as a Student �������������������������������� 72 Further Reading �������������������������������������������������������������� 75 6 P  reparation for the Foundation Doctor Job Interview ���������������������������������������������������� 77 6.1 Introduction���������������������������������������������������������� 77 6.2 What Is a CV and How to Prepare One���������������� 78 6.3 How to Prepare for the Interview�������������������������� 79 6.4 All About the Big Day������������������������������������������ 83 On-Site Interview�������������������������������������������������� 84 Online Interview �������������������������������������������������� 84 Further Reading �������������������������������������������������������������� 85 7 L  ife After the Medical Course�������������������������������������� 87 7.1 Introduction���������������������������������������������������������� 87 7.2 What Comes After the Completion of Medical School? ���������������������������������������������� 88 From Interview to Getting into the Speciality You Want���������������������������������������������� 89 The Hierarchy of the Clinical Professional World������������������������������������������������ 90 An Insight into the Medical Doctor Life�������������� 92 7.3 Is Medschool the End of the Studying Journey?������������������������������������������������ 95 7.4 I Do Not Know What Speciality I Want to Pursue: Should I Worry? ���������������������� 97 7.5 An Overview of What Each Speciality Offers You ������������������������������������������������������������ 99 Further Reading ��������������������������������������������������������������103

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Why Medical School and How to Enrol?

1.1 Introduction Many perceive that successfully enrolling into medical school and gaining the status of a medical student is the pinnacle of the undergraduate journey. Some may also envisage it as having managed to overcome the biggest hurdle of their professional life or else the golden bullet towards becoming one of the elites, a medical doctor. Although it is prestigious to be enrolled into medical school, it is not the end but rather the start of a long and treacherous road that you need to take seriously. You need to be prepared for hard work ahead while always remaining humble. I am not saying this to scare or to dishearten you but rather to provide a realistic picture of what is to come. Many have succeeded, and so will you, but you need to be prepared. Something that you should know from the start is that becoming a doctor is not for the fame and fortune but to passionately help others, to dedicate your life to help maintain the health and well-being of the individuals under your care and ultimately to save lives. This might sound equally scary and thrilling. Whichever emotion you might be experiencing, you need to remember that there is a whole process that you must endure and undertake before you are cut loose to be a fully fletched self-sustaining doctor. The first step is to successfully enrol into a medical school.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Cuschieri, A Pocket Guide for Medical Students, https://doi.org/10.1007/978-3-031-27342-1_1

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1  Why Medical School and How to Enrol?

1.2 Reasons to Enrol or Opt Out of Medical School There are various reasons that should prompt anyone interested in medical sciences to apply for a medical degree. Obviously, this can only be done if one has obtained the necessary examination grades and is eligible to enrol into a medical school. Table  1.1 provides a summary of the reasons to opt in or out of enrolling into a medical school, while below you will find a more comprehensive explanation for each of these reasons.

Reasons for Opting to Enrol into Medical School As already mentioned, the prime reason for enrolling into medical school should be based on your passion to alleviate people’s pain and suffering. There are various ways to achieve this, it does not mean that every doctor needs to be working at the accident and emergency department! There is a multitude of different specialities that stem from graduating as a medical doctor. These range from clinical based to research based. Some doctors opt to continue their professional careers in clinical research. This provides the opportunity to identify and establish potential new cures or medicines for certain diseases, such as cancers. However, we will be discussing the various specialities and career opportunities later in this guide, so stay tuned. Table 1.1  A summary of the reasons to opt in or out of enrolling into a medical school Medical school Opt in Improving health and well-being of others Health leader Diverse job opportunities both clinical and non-clinical Jobs in high demand Contributing to new cures and medicine Continuous learning

Opt out Just for the money Just for the prestige Medical TV dramas look cool Pressured from parents Want a great work–life balance

1.2  Reasons to Enrol or Opt Out of Medical School

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Graduating as a medical doctor opens the doors for many career choices ranging from working in hospitals, in primary healthcare, in research labs, in universities as well as in the industry and in management positions. The world is your oyster once you graduate. It does not necessarily mean that you will know what speciality or career path you want to embark upon from day 1 of your medical school, nor while you are still a junior doctor. Your interests may change overtime as you experience new opportunities. Speaking from experience, I was faced with a career crisis when I came for my basic speciality trainee (BST) selection. Upon entering medical school, I was convinced I wanted to become a surgeon, and this ambition continued to grow across the years. The number of hours I spent in an operating theatre assisting different surgeons during my medical school years is unprecedented, yet when I started to work as a junior doctor, I realised that as much as I loved (and still do!) surgery, it was not something that I can realistically pursue. This hit me hard, and I was faced with a very difficult decision of “What am I going to do with my life?” Although I did apply for different specialities and got accepted, my heart was not really into any of my choices. However, I got very lucky to land the opportunity to apply and get accepted for a fulltime academic and researcher post with the Faculty of Medicine and Surgery at the local university. At the time of enrolment, I was still shaken by this decision, I was leaving behind the clinical practice world which I was accustomed to, for an unknown territory as I moved into an academic career. Ten years down the line, I do not regret my decision as I found my true calling. So, the morale of the story is, sometimes opportunities present themselves unexpectedly, do not be afraid to leap and take a chance. Once a doctor you will always remain a doctor for life, and you are able to find medical jobs anywhere in the world. Indeed, doctors are in high demand in some countries more than others, so it is difficult not to find a job. A medical career also offers a lifelong learning opportunity and an intellectually stimulating process. As a doctor you have a duty towards your patients to keep on learning, acquiring new knowledge and skills throughout your professional life. Additionally, becoming a doctor means you will be a health leader. Although initially as a junior doctor you will mostly be

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carrying out the tasks entrusted by your consultant, in time you will become fully independent and a leader for your patients. It needs to be highlighted, that even as a junior doctor, you will still be perceived as a leader by your caring patients and their relatives as you will interact directly with them throughout their admission to hospital. Even though not everyone is born with flawless leadership skills, time and experience will get you there. So, no panic!

 easons for Opting Out from Enrolling into R Medical School If the main reason for wanting to enrol into medical school and becoming a doctor is to become rich, then you have the wrong mindset. In which case, it is better if you opt to become a lawyer or a banker or get into business. You need to love what you are doing irrespective of the hours you are working or the number of patients you are consulting/operating. Another aspect that you need to keep in mind is that most students need to pay for medical school and postgraduate training later. This is very expensive, and you will be dealing with huge loans, so a proportion of your doctor’s wage will be going towards these loan repayments. A doctor’s job does come with prestige. This alone should never be the reason for choosing to become a doctor. If it is, you are heading towards a life of dissatisfaction. In time, you will realise that graduating as a doctor should be the first step towards finding your call-in life. Whichever path you decide to take in your professional life, you will be required to undertake postgraduate exams and degrees that will enable you to achieve more qualifications and progress in your profession. Do not apply for the medical course if your inspiration is solely a TV medical drama. There are loads of medical TV dramas from the famous “Grey’s Anatomy” and “House” to “ER,” “Good doctor,” “Scrubs,” and “New Amsterdam” among many others. Although these are based on a doctor’s job, they are a far cry from illustrating the real deal, with a lot of discrepancies, unrealistic scenarios, and some simply crazy ideas! I am not in any way implying or suggesting that these cinematic productions should

1.3  The Process to Enrol into a Medical School

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be abolished. I love watching them as they are entertaining. One needs to take them at face value and not let him/herself pursue a medical career based solely on fiction. Some of you might be coming from a generation of medical doctors and this might subconsciously pressure you in applying and enrolling into medical school. However, You, as a person needs to have the passion for this life and profession. Neither of your parents will be doing the studying for you nor carrying out the long sleepless nights during the night shift calls. So be sure that your decision to enrol to medical school is based on your own desires and aspirations and not someone else’s. The work–life balance of a medical doctor needs some time to get accustomed to. It is not the typical 9 a.m. to 5 p.m. job, free relaxed weekends, and predefined holidays (Christmas, Easter, Summer, etc.) are not a guarantee. Additionally, there are days where you will be covering night shifts, meaning you will not be going back home to your cosy bed but rather will be spending the night at hospital, working. For some, this type of lifestyle is acceptable but for others it is a living nightmare. I am one of these people, I could not tolerate night duties as much as I tried to get into the correct mindset. I was simply not cut out for it. This played a major role in my decision to shift from a clinical based job to an academic one. These are some of the pros and cons that you should be aware of before venturing into the medical world. I understand that I might have dropped a bomb upon some, but if deep down this is what you want to do, there is no stopping you. Dedication, hard work, and perseverance are the key to success.

1.3 The Process to Enrol into a Medical School The application process to apply to a medical school is country and continent dependent. It is paramount that from an early stage you get acquainted with the medical school’s enrolling process of each university you have targeted. Personally, I come from a UK-­ based university structure; however, I will be briefly outlying the typical application process for medical schools not just situated in

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the UK but also for those in the USA and in Europe. However, it is highly recommended to go over the application requirements meticulously for each individual medical school.

Applying for a Medical School in the UK All the medical schools across the UK (England, Wales, and Northern Ireland) require an application form that includes a personal statement. This highlights the reason/s why you want to enrol into a medical school along with an understanding of what you have achieved in your life so far. Therefore, the personal statement should include any academic prizes or sports achievements, the mention of any projects you have worked on, your personal life interests and hobbies. Evidence of any work experience or voluntary service at a medical or healthcare facility is expected, along with letters of recommendations. Additionally, the prospective student requires to have achieved a good GCSE grade in science, mathematics, and English with a combination of AS and A-levels. An A-level in both Chemistry and Biology is a requisite, with often another science subject being required such as physics or mathematics along with a good grade A-level in an arts subject. There is the possibility of applying to a medical school with other qualifications, but this is subject to each medical school’s regulations. Some medical schools also apply admission tests as part of the application process, such as the UCAT. Proof of English language proficiency is another requirement. It is standard practice to be invited for an interview if your application form is accepted, before being offered a definite spot in the medical course.

Applying for a Medical School in the USA The USA admission system differs from the UK and the European one. Medical degrees in the USA are considered as a second entry degrees, where a prospective student needs to first finish a bachelor’s undergraduate degree in a science subject, with the popular choices being Biology and Chemistry. It is only after successfully

1.4  Practical Points to be Aware of Before Enrolling into Medical…

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completing this degree that a student can apply for a medical degree. The general admission requirements to a medical school include having a high school diploma, an undergraduate degree in a science subject, a minimum undergraduate GPA (grade point average) of 3.0, a good TOEFL (test of English as a foreign language) language score, minimum MCAT (medical college admission test) exam, letters of recommendations, personal statement, and evidence of extra-curricular activities. Some medical schools in the USA have additional requirements like the completion of premedical courses.

Applying for a Medical School in Europe The European medical schools although sharing similar admission criteria have unique processes, so again I stress the importance of acquainting yourself with the medical school/s of your choice. Additionally, medical schools across Europe typically require students to have a good proficiency in the native language example German, Dutch, Finnish, etc. The most common requirements are a high school diploma, good marks in Biology, Chemistry, Physics, and Mathematics, Letter of motivation, Letters of recommendations, and evidence of voluntary or work experience related to healthcare. The setup of the medical course also varies between countries. An example are the Netherlands and Germany, where a Numerus Clausus applies. This means there is a limit as to how many students are enrolled to medical school each year.

1.4 Practical Points to be Aware of Before Enrolling into Medical School I come from a non-medical background, and I was the first family member to venture into this field. With no prior knowledge of what is in store for me, I was a bit at a loss of what to expect. The passion and drive to become a doctor evolved from my younger years. As a small child, the thought of helping others always fas-

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cinated me, but that was it. I did seek advice from two doctors that just graduated at the time I was applying for medical school. They advised me there was a lot of studying involved and that I might not feel it is worth venturing into the medical world. At the time I felt like they were trying to dishearten me from applying to medical school but looking back I understand their point of view. Maybe finding a more diligent way to share their experiences might have been beneficial, which is something I will be trying to do in this section. Medical school is not a piece of cake, you need to have perseverance and be ready to be knocked off your riding horse multiple times. The most important thing is that you stand up, shake off any bad emotions, and learn from the experience. Medical school is there to help you reach your goal in a progressive fashion. Do not expect to be dealing with patients from day 1. You cannot run before you learn how to crawl; this also applies to your medical training. The first years, also called preclinical years, you will face a mammoth amount of memory work. New concepts, principles, and terminology will take up most of these years. You may at some point in time feel like you are drowning in material that has no significance to becoming a doctor at all. Some people may also start to get disheartened and ask the questions “what am I doing here?” “this is not what I signed up for, is this what makes up a doctor’s life?” Let me assure you that it will get better. Even if at the time you will feel that your preclinical years are a total waste of time, I did when I was at that stage, looking back I understand that those were the basics that shape up your clinical years. If you do not have good foundations, the end product will not be strong but rather wobbly. So be prepared, the preclinical years are laying the foundations. You will find these extremely useful as the course progresses. It becomes more intellectually challenging, and intriguing as you carve your path through medical school. Your studying technique might need refining or even a complete overhaul. In medical school you need to continuously be on top of your study, you cannot afford to leave the studying to the end of the semester. If you do, you run the risk of not passing the exams, apart from the fact you will be missing out on participation in small group teaching and understanding the concepts.

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Wearing my academic hat, I can tell you that we can spot a well-­ read and prepared student from a mile away. It is that student that will be able to comprehend the topic well, be able to follow lectures flawlessly and participate in a critical and analytic way during small group teachings. Those that do not prepare continuously will miss out a lot and it is a shame. This is apart from the fact that it is really frustrating as an academic to be met with blank stares instead of positive interactions. Academics are there to help you excel and reach your goal, but we are not there to spoon-feed you nor to hold anyone’s hand. Therefore, consistency in your studying routine is paramount as is time management. By no means am I saying that you will be a slave to your studies, a study–life balance is important, and this will be discussed in more detail later. You need to have the mental and characterisable plasticity to work around these changes. This also applies with regard to the format of examinations. Not every medical school will follow the same examination format but multiple-choice questions, extended matching questions, best out of five questions, short answer questions, and essays are the typical examination formats, apart from the clinical examinations and oral exams. Identifying the best study routine that fits your personality and needs might take some time and getting used to. What works for you does not necessarily work for someone else. Therefore, do not compare your studying style to others, nor do you get intimidated by what your peers claim. You will meet peers who will brag that they never study, or that they cannot comprehend the studying process and they are going to fail, etc. They might be genuine and if you have the capacity to help them out, do so. Afterall even if medical school is very competitive, compassion and collaboration should take frontstage, as this is basis of being a good doctor. However, there are students who use the “no study” or “I am not going to pass” mantra to throw their competition off their path, a way to intimidate their peers and get into their heads. I have experienced first-hand a peer who used such mantra just before examinations. Although during my first year I got intimidated, I soon realised that this was a cunning tactic to derail the competition. This student used to get very high grades across the board, so it was very clear what the intentions were. What I used to do is to

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stay away from the examination hall until the very last minute to ensure I do not get any negative vibes from any of my peers while concentrating on my examination preparation. Additionally, it is important to remember that you are studying to become a good doctor and not to pass the exams. The latter attitude will lead to frustration and insufficient knowledge as you progress across the medical school years. Peer support is important, finding a supportive group of friends is imperative. Entering medical school as a lone wolf is tough but it does not preclude you from starting a conversation with the person next to you. Interaction with your classmates is important and it is through such exercise that you will meet and formulate friendships. I know, it is easier said than done, and here again I speak from experience. Unfortunately, the group cliques will dominate, especially if a group of students will be entering medical school from the same previous institute and were already friends. If you are not part of that group, you may not be welcomed with open arms. It does not necessarily mean that things will not improve but it is a reality. The competitiveness of the course and human nature attitude that no one wants someone else better than oneself might also hinder strong friendships. Yet, I would encourage you to identify at least one other person that you can trust and that together you can support each other. There will be instances where you need someone to talk to, someone who is in your exact situation and can understand your frustration, your joys, or your concerns. Later, when you are on the wards, you will need someone to be there with you while you are talking to patients or examining them. So, do not isolate yourself from your peers or perceive that you can manage on your own. Very few might be aware of the importance of starting to work on your curriculum vitae (CV) as early as first-year medical school. Unfortunately, as years progress, it is becoming more and more competitive to get a job in certain hospitals or rotations that you might wish to explore. Your fate will be dependent not only on passing your medical school exams but on your CV and the final job interview. Although these will be discussed in more detail later in this guide, you need to be aware that CV building is important and should be on top of your medical school agenda from the word go.

Further Reading

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Further Reading Kumar K, Roberts C, Bartle E, et  al. Testing for medical school selection: what are prospective doctors’ experiences and perceptions of the GAMSAT and what are the consequences of testing? Adv Health Sci Educ Theory Pract. 2018;23:533–46. https://doi.org/10.1007/s10459-­018-­ 9811-­8. McManus IC.  Medical school applications—a critical situation. BMJ. 2002;325:786. https://www.bmj.com/content/325/7368/786.long\.

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Congratulations on Making It to Medschool: Now What?

2.1 Introduction Receiving the medical school letter of acceptance calls for celebration and may be even merits popping a bottle of champagne! You do deserve credit for this milestone. This also means that you are about to embark on one of the toughest (if not the toughest!) undergraduate courses. As the first day of medical school creeps forward it is natural to start getting goosebumps and potentially some concern about what is going to happen once you walk through those large lecture room doors. Self-doubt may be experienced on whether you are good enough, how you compare with your fellow students, how demanding the lecturers might be, etc. Let me stop you here and ask you to breathe in and out. We have all been in your shoes. Yes, it is daunting to start a new degree especially after the big build-up towards high expectations and demanding aspects surrounding the medical course. But if you have been accepted into medical school it means you have shown the potential, ability, and quality to be part of the first-year medical students’ cohort. This does not mean that you can relax and let your intuitive guard down. Rather apprehend the fact that you belong in the course, and it is now time to roll up your sleeves to continue working to achieve the ultimate goal, i.e., graduating as a doctor.

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2  Congratulations on Making It to Medschool: Now What?

2.2 Preparing for the Big Day: The First Day at Medical School As the first day of medical school approaches, it is advisable that you familiarise yourself with the layout of the first-year curriculum and modules. Every medical school has an online presence outlining modules’ description. They commonly portray the expected yearly outcomes including their objectives, expected skills to be achieved at the end of the module and the corresponding core textbooks required. Ideally you identify the core textbooks that you will need for your first year early on, in order to give yourself ample time to obtain a copy of each book before starting the academic year. Whether you opt to have an online version or a paper version of the textbooks is totally up to you. Call me old-fashioned, but I prefer a paper version that I can scribble notes on, stick coloured sticky notes, and get the satisfaction of turning a physical page over as I progress in my study. Yet, with the dominating digital era, a virtual book might be more up your alley. Whichever route you decide to take, make sure that once the textbook is acquired, you go over it, just to get the feel of what is to come. A tip on core books especially anatomy books. There are a lot of good books on the market which may or may not be on the reading lists provided by medical schools. It is advisable to familiarise yourself with them before purchasing and identifying which book fits your learning personality. Once you have done that, stick to it. It is useless buying all anatomy books under the sun and trying to read/study them all. Anatomy is and will remain anatomy, it will not change, so it will be a waste of time to try to divide your precious time to go over a million books! You can always seek advice from older medical students about which book/s are best suited for you. Considering you will be nosediving into the medical world; you need to appreciate that there is a whole new jargon and medical terminology that is unique to medicine. It is highly advisable that you familiarise yourself with these before starting off the course. It will save you a lot of frustration during lectures as academics will be using these terminologies across the course

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e­ xpecting you to know what they mean. Obviously, it does not preclude you from politely inquiring about a terminology or concept during lectures if you run into difficulty. Your lecturers will define it for you and explain the concept. However, this cannot be a recurring theme across the whole lecture. It needs to be appreciated that the medical course is very demanding with a lot of material required to be covered within a restrictive timeframe, hence academics need to be strictly on-point with the lecture programme without too many deviations and distractions. So, it is imperative that you do your bit and be prepared before each lecture. This takes us to another important point: preparing before lectures and small group teaching. The distribution of the medical course is very subjective to each medical school but what is certain is that prior reading and familiarising yourself with the upcoming lecturing material is a must. It is advisable that this starts from before day 1 of medical school. As an academic I expect my students to have at least some basic knowledge before entering my lecture room. The time constraints and the level of the course do not allow baby-­sitting type of teaching. Apart from this, medical students need to remember they have now entered the university arena and they are responsible to keep up with the work and studying that the course entails. The onus of learning needs to shift primarily onto the student. If you happen to know older medical students in their second year or beyond, it may be a good idea to have a chat with them about the course. Medical students who have recently experienced first year are more likely to give you a detailed account of what is required along with tips and tricks to help you get through the year. Recently I got my hands on a set of well documented tricks and tips that medical students at my university share among themselves, notes that are updated yearly. These notes provide future students with what is important in each year, during which lectures you need to take additional notes, the expectations of each lecturer, etc. I must admit I was fascinated to read such detailed accounts of all the modules and lectures’ do and dont’s, including for my own lectures, “do not dare to go late for her lectures.” As you might guess I am very strict with time, if the lecture starts at

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2  Congratulations on Making It to Medschool: Now What?

8 a.m. you need to be there by 8 a.m., late comers are not allowed in (with few exceptions). Identifying whether there is an established medical students’ association at your medical school is another item on your bucket list. These associations are set up to help medical students throughout the whole course. We will be discussing the importance of these associations in more detail later. However, these associations might have introductory sessions specifically targeting first-year medical students to not only welcome them on campus but also to guide them and prepare them for the first year of medical school. Some associations might also offer a buddy system where each first-year medical student is paired up with another older medical student to be their mentor and protegee during the first year. Therefore, reaching out to these associations or subscribing to their social media accounts or visiting their websites is a must before starting off medical school. It is typical to have an orientation period during the first week of the academic year. It is the time where you are shown through the departments, lecture halls, labs, and dissection halls (if available) to familiarise yourself with your new “home.” As noted, before, not all medical schools follow this programme; therefore, it is imperative to enquire beforehand about the possibility of an orientation period. There may be cases that you need to register for them in advance or on occasions the orientation is done weeks before the actual start of the academic year, if at all. Whichever option is offered by your medical school it is important that you are informed to ensure that you do not miss out on anything. If for some reason you missed orientation or else the medical school does not offer one, it is not the end of the world. Just arrive at the campus a few days before the start of the academic year and familiarise yourself with the various departments. If you are lucky to encounter other older medical students, ask them to show you around. I can guarantee that you will be welcomed with open arms. It is also important that you familiarise yourself not just with lecture halls but also with essential locations such as the restrooms, the canteen, the cafeteria, the

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students’ lounge, etc. Remember this will be your home for the next couple of years, every small detail is important. As the first day approaches you will be receiving your timetable along with your small group teachings timetable. The format of this timetable will vary according to the medical school you are attending, so make sure you enquire with the preclinical secretary beforehand, if you have not been notified already. At my university, a live online timetable is available, which is updated regularly. Therefore, students are expected to keep an eye on the timetable daily since some lectures might change their time or venue. Familiarising yourself with the timetable, including potential abbreviations for the different sessions such as clinical skills and critical thinking session among others, will enable you to be in the right place at the right time. Try to arrive at the lecture room a few minutes before the start of the session, hence why prior orientation of where each lecture room is situated is so important. In the medical world there are various professional ranks that you need to be aware of. Each rank is an achievement reflecting hard work, and some do not take it lightly if this is not acknowledged. Therefore, familiarising yourself with the academic staff profiles before starting medical school is recommended. You do not want to start your medical school on the wrong foot with your academics just because you referred to them incorrectly. As a basic introduction to these ranks anyone with a PhD after their name is a doctor irrelevant if an MD is also present or not. If the academic is a qualified surgeon from a UK institution, then you will not call him/her “doctor” but rather “Mr” or “Ms” according to the gender. In the academic world, as one climbs up the professional ladder, the title may change from “doctor” to “professor.” Achieving the promotion to “Associate professor” and more so to “Full professor” is a big deal; hence, it is only respectful that you acknowledge this if you are going to speak to or email the respective academic. During sessions if you would like to politely draw the attention to your lecturer make sure you do not call him “sir” or her “miss”! If you are not sure of their academic status, the safest option is to use “doctor.”

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2.3 What Is the Difference Between Preclinical and Clinical Medical School Years? Typically, the medical course is subdivided into two parts: the preclinical and the clinical years. It is every medical student’s dream to have hands-on practical experience involving patients, visiting wards, attending outpatient clinics and surgeries from day 1. However, not to burst your expectations and longing bubble, this will not be the case. The first part of medical school, the preclinical years, typically 2 years in duration, will be mostly based in lecture rooms and laboratories. These are the years where you build solid foundations for your future career. It is during the clinical years part of the medical course where you will move to hospital and be exposed to the actual clinical setting. The preclinical years are the precursors to what is yet to come. I understand that for some medical students, this period might be perceived as boring or useless. Some may even get the crazy notion to skip sessions. While as a freshly enrolled medical student the bombardment of basic sciences may not be perceived as interesting, let me assure you that without the preclinical years, your clinical years and the rest of your life as a doctor will crumble like a house of cards. The preclinical years will focus on basic sciences, anatomy, physiology, histology, embryology, cell biology, and biochemistry, among others. These subjects are the foundations required to gain an understanding of how the body works and what is the normal functional structure of the human body/ system. How can you identify and understand an abnormality, also referred to as a pathology in medical terms, if you have no comprehension of what is normal? This is therefore the reason why medical students spend the preclinical years in lecture rooms, tutorial rooms, and laboratories. If you are lucky to have a dissection hall at your medical school, then you will have another sublime experience. The cadaver and prosection sessions delivered within the dissection hall will provide complementary visual and hands-on learning to the anatomy lectures. The preclinical years are also the years where one can enjoy the proper campus life. The transition from the preclinical to clinical years is welcomed with open arms by medical students; however, it may be a

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What Is the Difference Between Preclinical and Clinical...

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shock to their campus-based life. Once you enter the clinical years your time management skills need to kick into another gear since your daily and weekly expectations will be way different compared to before. While the preclinical years are structured and “spoon-feed,” the clinical years are less so and you are expected to make the most of your clinical placements, scheduled lectures, and “free time.” The structure format of the clinical years will vary from one medical school to another, with either 1 day a week dedicated to lectures and the rest to clinical placements or else daily slots dedicated to lectures and clinical placements. Whichever format you are exposed to, it is important to comply to it and make the most of your clinical years. However, you are also expected to organise a set of tutorials with different doctors according to the speciality you have been attached during your clinical placement. This will not be allocated in your daily timetable, but rather you need to schedule it during your “free time,” which is typically in the afternoon when clinical placements finish. Additionally, you are expected to polish your clinical examination skills and history taking during your free time, apart from keeping up with the required studying. In other words, the clinical years are hectic, jammed packed, and may also appear overwhelming. Yet, these years are the most exciting and engaging as you are always inching forward towards becoming a doctor. Figure 2.1 provides an overview of how a typical medical degree is subdivided.

Medical Degree

Lectures

Preclinical

Clinical

(on campus)

(hospital based)

Tutorials

Laboratory

Lectures

Dissection

Ward rounds

Tutorials

Clinical practice

Clinical placements

History taking

Clinics

Surgeries

Fig. 2.1  Overview of the typical medical degree composition

Clinical examinations

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2.4 Help! How to Survive First Year? First-year medical school may be perceived as the hardest and most challenging year. The transition from sixth form/college/ pre-med to medical school is drastic. It takes time until the student adapts to the new study-life balance, which admittedly can be rather difficult. In reality, the hardest aspect is the internal struggle that students experience rather than the first-year medical course per se. Overcoming the “imposter syndrome” might take a while, for some it takes weeks while others may experience this for much longer. The “imposter syndrome” is the little voice in your head that tells you that you are incompetent, not worthy, not smart enough compared to the rest of the class. We all experience it at some point in time, even that peer who appears to be cocky and know it all will pass through such episodes. It is a natural experience when following a highly demanding and competitive course. Overcoming this stage as quickly as possible is important since once you realise that everyone is in the same boat as you are and you are there for a reason, then that nagging feeling of doom will be lifted. Indeed, as discussed before, you have been offered a place in medical school because you have the potential to be there. It does not mean that everyone will make it to the end and graduate, there is always a percentage of the first-year students that drop out by the end of the first academic year. This is not surprising especially if they enrolled for the wrong reasons, as previously discussed. Knowing that students drop out does not mean you will be one of them; however, it is imperative that you get the grips of how to successfully survive the first year of medical school. It is what will be discussed now. One major key in successfully surviving the first year (and the rest of the years, to be honest) is to start studying from day 1. Initially you need to identify the best studying and coping mechanisms. What used to work before, might not be good ­ enough now. This will take some time to identify and master, which might be one of the reasons first-year medical students struggle. There are various methods that can be adopted, such as using flow charts to accompany what you are studying, using online resources, watching educational videos, writing notes in

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your own words, among others. What you need to remember is that what works for others might not work for you. So, try to avoid comparing your learning and studying practice with others. Although it is always good to take advice from peers, especially those older than you, you need to critically appraise what you have been told and then do your own thing. Remember, that every student is in this course on his/her own. Focus on you and you alone. A group of trustworthy friends will help, and it is essential to have but at the end of the day, you are working hard to get your own doctoral degree. This applies for how you set up your studying scheme. Something which I used to do (and other students also follow such technique) is to set up a daily timetable which consists of study blocks, with timed breaks including daily exercise regimes. During the study blocks it is important to put your mobile phone in “airplane mode” or switch it off to make sure there are no distractions. Unfortunately, social media and communication apps are all distractions, and you will end up losing focus as well as valuable study time. I understand that studying may become boring, and you will give anything to entertain yourself but although there is a time for relaxation, this cannot be all the time. These study blocks are important to keep up to date with the material that was covered as well as with the material that will be covered during the upcoming lectures/tutorials. If you do not constantly revise and prepare yourself, there is a high chance that you might not make it to the next year. Do not underestimate the amount of material that you need to understand and remember. Despite this, it is more important to comprehend the basics and the most essential aspects of a module rather than stay learning the fine print and then getting flustered or forgetting the essentials. Therefore, make sure you know the general anatomy and physiology of each body system, and once you have a good grasp of this, you can move onto the learning and memorising of the details. Online resources might be helpful to revise a topic or else to further enhance your knowledge. However, when you are studying it is imperative to keep your eye on the prize, i.e., you are studying to become a good doctor and not just to pass the upcoming exams. If you study just for your exams, your knowledge acquisition technique will be short lived, and you will find it hard, as you

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progress, to recall what you have studied before. As an academic, it is very clear that most students just study for their exams. Some raise their hands and ask direct questions whether what I have been discussing is for the exam or else whether the PowerPoints used are enough to pass the exams. Hearing such questions always angers me and I specify that what they are learning is not for the exams but for their lives. Unfortunately, few do so, and it becomes very evident when they are in second year, and I ask them something that was covered the year before. What I am met with are blank faces and people looking down at the floor! It is common that first year’s medical students suffer from “FOMO,” which is the fear of missing out from scholar opportunities, from social life, etc. As you have realised by now, enrolling and surviving medical school requires sacrifice and determination. Scavenging for different opportunities such as conferences, courses, and research opportunities will become second nature to most of medical students, as they realise their importance to enrich their knowledge. Yet, you must not beat yourself up that you might have missed an opportunity to attend or apply for such a scholarly event. You cannot afford to continuously be web-­hunting for such events since you will be missing out on your studying. As much as a colourful CV is important for your future job interviews, if you fail to pass your exams, you will not reach far in your career. Another FOMO dilemma that medical students may experience is concerning their social life. Maintaining a social life is imperative as one cannot lock himself/herself up in a room or in the library and just study. Yet, the social life of a medical student cannot be compared to that of other university students. Self-restrain and prioritisation towards studying is a must for a medical student. Hence, flicking through social media and seeing friends partying should not be taken as missing out on life, even if it feels like it is. Again, I stress the importance of keeping your eye on the final prize, i.e., graduating as a doctor. All you are doing and all the sacrifices you are making will be worth it in the end. This does not mean that you cut off all social life, it rather means that you need to have a strategic plan that involves everything that is required for a healthy and balanced lifestyle. This takes us to another important aspect: the mental health and well-­being of medical students.

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Both mental health and well-being are known to be fluid among medical students which are induced by various stressors triggers. Typical stressors include academic stress, sheer volume of information that needs to be studied, lack of time for oneself, issues with study–life balance, conflicts with peers and within romantic relationships, the constant need to be successful, among others. Unless you are aware of these anxiety and stress induced triggers and the importance of seeking out psychological help (if required) as early as first year, you might be heading down an unpleasant trip. Although experiencing some degree of anxiety and stress comes with the territory, it does not mean that it overtakes your life. Understanding the need to reach out and ask for help is important. Without a clear headspace you cannot concentrate, which will inevitably affect the academic performance as well as the studying outcome. Do not be afraid to speak out and seek help, nor feel that you will be judged, or you feel a failure if you need help. None of these is true. If you do not recognise the need to take care of your mental health, you are running the risk of a mental burnout. This is not something you want to be experiencing since it is hard to recover from. Remember, you are working hard to become a doctor, but to do so, you need to be healthy both physically and psychologically.

2.5 An Insight into the Preclinical Students’ Life Life as a preclinical medical student will mostly revolve around lecture rooms on the university campus. Life at a university campus should not be missed and you should take this opportunity to socialise with not only your classmates but also with other ­students. It is the time where you will form friendship bonds with your classmates, friendships that may last you a lifetime and may also serve as a lifeline later during the clinical years. Even though you do need to roll up your sleeves and start studying from day 1, you can still enjoy students’ life on campus. The key is time management. I do recommend you try to get involved in the campus life as much as you can, as this will be once in a lifetime opportu-

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nity. Once you step into the hospital based clinical years, you will no longer be visiting the university. Therefore, attend any organised students’ fests and activities while obviously making sure you are keeping track of the preclinical requirements. The preclinical period is also the time to familiarise yourself with the medical students’ association (if available) and even get involved in the organisation if this is up your alley. Medical students’ associations are usually made up of different sub-­ committees targeted at different medical aspects such as medical education, public health, migrants and refugees, leisure, exchanges etc. You may find one of these sub-committees of interest and might consider joining their team. The university may also offer extra-curriculum activities or courses (e.g., learning sign language or a craft or a sport) that you might be interested to follow. The preclinical years are typically the best time to undergo such courses. I still have vivid and fond memories of my preclinical years. Holding on to such memories after a pretty long time now means they were epic times! I do have a type A personality, always striving to be the best and always eyeing the prize but I did enjoy the preclinical years as much as I could. I got highly involved within the medical students’ association public health sub-committee from way before the start of first-year medical school. Indeed, I was one of the main organisers for World Diabetes Day activity held in November where, as medical students we used to step up a mobile clinic at the entrance of the capital city to perform free blood glucose capillary testing, blood pressure testing along as offering advice to the public. At the end of the first academic year at medical school I ran for the exchange officer post within the same association and got elected. I spent the next two terms holding that position until I felt I had to step down as I entered my fourth year (second clinical year) due to the high volume of studying material. Apart from this, I used to attend as many activities organised by the other sub-committees as was possible. Having been highly involved does not mean I did not study or that I let my grades slip. In fact, I have never in my life had any resit exams, so I must have done something good. The morale of the story is to enjoy your preclinical years as much as you can and after all “All work and no play makes Jack a dull boy.”

Further Reading

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Further Reading Im C. Major developments during medical school. JAMA. 2022;328(16):1591. https://doi.org/10.1001/jama.2022.18666. Picton A, Greenfield S, Parry J. Why do students struggle in their first year of medical school? A qualitative study of student voices. BMC Med Educ. 2022;22(1):100. https://doi.org/10.1186/s12909-­022-­03158-­4. PMID: 35172820; PMCID: PMC8848907. Reimer D, Russell R, Khallouq BB, Kauffman C, Hernandez C, Cendán J, Castiglioni A.  Pre-clerkship medical students’ perceptions of medical professionalism. BMC Med Educ. 2019;19(1):239. https://doi. org/10.1186/s12909-­019-­1629-­4. PMID: 31262283; PMCID: PMC6604300.

3

Is It All Study and No Fun?

3.1 Introduction At first glance medical school life appears grim, isolated, and stressful, with no room for social life. Well, you can opt to lead such a lifestyle; however, this choice does not secure you a slam dunk pass and graduation. It is more likely to lead you to frustration, dissatisfaction, and burnout by the end of medical school. Opting to have some fun even in moderation is a must! It is the only way to ensure you enjoy good psychological and physical well-being and of course enjoy your youth. After all, we all live once, and it would be a shame to let your youth slip away. Despite this you cannot let your guard down and stop keeping up to date with studying and medical school requirements. As already mentioned before, time management is the key. It is essential to keep in mind that every student has a unique learning and memorising technique, so make sure you come to terms with these very important aspects as early as possible. These are crucial elements to take in consideration when planning the fun part of your medical school life. This means that if you need to revise a chapter at least twice or three times before you have a good grasp of the subject, then make sure you allocate ample time to do so when planning your weekly timetable.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Cuschieri, A Pocket Guide for Medical Students, https://doi.org/10.1007/978-3-031-27342-1_3

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3.2 Extra-Curricular Activities There are various extra-curricular activities that you can engage in. The choice of activities varies according to your preferences and allocated free time duration. Yet, you can be strategic about how to go about the choices of the extra-curricular activities so as the time spent can serve a dual purpose; act as a break and have a positive impact on your personal growth, such as learning a skill. You may decide to partake in extra-curricular activities that can place you at an advantage later in your medical career, while at the same time serve as a change of scenery from your medical books. It has become customary that as part of the job application process for a medical officer (foundation doctor) post, you are asked whether you have any voluntary work experience. Hence, you may decide to dedicate some of your free time to such activities. It may be spending time at a local shelter or an orphanage, etc. Your local hospital may also be on the lookout for volunteers to work in the hospital’s outpatients or outreach programmes. Another option may be spending your summer holidays abroad in low-income countries doing missionary work. These are some of the few examples that you might opt to embrace. These activities will not only enhance your personal growth while embracing your humanity, but at the same time this experience will enrich your CV.  Another potential extra-curricular activity that might be of interest to medical students is signing up to learn sign language. This skill is being offered by many universities and is an essential skill to acquire especially as a future doctor. One cannot choose his/her own patients and you will at some point in your professional life encounter the need to practice this skill. Moreover, it is an appreciative accomplishment and something outstanding to put down in your CV. Some medical students may envisage going abroad to attend courses or conferences as extra-curricular activities. Although for CV building this is important, I would not really classify these “activities” as extra-curricular. A better option would be to enrol into a sport or for yoga or Pilates classes, if this is something you enjoy doing. It is not healthy to just focus on medical related activities and forget that there is a whole world out there.

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3.3 Engaging in Student Associations As part of life on campus, preclinical students are exposed to several student associations. Indeed, every university will have its own set of organisations and student associations set up that any student can join or participate in. Joining one or more associations is your prerogative yet remember that your free time is limited once you kick start the medical course. Despite this, joining an association is a good recreational commitment as well as an opportunity to socialise with other students. It is the time to let your hair down and enjoy your student life as well as learn new skills such as communication, outreach, etc. All of which are essential skills for a future doctor. Joining the medical students’ association should be on top of your agenda as this association tends to provide medical students with a lot of different opportunities across the medical school years. As previously discussed, medical student associations can be a life saver to first-year medical students as they provide the much-needed guidance to these newcomers. However, the association offers much more than this. I will be describing briefly what the local medical school association offers its members; however, different associations may offer different opportunities to their members. Medical student associations are usually affiliated with the International Federation of Medical Students Association (IFMSA) and follow a similar setup with different sub-committees and activities. The various sub-committees making up the medical students’ association have different objectives with a global aim to enhance medical students’ skills and prepare them towards becoming a good doctor. Some examples of initiatives include the organisation of surgical suturing courses and research conferences by the medical education sub-committee, organisation of health awareness campaigns and measuring of blood pressure drives by the public health sub-committee, among others. Such activities provide the opportunity to start practising communication skill as well as patient–doctor relationships. Meanwhile, the leisure sub-committee is responsible for organising fun activities for medical students, such as a gala night, ­beginning of summer party, treasure hunts, etc. An additional perk

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to actively participate in such an organisation is the possibility to be granted a chance to participate in a summer exchange programme. Every year a set number of clinical-based and researchbased exchange programmes are provided by each medical school association across the world. Each association is responsible for providing lodging and a supervisor (clinical or research or both) to foreign medical students. In return, local medical students will be hosted by other universities. Hence why this programme is an exchange.

3.4 Clinical and Research Exchanges Medical students’ association exchange programmes are typically set up during the summer period (July–September) and last a whole month. The medical student on exchange will be attached to a clinical or research team (depends on the options provided on application) along with complementary accommodation. The host medical student body will also organise social events for the visiting students. As a medical student I had the opportunity to take part in two clinical based exchange programmes. In my second year I went to Warsaw, Poland where I underwent a surgical rotation, while in my fourth year I went to St. George’s Hospital London, UK, where I underwent a neurology rotation. These exchanges were a great experience as I had the opportunity to travel to another country, get acquainted with different medical practices to my own. I learnt new techniques as well as networked with other medical students and professionals. I would recommend everyone to try such an experience. This also will look good on your CV, as it shows initiative to extend your experience and practice beyond your own university/hospital. If your medical students’ association does not provide such opportunities or else you were not able to secure a place in such an exchange programme, you can then apply for an elective exchange. An elective exchange is different from a medical students’ association exchange programme since for the former type you need to identify the host university/hospital yourself and apply accordingly. It also means that you would need to pay for

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the tuition and the accommodation during your stay. However, in an elective exchange you have the liberty to choose your own programme, without having a restrictive list of exchange programme options that you can chose from, as in the case of medical students’ association programmes. You may also have more flexibility with regard to the duration of your stay. It may be a good idea to seek advice from your university as to whether a bilateral agreement is in place between your university and the host university, before applying for an elective exchange programme. In some instances, pre-arranged exchange programmes are available between universities which you may benefit from. So always have a chat with your medical school administration before going ahead with your planned elective.

3.5 Study-Life Balance The importance of maintaining a healthy and balanced study-life lifestyle has already been discussed extensively across the previous sections. Despite this, I am going to take this opportunity to provide a summary of what you should aspire for during your medical school years. The preclinical years should be dedicated to getting acquainted with the best study and learning techniques that suit your needs. It is also the period where you socialise with your peers along with students following other university’s degree courses. If you manage to identify the best studying and preparation techniques from an early stage, you will be able to manage fun activities along with keeping up to date with the medical school requirements. Formulating a daily or weekly timetable with blocks dedicated to studying and breaks is recommended. If the opportunity arises to get involved in students’ organisations and/or undertaking work experience including taking part in exchanges, do not hesitate but go for it. I would urge you to make the most of the preclinical years and the life on campus since time will fly and sooner than you think you are transferring to the clinical years. Indeed, make sure that you enjoy your summer holidays to the full, since once you graduate these will dissipate! Having said that, I still recom-

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mend that you dedicate some time to revision and perform some light reading of the upcoming modules to be covered in the next academic year. As you transition into the clinical years, you will be spending most of your time in hospital. Your daily routine will be more hectic than before, with the addition of clinical attachments and clinical practice on top of the scheduled lectures and tutorials. This will challenge your study-life balance and unless you are mentally prepared for this transition and learn how to manage your time adequately, you will be faced with stressful periods. It is imperative to allocate a period just for yourself, for your hobbies, for an activity that helps you to de-stress. This does not necessarily mean you spent a whole day “relaxing” but to dedicate a couple of hours a week to something unrelated to medicine. The important thing is to lead a balanced lifestyle as much as possible and not let the years spent at medical school be dedicated to just studying while sacrificing your social life.

3.6 Relationships Everyone dreams of experiencing love and romance in their life, but no one knows when this will happen. Do not enter medical school with the preset mindset that you will not have time for relationships or that knights in shining armour are just part of fairy tales. Some may enrol into medical school while they are already in a relationship with someone that is not part of the medical community. Is this relationship doomed? Relationships in par with medical school are not doomed, nor are they something to be afraid of or to avoid. As already discussed, time management is key. Being in a relationship with someone also following the medicine degree course, whether is in the same class, older or younger will have its advantages and disadvantages. The main advantage is that your partner will be in the same boat as you and is more likely to have a clear understanding of stressful periods and studying commitments. Being able to study together or seeking advice from each other are also ­highlights of these kinds of relationships. Yet, such relationships

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might run into awkwardness if you break up or else have an argument and you are stuck in the same environment. This is avoided if you have a relationship with someone not forming part of the medical ecosystem. Despite this, such relationship might run into difficulty when you need to spend days studying and hence cannot go out or need to miss some social event which your partner is set to go to. Obviously if your partner is understanding and supports what you need to do, then there should not be a problem. Ultimately, if you want to opt for a relationship or not during medical school is your provocative. However, remember that you have a goal, make sure you are not too distracted due to any relationship that will hinder you from studying and passing your exams.

Further Reading Dijk S.  A day in the life of a medical student from Portugal. BMJ. 2021;373:m4503. https://doi.org/10.1136/bmj.m4503. Huang K. A day in the life of a medical student in China. BMJ. 2022;379:o2830. https://doi.org/10.1136/bmj.o2830. McKerrow I, Carney PA, Caretta-Weyer H, Furnari M, Miller JA. Trends in medical students’ stress, physical, and emotional health throughout training. Med Educ Online. 2020;25(1):1709278. https://doi.org/10.1080/108 72981.2019.1709278.

4

The Clinical Years

4.1 Introduction The clinical years are long awaited by medical students as it is the time to put on your white coat or your medical school scrubs with your stethoscope in one pocket and a clinical medical handbook in the other. It is the start of a brand-new journey that will take place within the hospital setting. This will involve direct interaction with patients as well as with medical professionals. It is a very exciting time for any medical student, but it also comes with great responsibility, diligence towards the care of the sick and respect towards the medical professionals. Students will soon realise that they have stepped into a completely new world and lifestyle as compared to what they were familiar with during the preclinical years. Indeed, the clinical years are a new ball game, and it may take some time to get accustomed to the new way of life of a clinical student. To aid this transition, medical students should be aware of several aspects such as what is expected of them as they step onto the wards, what are the medical school new requirements, juggling academic requirements and clinical placements and so on. These and other important clinical years related aspects will be discussed in this chapter.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Cuschieri, A Pocket Guide for Medical Students, https://doi.org/10.1007/978-3-031-27342-1_4

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4.2 The Expectations of Clinicians Out of Clinical Students The clinical years are divided between learning core knowledge during lectures and tutorials while acquiring clinical experience and having hands-on practice during clinical placements. It is customary that a small group of students are assigned to a consultant clinician/surgeon for a couple of weeks. The clinical placement timetable is usually available from the start of the academic year so there is no excuse for the students not to familiarise themselves with their clinical placement consultant and the respective speciality. Consultants expect students not only to shadow their clinical work on a daily practice but also to have basic core knowledge about their speciality. It is paramount that the students familiarise themselves with the weekly schedule of their assigned consultant before the start of their placement. This ensures that each student is subject to the best experience and clinical outcome during the placement by knowing exactly where he/she needs to be during the week. Great effort needs to be given to being on-time to the start of the ward rounds or the clinic or to surgeries sessions. Consultants do not appreciate students being late for such sessions, as it not only disrupts the workflow, but students will miss out. Of note, not every consultant will have the same weekly schedule, so familiarising yourself with each individual consultant’s schedule is a must. It needs to be noted that it is also common practice that one consultant may have different scheduled sessions every fortnight, making your clinical placements more enjoyable while at the same time a bit more complex to comprehend. Just to give an example, 1 week a consultant may have only morning sessions, while the next week there might be an afternoon or an evening clinic or surgery session. Surgeons may have alternate week elective operating days that you should do your utmost not to miss. Additionally, the start of sessions may vary from one consultant and speciality to another. Surgeons tend to start off their day much earlier than physicians for the simple reason that on most days they have surgeries to perform. So, no need to look shell shocked if asked to be present at 7 a.m. for the start of the

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ward round. If you want to learn while making a good impression, make sure you are on time. Attending the clinical placements is fruitless unless you have acquired basic core knowledge about the subject. The consultant and his/her team will expect you to be familiar with common pathologies within their speciality, along with their management. Starting off a clinical placement without prior knowledge will put you on the wrong foot with your clinical team as from day 1. First impressions do count, apart from the fact that you will feel lost during the session. I still remember the first day of my clinical years, I was attached to a nephrologist. As we were cruising from one patient to another during the ward round, we came upon a patient with diabetic nephropathy and that was my group’s demise. No one had warned us that we needed to have read up on the subject before attending a clinical placement nor did we know what diabetic nephropathy was. This was inexcusable from our side. The moment we were put in the limelight by the consultant as he asked us a clinical question, hell broke loose. The consultant was far from amused that we all stood in front of him like wax figures unable to answer him. It gave him the wrong impression that we were lazy, and we did not bother to prepare. Unfortunately, it also meant that for the rest of the placement period we were hardly acknowledged or involved in the team’s discussions. It is unfortunate stereotyping that sometimes occurs, and students end up missing out. It all boiled down to not having had basic knowledge before starting off our clinical placement. So, take it from me, make sure you are on top of your game before attending clinical placements. Consultants expect you to take the initiative during your placements. You are not there as sitting ducks but rather to listen, learn, ask, and interact. Getting to know the patients admitted under your consultant’s firm is appreciated by consultants since during ward rounds you will be able to follow the management plan and decisions being taken. It will also enable you to interact with the team either by asking questions or being in a good position to answer any questions that are put forward. Starting an intellectual conversation with the team (consultant or one of his/her doctors) about a patient’s case seen during ward rounds or clinics will open

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the door to an enjoyable experience. Having an eager student wanting to learn and trying to interact with the clinical conversation is appreciated by the clinical team and this will translate into a fruitful clinical placement. If you are given a task by the consultant or one of the doctors in the team, such as clerking a patient, make sure that you comply. Even if it is very late in the day and you are tired or you have lectures and tutorials scheduled and will not have time on that day. Make sure that the next morning you perform that task because the next time the doctor will see you, he/she will grill you about it. Excuses of why the task was not performed are not taken lightly and you really cannot afford to be on the black books of your seniors for various reasons. First, they will be your future colleagues (unless you change locations or country) and you want to have a good working relationship with them. Another factor is that most of the consultants will be your future examiners when you come to the final clinical exam. It is important that you have a good rapport with them, and they have a good impression of you as a student and a future colleague. Surgeons are a different kettle of fish from medical physicians, and you will realise it from the first day you are attached to one. Even more so are certain surgical specialities, namely orthopaedics and plastic surgeons. They tend to have an ego and an aura of being untouchables, with a typical male dominated ecosystem. Yet, this gender inequality within the surgical specialities is being phasing out slowly, more rapidly in some countries than others. However, female medical students are more likely to feel intimidated during surgical placements especially if an all-male surgical team is the order of the day. I would strongly urge you to get over such emotions, you are as good as any male student, know your stuff and you will gain their respect. Attending surgical theatre to observe an invasive or non-invasive procedure is always the highlight for most medical students but this does not come without peril. Entering a surgical theatre for the first time you will notice that there is a whole new environment. You will feel lost and out of place unless you have prepared for it. Not all medical schools prepare their students for the theatre etiquette beforehand, hence it is your prerogative to gain an understanding of your hospital’s regulations and practice. It will also ensure that you make the

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most of your surgical placements. Do not expect the consultant to hold your hand as to what you need to do. Theatre days tend to be the busiest and most stressful days for surgeons (undoubtably as they are about to operate on a human), so you need to complement the surgical team and not hinder them. Asking assistance from other medical professionals or the younger doctors might be a good option, but I highly recommend taking the initiative and gaining a deep understanding of what is expected of you before stepping in the theatre suite.

Surgical Theatre Expectations The surgical theatres can be considered as the hospital’s Holy Gail. It is the place where bodily structures are fixed (e.g., fractures), replaced (e.g., heart valves or transplants), removed (e.g., operable cancers) or compromised body systems are mended (e.g., heart by-pass or peripheral vascular by-pass). Additionally, it is the place where surgical emergency care is provided, being it the removal of a burst appendix or a splenectomy following a traumatic event or an orthopaedic emergency such as fasciotomy due to compartment syndrome. Performing such operations requires specific infra-structure, trained personnel and sterility protocols that are not seen anywhere else except for the operating theatres. Medical students may therefore feel like fish out of water unless they have been advised what to expect. The first thing that anyone entering a surgical theatre needs to do is undergo a change of clothes, from the “outside” clothes to the theatre scrubs (typically green or blue in colour). Even if as a medical student you are already wearing a scrub, this is considered as “contaminated outside” garment that needs to be changed. This goes without saying for the shoes. Surgical clogs need to be worn, along with hair nets and a surgical mask. The rationale for this change of clothes and shoes is to ensure that no pathogens attached to the clothes enter the sterile theatres. Hair needs to be covered for hygiene purposes, while surgical masks prevent any potential air-droplet pathogens from transferring from one person to another including the patient. The question you may be asking

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is “do we need to buy these surgical garments?” and the answer is “No.” The hospital will supply these, all you need to do is identify the depot area and get your change of garments. Make sure that you get the right size since you will be spending a good couple of hours in this change of clothes and shoes, and it is important that you feel comfortable. Another important fact to know is that no handbags or satchels can enter the theatre. Leave everything in the theatre changing room or the locker room. You will earn yourself a good telling off if you bring these items inside the theatre suite. The next thing that you need to do is to identify the surgical theatre your firm will be operating in unless you have been told beforehand. There is usually a theatre desk where you can enquire or else a whiteboard/notice board with the day’s theatre distribution according to surgeons and speciality. On reaching the designated theatre you cannot just barge in through the first door you identify. Doing so, especially if an operation is underway will cause chaos and you will be compromising the successful outcome of that surgery. There are usually several doors leading directly or indirectly to each theatre. You need to identify the entry door, which usually takes you to the scrubbing room rather than directly into the operating room or the prep/recovery room. If you are not sure, ask. This brings us to the importance of going to theatre with your attached surgical team, since they will let you in on the procedures of that theatre. On entering the theatre, it is die-hard rule not to touch anything especially anything draped in sterile surgical drapes (cloths), which are typically green or blue in colour. Touching does not only imply your fingers but also to your clothing and hair. So, walking by a sterile area and having your scrubs touch it will contaminate a sterile field. Apart from the theatre personnel reaction, you will be jeopardising a whole procedure. The whole area will need to be resterilised from scratch. This is a laborious, time consuming, and expensive process, and it may imply that operation needs to be cancelled or postponed especially if the area you have touched contained an implant or special equipment that is not readily available and needs to be sent for sterilisation before it can be re-used. By now I hope you are realising that entering a surgical theatre without knowing what the expectations are and the great “No No” actions might get you into a fix.

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Students are usually allowed to stand in the periphery of the theatre room. This may lead to visibility problems in following the surgical operation unless a theatre camera and screen are available for students to follow from. Such issues should be pointed out politely to the surgeon or the team for modifications to be implemented. Some surgeons offer medical students the opportunity to assist them during the operation. If that is the case, you are in for a treat! However, it means that you need to “scrub” to be allowed to participate in the surgery. It also means that you have a great responsibility not to cause harm while within the operation field by poking into organs, by feeling faint and falling, or by touching unsterile areas followed by touching sterile areas. If you are offered such opportunity, grab it, but be honest and ask for help in scrubbing, donning, and doffing the sterile garments if you have never done it. You will never be told off for asking, but you will be if you mess up. Usually, the theatre nurses or else the surgical assistants will come to your aid and teach you how to scrub. Scrubbing means that you need to wash your hand up till the elbow with soap and sterile solutions in a specific manner. Then without touching anything, use a sterile towel to wipe your hands/elbows and wear a sterile gown and gloves while following a sterile technique. Being scrubbed means that you need to keep your hands elevated while not touching anything until you are within the sterile surgical area where the patient is prepped for surgery. Although this might sound confusing or out of your league, it is not. You need to get familiar with the sterile procedures, if not live, use online videos to help you. Practice makes perfect but it is imperative that you do your utmost to learn as quickly as possible the scrubbing technique. Then you can enjoy assisting the surgeons and being part of the surgery, while keeping alert to follow instructions provided by the lead surgeon.

4.3 Surviving the Clinical Years It has already been well established that the transition to clinical years will be a “shock” to your accustomed student life, yet, thousands of students have experienced this and were successful. So

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will you, as long as you do your part. Preparation for your first year into the clinical phase should start from the summer period between the preclinical and the clinical years. It is the time to not just unwind from busy academic preclinical years but to also start exploring what is to come. By now you should have made acquaintances (if not friends) with older medical students that you can reach out to, to gain an insight on the best clinical books and other associated digital aids that you will need. The same kind of guidance can be acquired from medical students’ associations or else from your university’s website, although if I were you, I would rather have a chat with other students who have just experienced their first clinical year to gain a more recent and student oriented advice. Getting your hands on these essential tools early on will give you time to start orienting yourself with the study matter. I am not implying that you should forfeit summer, but rather to start getting a “feel” of what is to come. Once your timetable is announced, it is time to take your preparation to the next level. Let us take an example. If your first clinical attachment is with an endocrinologist, then I would highly advise you to start reading the endocrinology chapter from your clinical medicine book while refreshing your anatomy and physiology of this system. At this stage, you do not need to know the fine details, but rather acquire knowledge on the different pathologies and basic management plans e.g., what is diabetes? what are the different types of diabetes? and their basic management including examinations, blood testing, and common medications. The reason you are going to invest your time in this exercise is to ensure that once you step through those hospital doors and meet your consultant and the rest of the team, you will have the best clinical experience that you can possibly have. There will be no introduction to the subject nor hands holding once you are on the wards or in clinics. The firm doctors (the team of doctors assigned with the consultant) do have a role in teaching you but their primary goal and duty is to their patients. Their daily work schedule needs to be carried out faultlessly and cannot be hindered to accommodate your lack of knowledge. Hence, it is your duty to equip yourself with the knowledge so when you are on the wards/

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clinics you understand what is going on and you use your time to ask questions that will help your clinical growth and understanding. Exhibiting an understanding of the pathology at hand will show your firm doctors that you have taken the first step to learn and you are ready to sponge up what they have to offer. Every doctor knows that you are a student and you do have your limitations, so it is ok to make mistakes and ask for help. Obviously, the way you approach your mistakes will also set the scene with your firm. Your ability to be humble, know your limitations, owe up to your shortcomings and mistakes, will make or break you. If you follow a “know it all” attitude, it will not take you long to land onto the firm’s bad side with potential bad repercussions. You need to understand your place, you are a student, you are there to learn, to ask questions to enhance your knowledge but not to challenge the doctor’s clinical practice or management plan especially not in front of patients! Your biggest downfall will be committing such unethical medical crimes. Doctors (young, senior, and medical students) stick together, even if you share strong opposition against a particular decision, you do not criticise or humiliate a doctor in front of patients. If you really have concern, you can share your views in a private setting with the caring doctor but that is it. This is exceptionally important if you are a medical student. Another important point to keep in mind is that if you make a mistake or you do not know something, just owe up to it and politely ask for help. “Rome was not built in a day” and everyone knows it. As much as clinical textbooks are essential and a must have, what you pick up and learn during clinical placements is equally important. Having hands-on experience, observing “live” pathologies and their complications will remain impressed in your memory forever. I used to always carry with me a small notebook in my pocket and jot down interesting clinical details I observed and learnt. Then later I would revert to my books to get a better understanding of what I had observed during my clinical placement. These experiences will mould you into a great student and doctor. It will also help you when you are sitting for your exams. During my paediatrics clinical placement, I came across a particular condition that I had never heard about. I do recall being atten-

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tive to the consultant’s management plan and then when I went back home, I read about it. Months later as I was sitting for the written part of the paediatrics exam and reading one of the clinical cases presented, I realised I was familiar with the pathology. I was transported back to months before when I was lucky enough to have encountered a patient with the same condition. I thanked all the angels in the sky that I had taken an interest and read up. As my experience helped me go through the whole question and later, I got to know that only three students (one of them was myself) got that question correct. The rest of the class (85 students!) had no clue what the clinical case was all about. This brings forward the importance of attending clinical placements and making the most of these experiences. You will never know when that acquired knowledge will come handy. It is important to accept the reality that not every clinical placement that you will be assigned to will deliver the same experience. While some placements will be memorable and provide golden opportunities to learn as well as provide hands-on experience, others may be perceived as dull and not worth the hassle. This holds true also for the consultant that you will be assigned to. Some consultants are proactive and involve students throughout their placements, while others may not be so keen on bedside learning or at all. Such an attitude may not be based on any discriminatory act or lack of interest in students, but it is important to remember that everyone is human. Everyone passes through rough patches in his/her life, each person has a unique personality so no one should be judged. Another element requiring factoring in is the daily workload of each and every doctor. There are huge variances between different specialities as well as within the same department. While some consultants may have a whole day dedicated to ward rounds, giving them plenty of time to interact with patients as well as with students, others need to squeeze in a quick but effective ward round before starting a clinic or a theatre list. The latter doctor will be pressed for time and will need to focus the little time allocated to the ward round to the care of their patients and not to teaching. This is an unfortunate situation, but if you come across it, it does not mean that you do not show up to the ward round or

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dismiss the clinical placement altogether. It just means you need to work extra hard and be patient. There is a learning opportunity in every placement you will be assigned to. It is what you make out of it and how you deal with the situation that counts. A misnomer that needs to be dealt with is the notion that surgeons are the worse bedside teachers, as they are always running to theatre or outpatients with little time to spare for students. Let me stop you right there in your tracks for this is far from true. Yes, surgeons do tend to have a rough exterior and a very tight schedule. Does not imply that they cannot teach valuable lessons and take-home messages. I had some of the best clinical placements while I was doing my surgical rotations. The trick is to get acquainted with your consultant’s schedule and the do’s and don’ts’ way before your placement. The ward round might take place at seven in the morning and be ready by 8 a.m., which means that unless you are bright and early on the wards you will miss this. It also means that wearing a pair of comfortable shoes/sneakers and accompanying clothes will enable you to move from one place to another with ease while catching up with your firm. Some surgeons might allocate time for clinical teachings or tutorials during the theatre break as one patient is rolled out of theatre and the next one is being prepped. Others might ask students to divide themselves into pairs when attending surgeries so as they both can scrub and visualise the operation as part of the team on the operating table. Another aspect to keep in mind is to avoid formulating an opinion about a clinical placement before you have attended. Your personal impression about a speciality or comments by other students should not cloud your expectations of the upcoming placement. You might actually enjoy it! The junior doctors (a.k.a Foundation doctors) forming part of your consultant’s firm are usually invisible to or not given much attention to by medical students, as they consider the most senior doctors and the consultant as their role models. This is a far cry from reality. You are attached with the whole firm which includes the junior doctors. These young freshly out of university doctors might not hold all the knowledge the other more senior doctors do, but they do hold the key to your learning. It is the job of the junior doctor to know the patients inside out, to examine them

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daily, to order and chase investigations and that can be your winning ticket to success. Acknowledging the junior doctors and making their acquaintance is a must. They will be able to point to you the best patients to examine, to auscultate for a distinct murmur, to observe a clinical sign, or to examine a remarkable pathology. As busy as they are, as they manage the wards, they can teach you invaluable lessons and tricks. Remember, they would have been in your shoes only a couple of years back, unlike the other senior doctors. They can understand your position as well as what is required from you as a medical student. Therefore, junior doctors are assets not just for your medical school years but also for later in your career, when you start your own foundation years, and they might be your seniors. As a medical student you have access to the wards and the patients’ files/records. Different hospitals follow different protocols on how medical students can access the confidential patients’ files/records, so your first task at hand is to get acquainted with this. Once you have clearance, you can use these patient’s records as learning tools. When coming across an interesting case during ward rounds or through a recommendation by a doctor, accessing the patient’s records will give a holistic background of the past medical/surgical history, the presenting complaints as well as the management plan (past and future). Here I need to stress the importance of confidentiality. Just because you have access to the patient’s records does not mean you can disseminate the information you acquired to other individuals including to other students. You have been entrusted with confidential information and you are bound with doctor–patient confidentiality even if you have never spoken to the patient. Putting forward confidential information without permission is a serious offence that is not taken lightly.

4.4 An Insight into the Clinical Students’ Life Stepping for the first time in hospital feels so grown up and doctor like, you will feel like you are on cloud nine and ready to save the day. This feeling tends to dissipate quickly and like a burst balloon, you might feel you want to crawl into a ball and wake up when the

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nightmare is all over. This is a process we all have passed from; you need to learn to be patient and give yourself time to get used to your new clinical life. Getting the hang of the clinical life rhythm and your new colleagues (the whole firm of doctors and other healthcare professionals) is a process that needs its own time to settle in. Your days will vary, some days will be short, but some will be super long. It all depends on your hospital and the specialty you will be attached to, as well as how much time you want to invest in your own learning. The amount of time you spend in hospital following cases, surgeries as well as practising will reflect in your final exam and in your practice as a future doctor. You might also be required to attend for hospital clinical placements or tutorials on a Saturday. Saturday is a normal working day for most doctors so get used to going to hospital on the day. If you happen to have a short day, and you are sure that there are no tutorials scheduled and you have done your fair share of clinical work, then take advantage of this extraordinary short day to go home and either study or else have a “chill” day. You do need to have some time to relax and recharge your metaphorical batteries on a regular basis. Being constantly under stress and studying hard while keeping up with your placements will wear you down, so it is important to know when you need to take a break. Being proactive during clinical placements will take you far. Engaging in the clinical conversation during ward rounds and asking questions to your doctors is part of your learning process. You need to get out of your shell and engage while still maintaining professionalism and showing respect to your firm as well as to the patient. Although we do sometimes forget, the patient is the star of the whole clinical years’ experience as well as a doctor’s working life. All that you are learning, and you will be working for, is to ensure a healthy and safe life for your patients. So, during your ward round or outpatient days, make sure that the patient and his/ her needs are considered as well as showing respect towards them. This includes when you are practising your history and examination skills. When targeting a patient to practice clinical skills, it is important to approaching the patient with professionalism and ask for permission to speak to them as well as to examine them (remember to be chaperoned when you do examine a patient!).

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Most of the patients will gladly comply with your requests but not everyone will. This does not call for an outburst or an irritative snort from you but rather respect their wishes, thank them, and move on. The patient’s dignity and respect are paramount. You need to remember that patients are in hospital for a reason, they are sick, so they may not always be in a good mindset for students to poke and talk to them. So be considerate of the patient’s wishes even if you have been tipped off by a friend or a doctor that the patient has a rare condition or has interesting signs. It is common in such situations to find out that the patient has already been repeatedly bombarded by fellow students. This is not a nice experience for the individual, so always keep it in mind. I recall such an incident when I was in my final clinical year. I got tipped off by a doctor about a patient diagnosed with retinitis pigmentosa on a particular ward. Retinitis pigmentosa is an ophthalmic condition that is hard to come by, yet it is a favourite ophthalmological case during the final clinical exam. As expected, I made my way towards the bed of this patient, and before even introducing myself, the patient snapped at me that he will not allow me to examine his eyes as he was fed up. At that point in time, my mind raced through a million thoughts varying from disappointment, anger to what am I going to do! In a split of a second decision while thinking on my feet, I told the gentleman that I was not there to examine his eyes but rather to examine his chest if that was fine by him. I was extra polite trying not to show my real disappointment. To my surprise, the patient agreed to have his chest examined. After finishing off the full chest examination, I chatted a bit with the patient and as I was packing to leave, he offered to have his eyes checked! As you can imagine I was over the moon, I still remember the feeling of relief as I enquired if he really was up for it and took out my ophthalmoscope. That was the day I examined my first (live) retinitis pigmentosa, the second time was during my final clinical exam. The patient had appreciated that I had considered his wishes and did not act out, getting to know me during the chest examination, made him change his mind and offer me a chance to enhance my knowledge. I was and still am, extremely grateful for that experience and it goes to show that respect and professionalism always triumph at the end.

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Growing a thick skin is part and parcel of being part of the clinical year cohort. You need to become accustomed to being rejected by patients to take their history or carry out an examination. This also applies for instances when senior doctors might not allow you to join them in clinic or a theatre session. Although such an occurrence does not occur on a regular basis, it can take place in instances where there are sensitive cases or a highly complex cases that require precision and minimal distractions, among other reasons. You also need to get accustomed to the idea of being scolded or corrected by doctors, which should not be taken as personalised criticism. Being told what you did wrong is part of the learning process and you should take this as an opportunity to learn and grown. It is important to accept that you are not perfect, actually no one is, but it is essential that you come to terms with this at an early stage. If you live in a “I know it all fantasy land,” “feeling untouchable,” you will be surrounding yourself with an unpleasant circle of senior colleagues apart from the fact you will be dangerous for the safety of the patients. It is part of a good doctor’s practice to consult with his/her teammates apart from carrying out consultations with different specialties. You need to learn to be part of a team and tag along with your colleagues. Last and not least you need to remember to eat and drink during your clinical placements. Without nutrition you will not be able to function or to memorise things. This goes without saying that you need to get enough sleep every night. You cannot sacrifice a good night sleep even if you feel that you are behind in your studying, as without proper sleep you still will not be able to retain much study material. Therefore, studying consistently and doing things at your own pace is vital to ensure you are always on top of your game.

4.5 Harassment Harassment can take many shapes and forms including bullying, discrimination, and sexual harassment. Uttering the word “harassment” might bring forward uneasiness, shamefulness, and negativity to many, let alone those who have had the misfortune to

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experience one or more forms of such harassments. It is not uncommon for these types of harassment to surface during your years at medical school and even if you are aware that you are a victim of harassment it is not easy to break the silence and step out of your shell and speak up.

Bullying Bullying can occur in a subtle way or overtly, although both are considered as unreasonable and undesirable behaviours. For a behaviour to be considered as bullying, it needs to be a repeated act which is unwelcomed and unsolicited. This can occur through verbal abuse, sarcasm, gestures, insults, and teasing in front of an audience. It can also take the form of exclusion from an activity or denying access to information or resources. Unfortunately, bullying can be a common occurrence in medical schools. This can be brought about by peers as well as by academics or health care professionals. Any type or form of bullying is unacceptable and if you happen to be on the receiving end of such a behaviour you should act in your best interest and deal with it, such as speak up and report it. However, it is easier said than done. Of importance is to make a distinction between actual bullying and your teaching staff (academics, professionals) providing legitimate advice, criticism, or comments set out to help you grow in medical knowledge. Some students might perceive as bullying. Do not interpret difference of opinions between yourself as student and your seniors as bullying. Having peers bully you because you achieve high grades or because you dress better than them or maybe because you come from a family of doctors or even because you have a partner that happens to be a year ahead of you in medical school are typical examples of bullying that you might experience. I speak from personal experience, bullying can make your life miserable, feel left out, and even question as to “what have I done wrong?” And the answer is “Nothing.” When you reach the final year of your medical school, it is not unheard of that your once best mates might undergo personality changes. The final year is stressful,

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everyone is gearing up for the clinical final exam which typically takes the form of a viva and a clinical examination of patients. This requires a lot of hands-on practice including examination of patients on the hospital wards especially those who have interesting and important clinical signs, in combination to tutorials with different specialists. This is when competition and bullying might kick in. Students might start working on their own and not sharing information about patients with each other or organising extra tutorials without involving the usual group of students. It is frustrating and heartbreaking to experience such behaviour from your peers. Greediness and self-centred attitudes might help you get through the exams, but they will never pay off in the long run. There are also other forms of aggravated bullying that might be originating from other health professionals.

Discrimination Discrimination occurs when an individual or group is treated less favourably than others on the basis of gender, race, gender identity, ethnic or religious backgrounds among other characteristics. The importance of inclusivity is being highlighted by many institutions with the creation of policies as well as advisory boards to ensure that discrimination does not take place. Yet, one may still experience discrimination while at medical school.

Sexual Harassment Sexual harassment is when an individual receives uninvited or unwelcomed behaviour of a sexual nature that results in intimidation, humiliation, or actually be outright offensive. Typically female students encounter such a behaviour much more frequently than their male counterparts. So, what do you do? Keep enduring the harassment or report it? After all, these peers and even professionals will be your work colleagues in a couple of years’ time. It is a dilemma that most are

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faced with, yet you will feel you are at cross-roads. What are the repercussions that may occur if you report it? Should you keep on enduring such behaviour? Will this have negative repercussion to your mental and psychological health? These are all valid questions and no easy answer for them. Although I am no expert in the matter, what I can relay is from personal experience. The form of harassment you are experiencing needs to be scaled up. Is it ­something you can endure without negative repercussion on your personal self? Or is it so much out of control that there is no other way out but to report it? What I would strongly advise is to seek advice. Although there are usually designated persons for such tasks, you might feel that opening to medical school appointed councillors or advisors would be portrayed as reporting your peers/professionals, in which case it may hinder you from seeking help. I would recommend identifying someone, even outside of medical school, that you trust and has your best interest at heart. Whichever way you consider moving forward the most important thing is that you do not get entwined in a downward spiral that might cost you your MD. Remember, you have been working so hard for many years to achieve your goal, i.e., to become a doctor, do not let anyone hinder your dream. Harassment should never be accepted in any form or manner. Don’t be afraid to open up and report it.

4.6 The Final Clinical Exam Reaching the final year of your medical school journey is a milestone and can be perceived as the final hurdle in achieving the keys to your long-awaited career. Nonetheless, this is the most stressful and nerve wrecking year of your life. Different medical schools may have different procedures but generally, this year will consist of several clinical placements followed by written and clinical examinations. Clinical placements and written exams are something that you would be very familiar with up till this point in time, however, not every medical school provides their students the opportunity to experience a mock clinical viva examination before the final one.

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What Is a Clinical Viva Examination? This usually consists of several stations, where in each station you will be examined on a particular topic or skill. For each station, you will have at least two examiners (usually consultants working in hospital). Their role is to assess you through asking you questions as well as asking you to demonstrate a clinical examination or a skill. Although this exam varies between medical schools, I am going to give an example out of my final year experience. I had four final clinical viva examination blocks, as follows: Surgery, Medicine, Obstetrics and Gynaecology (Obs and Gynae), and Paediatrics. For each exam I had a different number of stations but the basic setup was the same. The history taking station. This is where you are presented with a patient or an actor and you are asked to take a full medical history and come up with a potential diagnosis. Later you might be asked about the management plan. For the surgery history taking session, my patient was admitted for cholecystectomy. I was asked by my examiners to get an informed consent for the proposed surgery from the patient. Obviously, this is only relevant in surgical scenarios. There are several clinical examination stations, typically covering all the different clinical examinations (Abdominal, Cardiovascular, Neurological, etc.). For the surgical clinical examination, you may also have a station for “lumps and bumps” meaning you are examining cysts such as sebaceous cysts or a lipoma or a hernia. While for the Obs and Gyane exam you might have a pregnant mother to examine (live or a mannequin). The skills stations are set to assess your ability to perform certain skills such as interpreting ECGs, Blood results, Imaging, Growth charts (Paediatrics), performing a pap smear (Obs and Gynae), using an ophthalmoscope among other skills. Then there will be the “spot diagnosis” stations, where you need to identify the pathology without speaking to the patient or performing a full examination. Examples of spot diagnosis stations are: a patient with kyphosis, acanthosis nigra, A-V fistula, acromegaly, among others. Sessions usually have the same amount of time allocated, typically 10 min, where you are expected to follow the examiners instructions and discuss the topic at hand.

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 ips to Surviving the Clinical Stations T and the Cross-Examination Your future depends on surviving 10 min of grilling by two examiners per station, with minimal room for error. Although different medical schools have different policies, as a general rule, anyone failing two stations, fails that exam. So how to ensure that you make it through alive? The crux of it all is that you need to have studied and know your stuff, without adequate knowledge you will not make it. This is not a written exam, where you might be able to bluff yourself through the exam. A clinical viva means you need to be alert, on your toes and ready to defend your case. Your main aim during those blessed 10 min is to bring forward the message that (i) you know your stuff, (ii) you are a safe doctor, while (iii) avoiding giving the impression that you know it all. Ideally, from the word “Go” you give a running commentary (if it is an examination) or what you are observing (if it is an interpretation station), etc. Your target is to reduce the amount of silence during your station period, since silence means you are giving way to further questioning by examiners. Having said that there is a limit to what you can say (provided your explanation is on point) without the examiners directing you to a particular topic. When you have been asked a question, take a couple of seconds to think about your response. It is imperative that what comes out of your mouth is not only the correct answer but you do not try to “show off” with some bombastic different diagnosis or management plan if you are not familiar with it. What you say during the viva might be challenged by your examiners, so make sure that you have good knowledge to back up your answers. It is useless trying to impress your examiners by recalling some fine print from your book but then you are unable to hold a discussion on the topic, if asked to do so. If you do not know the answer to what you have been asked, be honest! Tell your examiners that you are uncertain or that you do not know it, but you would consult with your seniors in this case. Being honest shows that, yes you do not know the answer, but you can acknowledge this fact and you are going to seek help. This makes you a safe doctor. However, this is not your exit strategy for all your stations. Do not expect to pass

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your exam without studying or doing your utmost to prepare for it. Another important tip is to make sure you are familiar with how to use medical instruments, most importantly a dual bell stethoscope, sphygmomanometer, ophthalmoscope, etc. You are expected to have used such equipment and understand how they function. Although this might sound ridiculous, you will be surprised as how one may perceive he/she knows how an instrument works and in fact does not. Familiarise yourself with the basic tools and make sure you have used them over and over prior to your actual exam.

Preparation for the Exam Having discussed what the clinical viva exam is all about, now it is time to understand what it takes to prepare for it. Unknowingly, you start preparing for it from day 1 of medical school, although the major effort goes into the last months during your final year. During this year you need to make sure you are exposed to different pathologies and clinical examinations as much as you can master. Additionally, you need to practice your clinical examinations and skills repeatedly, both on individuals with pathologies and without. By the end of the final year, you need to be so slick in your examinations, that you can perform them in your sleep. To reach this stage it needs a lot of practice. Therefore, watching online videos without getting your “hands dirty” will not lead to success. Unfortunately, the clinical examinations routines are not simple and there are various steps that you need to remember, while some examinations require additional steps if you encounter a potential pathology during the examination. From personal experience, I used to visit the wards daily (Monday–Friday) from early morning till late in the afternoon to make sure I made the most of each day. Early morning is ideal to examine pre-operative patients before they go down to theatre or as they wait in the Daycare unit before they are wheeled to the operating room. During this early period, I used to aim to have examined hernias, sebaceous cysts, lipomas, trigger fingers

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among others at Daycare unit. On other days, I used to pay a visit to the orthopaedic wards to examine an osteoarthritic knee or hip before a total knee replacement or a hip replacement. Or else visiting the ENT ward to examine enlarged parotids or any other ENT pathologies. The trick is to know beforehand where to find these patients by befriending ward nurses and junior doctors. They will have access to the following day’s operating lists. This will allow you time to plan your targets for the following morning. Remember, you are not the only student on the hunt to examine patients, meaning you may not always be lucky to reach the patient on time and examine him/her, as other students might have beaten you to it. The time to examine pre-operative patients is limited before they need to be in theatre. Therefore, prioritising the patients you want to examine is a good strategy. As the day progresses, you will need to either attend lectures or clinical placements. During this time, make sure to keep your eyes and ears on the lookout for good examinable patients. They may be your firm’s patients or else patients you come to know through students or professionals. Take note of these patients and as soon as you are free from medical school commitments, make your way to talk or examine these patients. Again, I need to stress here that you are one of many students on the lookout for good patients to examine and a patient might be tired from the constant bombardment of students. Always be professional, polite, and respectful to the patient. If you are refused, just thank the patient, and walk away. You may either try another time or the next day. If you happen not to encounter any recommendations for good patients on a particular day, then try different wards. I used to ask at the nurses’ desk or at the doctors’ office if there are any good inpatients with any neurological signs that I can examine or any good patients for history taking. This is how I encountered by first cerebral palsy, myasthenia gravis, and multiple sclerosis patients. The same process can be repeated for the different wards. As time goes by, the nurses and doctors get used to your rounds in search for patients and will tell you what you need to know before opening your mouth as you approach them. Remember, that if you do not take initiative and work hard to hone in to your skills, you will

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be left empty handed. Additionally, make sure that when you go to examine patients you are not alone, pair up with a good mate (ideally of the opposite sex). It is important to have a chaperone when you examine patients, it will avoid potential negative allegations that may pop up if you are alone, such as sexual assault, etc. However, there will be times that you are alone. It does not mean that you refrain from doing your rounds of examinations but rather if you be examining sensitive parts of the body, ask a nurse or an assistant to accompany you for a couple of minutes. My weekends were dedicated to catching up on study which is also important for your final examination. Good comprehensive knowledge is not only essential for your written exam but also for your viva. You need to be fluent in various topics to enable you to discuss different pathologies and skills with your examiners. Sunday afternoon used to be dedicated to practising all the clinical examinations on my parents. This made sure that I kept polishing all the examination skills for different body systems throughout the whole year. As the saying goes “Practice makes perfect.”

Further Reading Jenkins TM, Kim J, Hu C, Hickernell JC, Watanaskul S, Yoon JD. Stressing the journey: using life stories to study medical student wellbeing. Adv Health Sci Educ Theory Pract. 2018;23(4):767–82. https://doi. org/10.1007/s10459-­018-­9827-­0. Moss HA, Derman PB, Clement RC. Medical student perspective: working toward specific and actionable clinical clerkship feedback. Med Teach. 2012;34(8):665–7. https://doi.org/10.3109/0142159X.2012.687849. PMID: 22830325. Zhu G, Tan TK. Medical student mistreatment by patients in the clinical environment: prevalence and management. Singapore Med J. 2019;60(7):353– 8. https://doi.org/10.11622/smedj.2019075. PMID: 31378822; PMCID: PMC6658645.

5

Research During Med School

5.1 Introduction For most medical students, research is a taboo subject. The majority perceive it as either boring or as not being a requisite for their professional life. Very few medical schools provide hands-on research opportunities to students neither as a mandatory nor as an elective experience. Theoretical lectures are delivered as part of either a research module or the public health module, but this is a far cry from clinical research. Some medical schools do provide research-based projects to their undergraduates, but these are mainly reviews. This limited exposure to research might contribute to the general mentality shared by medical students that research is not for them and should be left on the back burner. Yet, as years progress and securing a medical doctor job becomes more competitive, embarking in some form of research and publishing has become a priority on most medical students’ agendas. However, most students are faced with a situation where they have no clue where, when, and how to carry out proper research. This in turn leaves students feeling lost and stranded on how to try to enrich their curriculum vitae (CV).

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Cuschieri, A Pocket Guide for Medical Students, https://doi.org/10.1007/978-3-031-27342-1_5

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5.2 What Is Research and Should I Engage? Research is conducted to address a systematic enquiry about a particular topic and can take the form of either an experimental or an observational study. The commonest experimental study is a random controlled trial, which to be frank is beyond a medical student’s capacity. An observational study can take the form of many different study designs, as shown in Fig.  5.1. It is more ­feasible to be conducted by a medical student, provided the student has the expertise as to what each study design comprises. In most cases, students are not equipped with this information and that is why students should always seek the aid of a supervisor. The lack of expertise should not discourage students from pursuing a research project but rather should push them to embrace this as an opportunity to learn new skills. Needless to point out that conducting research and successfully presenting or publishing the results hold a great advantage towards the upcoming job interviews. So, I would highly recommend trying to engage in a research project, irrelevant how small or big it is. The first attempt will be the hardest, the rest will be much more manageable. The extent of the research can vary and is highly dependent on the research question. A research question is a hypothetical inquiry that you set out in order to identify, investigate, and solve by undergoing a study. A detailed account of how to formulate a research question, conduct a research study, and how to identify an opportunity will be provided later in this chapter. Let us now briefly lay out the different study designs that are available, as shown in Fig. 5.1. Observational studies can be catObservational studies

Descriptive

Descriptive surveys (crosssectional)

Case reports

Analytic

Case series

Analytic Crosssectional

Case-control

Fig. 5.1  Representation of the different observational study designs

Cohort

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egorised as either descriptive or analytic studies. A descriptive study describes the characteristics of the study population. Meanwhile, an analytic study will provide tangible components that can establish relationships through statistical analyses.

5.3

I Am a Student. What Research Can I Do?

A quick answer to this question is “Every type of observational research.” In reality, the sky is the limit if provided with the right tools and guidance. Conducting research involves several steps, from formulating your research question to the study protocol, securing funds (if needed), and getting permissions including ethical clearance. All these steps are achievable if armed with the right knowhow. This is where I again stress the importance of having a supervisor. The question is “how do you identify a potential supervisor?” The first thing that you need to come to terms with is the topic of your research. In other words, what makes you tick? Maybe you are interested in population health or in cell biology or orthopaedics. Establishing your interest will be the first step in identifying a supervisor. The problem will arise if you have no clue as to what you want to do. This makes it hard to progress. Knowing the topic that you would like to explore will enable you to research your university’s staff research interests and identify potential supervisors. Research forms part of most academics’ work contract, hence by going through the university website’s academic profiles you will most likely identify who is involved in the same research subject you are interested it. Talking with the benefit of hindsight, a lecturer teaching a particular topic does not make him/her the default choice. The personal research interests might vary greatly from the topics being taught. In my case, I teach anatomy and physiology, whereas my research interests focus on epidemiology of non-communicable diseases and medical education. Once you have identified a potential supervisor, the next thing is to reach out to him/her to enquire whether a research opening is available within their current research studies. However, considering that you are not in a position to conduct research fulltime, putting forward such an enquiry might be in vain. This is unless you are planning to focus on a research study during your summer holidays. Most

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research projects carried out by academics take a long period of time, which may gain you some hands-on experience but possibly not the outcome you wish to reach, i.e., definite results that can enable you to present and publish them. Therefore, my recommendation is to reach out to a potential supervisor with a general idea of what you wish to carry out. It does not have to be state-of-the-art research question but at least a direction you would like to take forward. I do understand that this task will challenge some of the students especially those that were never exposed to any research. But if you have managed to conclude which topic you wish to pursuit, there must be something within that topic that interests you. Maybe it was an article you have read or an experience you had, which might provide an idea of what you would like to tackle. It is not the first time that I receive emails from students with a vague idea of what they would like to do. This will be a gauge for me to understand their interest and can guide them accordingly to what is feasible and what is not. Conversely, when I get an email from a student just claiming they want to do some research with me, my first question would be, but what do you want to do? What do you want to achieve? Unfortunately, those that cannot decide or come to a vague conclusion usually fail to undergo any type of research. It needs to be pointed out that although academics are always happy to help and guide students, they have their own commitments. Thus, it is imperative for students to be prepared and not expect academics to either conduct the student’s research themselves or plan the student’s research for them. Considering the time constrains of students to conduct any study along with limited research experience, the easiest and quickest type of study would be a descriptive study, as noted in Fig. 5.1. Another option is to undergo an audit, which is another type of descriptive study. The difference between a research survey and an audit lies in the research question and the type of outcome one sets out to achieve. If one wants to create new knowledge, e.g., “what is the mental health status of medical students following the COVID-19 pandemic?” then a descriptive survey is required. Conversely, if one want to test whether a particular clinical practice or measure that is already in place is providing adequate care outcome, then this is an audit. Whichever study modality a student chooses to follow, both can lead to interesting results that can be presented and published. As a rule of thumb, an

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audit result is more relevant at a national level as opposed to a survey which might target a larger audience interest even beyond the originating country. Hence, when it comes to publishing the article, an audit is more likely to be accepted in a local journal rather than an international journal.

5.4 All there Is to Know to Kick Start a Research Project There are several steps that need to be followed, as shown in Fig. 5.2, before you can start your research project. As already mentioned, the first thing that you need to establish is what topic you would like to Fig. 5.2  Provides a summary of the typical research process that needs to be followed for any kind of research

Choose your topic

Idenfy the problem

Literature review

Research queson

Study design

Permissions & other logisc aspects

Data collecon

Results

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research and why. Identifying the most appropriate supervisor is the next step. You can always enquire with peers or faculty members about who would potentially accept to supervise your research project. Even if you are still on the lookout for a supervisor, you need to ensure that you have identified the research problem that you would like to investigate. This goes hand in hand with extensive literature review on the topic/problem you would like to investigate.

Literature Review Literature review means that you perform a literature search on a particular topic using databases such as PubMed, Medline, Scopus, Cochrane, etc. The keywords used need to cover the topic you would like to investigate e.g., “Diabetes Mellitus AND COVID-19” if you wish to undergo research that covers the impact of COVID-19 on the diabetes mellitus population. Indeed, the use of Boolean Operators (AND, OR, NOT or AND NOT) are essential to narrow down your literature search. You need to appreciate that leaving your literature search vague will result in thousands of article hits, which is impossible to successfully cover on your own. Therefore, it is imperative to narrow down your search as much as possible by not only using Boolean Operators but also including other inclusion and exclusion criteria such as: publication year range e.g., 2012–2022; the type of study design e.g., systematic reviews only, etc.… If you are asking why is all this hassle required? The answer is simple, if what you propose to investigate though a research study has already been extensively researched before, then it is not recommended to embark on this research journey. Your results will not be novel unless you are targeting a specific population. When there is extensive work done in a particular area, there is a low probability that your article will be accepted by journals. Therefore, undergoing a literature review before proceeding to the actual study is of utmost importance. Another reason to undergo this process is that by reading articles within your target topic, you are not only familiarising yourself with the background information pertaining to your topic, but you might also pick up methodological tips that you might adopt for your own study.

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Study Design No research study can commence without having formulated a research question. Here you may be asking, “How do I formulate a research question?” The first thing you need to do is reflect on a topic or a clinical situation that interests you, for example, non-­ communicable diseases or the mental well-being of medical students, followed by a literature review, as discussed above. Once this has been done, the research question or in other words the hypothesis you would like to research will come naturally. If it does not, your supervisor will help you to come up with a focused research question. It is once this has been established that you be able to move on to determine the type of study you need to conduct. Each study design will provide a specific outcome, as shown in Table 5.1. The next question that you need to ask yourself is “Who is your target population?” Are you targeting medical students? Or the general population? Once the target population has Table 5.1  A summary of the different study designs Study type Systematic review and meta-­ analysis Cohort study

Description A collection of published studies on a particular topic is statistically compared together. Used to bring forward a comprehensive analysis of the literature covering a topic

Follows up a group of people for a period (typically 5–10 years) to track risk factors and outcomes over this period. Example: Do electronic cigarettes increase the susceptibility to lung tumours? Cross-­ This type of study can be divided into two: (1) health sectional examination survey and (2) health information survey. The survey principal aim is to assess the frequency (prevalence) of a particular condition or situation or aspect at one point in time. How to reach this outcome can take the form of a health examination, so you would be involved directly with individuals and need to perform several physical examinations, e.g., blood pressure measurement, taking of bloods, etc. The other form is through a survey that can be distributed in person, over the phone, through electronic means, through postal mail Case reports A detailed history of an interesting case or a small number of cases that merits recognition

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been agreed upon, then you need to decide which study design (Table 5.1) you would like to follow. This will determine whether you need to physically examine your potential participants or not. It will also determine the sampling technique, i.e., how you are going to reach your participants. It is beyond the scope of this chapter to go into sampling techniques, but this is where you would need help from your supervisor.

Permissions Before starting any research project, you need to assess which permissions are required. Ethical permission is almost always required in most cases, even if an anonymous approach is to be followed. Without ethical clearance you cannot start the data collection for your study. Other permissions may also be required, e.g., the permission from the head of department if you would like to distribute a questionnaire to a particular university department, etc. Data protection clearance might be another requirement especially if you need access to personal information of individuals or planning to use hospital records, etc. If you are not sure what type of permissions is required, do ask your supervisor.

Data Collection The study design and the tool of measure you will be using, e.g., distributing an electronic questionnaire or a paper-based questionnaire, will determine the logistics and consumables required to ensure adequate data collection. A budget to cover costs may also be required, again depending on the type of data collection you would be carrying out. If you do need to purchase equipment or consumables, it is important that you apply for scholarships or funding, unless your supervisor can cover the cost through a research grant. The necessity for funding is determined by the study design. Data collection via an electronic platform is a frequently used method that circumvents the need for funding.

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It is important to consider how you will be storing the data collected. This should follow a secure format that can be easily accessible through a spreadsheet database. Having the data on an electronic spreadsheet will enable you to perform a number of statistical analyses.

5.5 How to Write a Scientific Article as a Student Writing a scientific article can be portrayed as an art in itself. Most find it a daunting task, yet it is a skill that is learnt and polished over time as well as with trial and error. Having a supervisor who guides you and reviews your work will be a great asset. If you are in the unfortunate position where such help is not readily available, it does not mean you give up! It means you need to work a little harder. In the next couple of sections I will be providing you with a step-by-step process of what comprises a scientific original article and later how to try your luck in publishing it. An original article means that you are presenting the data that was collected along with a discussion about these findings. Having undergone a literature review at the beginning of your research journey should have already exposed you to the scientific style of writing. However, I do understand that there is a big difference between reading someone else’s work and starting on your own article from scratch. Everyone has his/her own way of writing a scientific article, even though the structure of an original article is always the same, as shown in Fig. 5.3. After a decade of publishing, I realised what works best for me. First start with the methods section followed by the results, then the discussion and lastly the introduction sections. The abstract is always the last scientific piece that is written.

The Methods Section This section needs to provide an in-depth step-by-step documentation of what you have done from the start of your study up till

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Running title

Abstract Keywords Introduction Methods Results Discussion References

Fig. 5.3  An overview illustration of the typical structure of an original research article

the end when you gathered the data and analysed it. The way I usually divide this section is as follows: (1) the study population, (2) the data collection, and (3) data analyses. The first sub-section of the methods section is typically dedicated to the study population you have investigated. Let us take an example, your study was carried out through an online survey that was distributed among your peers (medical students) with the aim to gather their perspectives on the conduction of research. Therefore, this section needs to provide a concise description of why medical students were identified as the best target population to answer your research question, why you selected a particular year or involved all the medical students to participate, how they were recruited, etc. Here you also need to provide an account of which permissions to access this population were obtained. An ethical clearance is always required, as previously noted. Indeed, granting of ethical clearance needs to form part of the methods section, along with the associated ethical reference number that you had been provided. If you had obtained any more permissions, then you need to list them here as well.

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The second sub-section will focus on the tool of measure you have used, such as an online questionnaire. In this section you need to give an account of how the questionnaire was developed. Did you create it yourself based on the literature or did you use a pre-existing questionnaire following permission? What were the themes of the questions and what type of data was gathered (quantitative, qualitative, mixed)? How was the questionnaire distributed exactly and what was the timeline for participants to respond? How responses were collected and transferred for data analyses? The final sub-section will provide details of how the collected data was categorised and analysed. It is important to note the statistical program you used, even if it was a simple spreadsheet program. Additionally, all descriptive and analytic analyses performed need to be documented along with the p-value cut off point (if applicable). As you might have realised by now, most of this section (if not all) can be prepared while you are still collecting your data. It may be a good idea to start noting down the methodological processes you had taken from an early stage of your study to avoid missing any step.

The Results Section This section should provide a concise but detailed account of the results that you have obtained from your study. It is customary to start off with the descriptive results first and then move on to the analytic results (if applicable). If you have many results, the utilisation of tables or/and figures might enable you to showcase your results in a clearer way. When using such graphical aids, remember to avoid repeating what these are illustrating in words. You need to introduce what the table and/or figure is showing but not re-write all the results. This is a frequent mistake carried out by students.

The Discussion Section The discussion section comes up just after the results. Here you need to provide a discussion illustrating how your results fea-

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ture against other researchers’ studies that target the same topic. If your research identified something different and never published before than you need to make sure to discuss this and give potential explanations as to what might have led to these results. It is also customary for you to provide recommendations based on your findings. The last paragraph of the discussion should always feature the study limitations of your study. No study is perfect, and we sometimes take decisions that might affect the study’s outcomes. Dealing with human participants presents its unique challenges. These include different types of bias as well as achieving a low response rate. All these limitations need to be part of the study limitations. Following these, I like to provide a short conclusion highlighting the main results and discussion points. Indeed, this very short paragraph (the conclusion) should provide a quick overview of what your article is all about. Some important tips to keep in mind when writing the discussion. Do not repeat the results in this section, nor provide new findings. Results should be presented within the results section and not in the discussion section. This is a very common mistake made by students that will delay the article process or even lead to rejection by journals. Additionally, it is important to remember that when comparing your results with other studies, you paraphrase and reference the other study correctly. Referencing other peoples’ work is a must and failure to do so will led to plagiarism with potential serious consequences. Therefore, referencing needs to be present not only within the discussion section but also within the introduction section and if applicable within the methods section. There are various referencing styles, with different journals requesting different ones. It is important that you read the journal’s article submission guidelines well to make sure you adhere to their requests. The use of a referencing manager software will facilitate this step. Such software requires that you upload the reference within the library first. Subsequently, you can change the referencing style as much as required with just one click of a button.

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The Introduction Section Even though I am describing this section as the last one, it is in fact the opening section of the article. It needs to be stressed that I leave this section for last only because I am very much aware of what needs to go within this section having done a thorough literature review on the topic beforehand. The introduction, also referred to as “Background” by some journals, needs to provide an overview of the topic that you will be investigating in your study. The way the introduction should be structured should follow a funnel type of structure. In the first paragraph you provide a general overview of the topic e.g., medical students and research in general. The next paragraph you narrow down your overview to your study population, e.g., medical students attending your university and research conducted there. The final paragraph needs to feature your research question along with the reasons as to why your study is important, why did you opt to conduct it and what is the expected outcome along with their relevance.

The Abstract and Keywords Once you are happy with the main article, then you can move on to write the abstract. Although there are two types of abstracts: structured and unstructured, the commonest type of abstract that journals request is a structured abstract. This means that the abstract should be divided into “Background, Methods, Results, and Conclusions” while keeping to the word count. The word count typically varies between 150 and 250 words. The abstract is a concise summary of your article. It is important to adhere to the word count since journals will not accept longer abstracts. ­Personally, I feel that writing the abstract is the hardest job out of the whole scientific article writing, as you need to be concise and decide which results and conclusions are the most important. Keywords are always requested by journals. These are individual words or phrases that describe your article. The role of these keywords is for other authors to identify your published

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article during a literature search. To help you identify appropriate keywords, I would recommend that you use MeSH words as provided by the National Library of Medicine (https://meshb.nlm. nih.gov). This database enables you to search for your desired word or phrase and if it is a valid keyword, it will provide you with a definition and other similar keywords.

5.6 How to Publish as a Student All students desire to publish at least one article before they finish off their medical school especially as the foundation doctor post is getting more and more competitive. To be successful, you need to have undergone a research study and have completed the article writing. I would urge you to seek advice and help from experienced academics or your supervisor prior to trying your luck and submitting an article. I understand the enthusiasm and the anticipation to get the process going but without the proper article preparation, you are facing a lot of delays and rejections. Remember that journals received hundreds if not thousands of submitted articles per year and they only accept the crème de la crème articles to publish. Hence, it is your job to present the best possible version of your article straight from the start. An article rejection means you cannot re-submit the same article again to that journal even if you do amendments. You will come to realise that the number of “free” journals available to submit as a student are limited; therefore, you do not want to miss out on a good opportunity just because you were stubborn. The “free” journals I am referring to are journals (subscription based and hybrid) that waive the Article Processing Charges (APCs) if your article is accepted. Open access journals are becoming increasingly common. Although these have several advantages for the research author, they do demand hefty APCs ranging from 1000 to 3000 euro for publishing just one article. As a student, it is highly unlikely you can pay this amount of money out of pocket unless your supervisor can help you with a research grant or you obtain a waiver. This imposes a publishing dilemma to a lot of students, which further brings forward the importance of presenting the best possible version of your article.

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There are journals that accept research specifically submitted by medical students. These mostly follow a subscription based and hybrid publishing system, making them ideal for students. However, every journal has its own scope for publishing and if your article falls outside that scope, then that journal is not applicable for you. Do not try to submit your article to such a journal since it is a waste of time for you and for the editor. Your article will be rejected for being out of scope at some point in time. This may take a couple of weeks after submission, resulting in “loss of time” from being submitted to a more appropriate journal. Therefore, it is always imperative to choose a journal that fits your article aims. There are two pathways how you go about identifying journals. You can either identify the journal before you start writing your article or else after you have finished it. The advantage in identifying a potential journal before writing your article is the ability to gear up your article and referencing style immediately in accordance with the journal’s guidelines as you are writing it. This will avoid having to amend your article at the end. Personally however, I always follow the latter pathway, i.e., I tend to write my article and then decide on the journal. Whichever pathway you follow, it is imperative that once you have identified a potential journal you ensure that you are following the journal’s guidelines for submission closely. Failure to do so will result in your article being sent back for amendments. Other factors to keep in mind when searching for journals are the journal’s impact factor or other journal metrics, its indexing and identifying whether it is a predatory journal. An impact factor, as the name implies, is a decimal number that is a measure of the journal’s publishing impact within the scientific community. This number is an indication of how articles published in that journal have been received by the scientific community and whether these same articles have been cited by other researchers. Indeed, almost all journals have an impact factor, provided they have been around for at least 2 years. This is because the impact factor is calculated by considering the journal’s publishing history over a period of 2 years. Of note, there are many other journal metrics apart from the impact factor that carry similar definitions. Identifying these journal metrics is important since it gives you an idea of the journal’s prestige within the scientific community. The higher the

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metric the more prestigious the journal and the lower the acceptance rate. I always encourage my students to aim high, but you need to be realistic as well. Unless you have partaken in a stateof-­the-art research project, there is a low chance that your article will be accepted in a high impact journal. You need to be humble and assess your article in terms of scientific value when choosing a journal. Although no one is stopping you from submitting to any journal, the turnover time, i.e., the time from submission to a first decision might take weeks if not months, and you may not be at a liberty to wait that long to have your article accepted. Hence, targeting a journal that is reflective of the scientific value that your article carries will give you a higher chance of acceptance. Another factor that you may consider when choosing a journal is in which databases the journal is indexed in. The prime reason for wanting to publish your research is for other researchers to read your work and consider your work as worthy of citing it. Hence, you want to publish in a journal that is accessible through several databases such as PubMed, Medline, and Scopus, among others. An unindexed journal will hinder your article from being readily identified. Predatory journals are journals that have been set up for the sole purpose to take money from the research author without providing rigorous peer review. Publishing in such journals has a deterrent effect on the authors. However, if you opt for a subscription-­based or a hybrid journal you will not run into any of these diabolic journals since these offer exclusively open access publishing. Having your article accepted after your first submission is very highly unlikely. Even experienced researchers have their articles sent back for revisions or rejections before the article eventually finds a home. So, do keep this in mind and do not portray your first rejection as a testament of your sub-standard work. If the journal sends you the article back for minor or major revisions, consider this as a good sign. Your article has potential for publication, but it needs to be amended. At this stage you must make sure that you go over the feedback meticulously and amend the article as per the reviewers’ comments or recommendations. As part of this process, amendments need to be highlighted and a point by

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point covering letter needs to be created to illustrate all the changes you have done in accordance with the feedback received. At this stage you may wish to consult your supervisor since the revisions made and the covering letter will make or break the article’s publishing future outcome.

Further Reading Cuschieri S. Are medical students interested in conducting research? A case study on the recruitment outcome of an elective research summer opportunity. Med Sci Educ. 2022;32(6):1279–83. https://doi.org/10.1007/ s40670-­022-­01645-­3. Cuschieri A, Cuschieri S. Medical students’ perceptions on research: results from a small European Island state. Med Sci Educ. 2021;31(6):1991–9. https://doi.org/10.1007/s40670-­021-­01426-­4. Ecarnot F, Seronde M-F, Chopard R, Schiele F, Meneveau N. Writing a scientific article: a step-by-step guide for beginners. Eur Geriatr Med. 2015;6(6):573–9. https://doi.org/10.1016/j.eurger.2015.08.005. ISSN 1878-7649.

6

Preparation for the Foundation Doctor Job Interview

6.1 Introduction It is every medical student’s dream to finish off medical school swiftly and start working as a foundation doctor. The beginning is always difficult. You will only envisage a long tortuous road ahead. Time always flies by and within a blink of an eye you will be facing the foundation job interview. The preparation for this big day (the interview day) needs to have started from day one of your medical school. The interview is not just a discussion that you (the candidate) will have with a number of interviewers (examiners), but it is also a showcase of what you have academically and socially achieved up to that day. Hence, starting to work to enhance your curriculum vitae (CV) early on in your student years is a task not to be taken lightly. I have witnessed first-hand what happens when a student does not invest in the CV. The consequences can be potentially ending jobless. Passing your exams allows you to progress in medical school but not necessarily enriches your CV. Do not commit the mistake of perceiving the conduction of research, undergoing voluntary work and participating in courses, conferences, or organisations as a waste of time. As the interview day approaches, then it is important to prepare yourself for your 20 min in the spotlight, as preparation is key to success. This chapter will be discussing and providing tips of how to prepare for the foundation doctor job interview and ace it along with how to enrich your CV across your medical school years. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Cuschieri, A Pocket Guide for Medical Students, https://doi.org/10.1007/978-3-031-27342-1_6

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6.2 What Is a CV and How to Prepare One A CV, short for curriculum vitae, is a written summary of your personal achievements through qualifications, education as well as providing an insight on your contributions to society. There are various styles one can follow, with templates that you can use or adopt. The basic information that should be put into your CV is the following: • Contact information (your name, home address, mobile number, email address). • Personal statement (a short paragraph to explain the reason/s why you opted for the medical course and how it fits your aspirations for the future). • Work experience (if working as a foundation doctor will be your first job, then this can be omitted). • Education (a list of the different exams/educational courses you have done excluding the medical course). • Professional certifications (if you have already finished another undergraduate course, then this is the place to note it down). • Professional associations (if you are affiliated to professional organisations, this is the place where you put them down). • Languages (most people speak at least two languages and some even more. It is important to put these down as it will show your language diversity). • Publications (having published research in peer-review journals is an important aspect of your CV.  Here you will note down those articles that have been published. Any articles that you are working on or have not been published yet should not be noted down). • Awards (if you have been awarded any awards for an outstanding performance or achievement, then do put it down in your CV). • Volunteer experience (if you have undergone or still undergoing volunteer work, then do list it down). • Attendance of conferences/courses (whenever you attend a conference or a course it is customary to be provided with a certificate of attendance and this event can also be noted down in your CV).

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As can be noted in this list, the CV is made up of various aspects, all having an important contribution not only to the CV but indirectly to your job interview. In fact, some interview points are allocated according to your CV achievements. Honesty and integrity are essential features in anyone’s life. Avoid falsifying any aspect of the CV. Remember that you will be asked to bring hard copy evidence of the certificates, publications etc. to the interview, unless these are required to be uploaded as softcopy files during your foundation doctor application. Even if this is not the case, in the digital era we are living in, all that is required is for one interviewer to type in your name on Google® and all the information about you and your achievements are just one click away. Becoming a medical doctor carry with it huge responsibility, being a cheat will only put you at risk of being disqualified right at the interview stage. I would therefore urge you to start working to enrich your CV early on, by undergoing different things and activities that were highlighted throughout the various sub-­ sections of the CV list above. If you run into difficulties as to how to construct your CV, even if you have followed a template, it is advisable to seek advice from a senior medical student or one of your professors. If you have finalised your CV, there is no harm in sharing it with more senior and experienced individuals to review it for you. It is not the first time I have been asked to review a CV by one of my medical students. Having a fresh, new, and experienced set of eyes reviewing your CV will ensure that you are on the right track, and everything is in order before you submit it. Remember that the CV will act like your personalised advertisement with your interviewers and enable them to form an opinion on you before actually meeting you. So, make sure you wow them! Remember “A diamond will shine brighter if its different facets are properly polished.”

6.3 How to Prepare for the Interview A medical student is invited to attend for a foundation job interview as the final stage of the job application process, following the submission of the application form. The structure of the appli-

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cation form varies between different countries; however, it typically consists of various questions that test the applicant’s knowledge and showcases the personality. As part of the application form, the applicant will need to upload the CV along with supporting documents, including certificates, published articles, among others. Once the deadline elapses, the application forms will be reviewed and shortlisted by the foundation doctoral school board of the hospital or trust that the applicant had applied to. Applicants that are shortlisted tend to exhibit great potential or a good fit to work in the targeted hospital. These applicants will be invited to attend a job interview. Although being invited to undergo an interview is a good sign, and the first step in being offered a job in that hospital/trust, it does not mean that you have the job in the bag. It means you stand a good chance to securing a job, but you still need to ace the interview. Therefore, it is imperative that you do your utmost to prepare for the interview. The whole point of the interview is to assess whether you, as the applicant, are a safe doctor apart from ascertaining that what you wrote and presented as part of your application form is factual. Indeed, the interview is typically divided into four sections (as below) and lasts around 20 min. 1. Portfolio station (CV and achievements) 2. Clinical scenario 3. Ethical scenario 4. Communication station As part of the job interview, the interviewers will ask about the CV you submitted as well as enquire more about skills you might have noted down or research you had conducted. This further highlights the importance that you are well acquainted with what you present in your CV and application form. It may be a good idea to prepare a one-pager CV that you present to your interviewers on the day of the interview. In this one-pager you highlight your top achievements such as certificates, publications, skills (such as basic life support, surgical skills), awards, etc. This will act like a summary of your portfolio and indirectly help the interviewers refresh their memory to your

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CV as well as possibly prompt interviewers to narrow their questions to your top qualities. It is customary during your foundation job interview that you are presented with two case scenarios: one clinical and one ethical. The clinical scenario is there to assess your medical knowledge and determine whether you are a safe doctor. Indeed, an acute medical or surgical case scenario is typically presented where you need to follow the ABCD approach when structuring your answer. It is important to know when to escalate and request senior help while being questioned by the interviewers. I still remember my clinical scenario, which was that of carbon monoxide poisoning, but others were presented with cases of cardiac arrests, severe traumatic injuries, among others. Table  6.1 presents various acute case scenarios that may be presented to you during the foundation job interview. Table 6.1  A list of potential clinical case scenarios presented during the foundation job interview  • Anticoagulation management: APTT and INR  • Electrolyte management  • Acute confusion states  • Chest pain  • Shortness of breath  • Post-op complications  • Urine retention  • Collapse and shock  • Syncope  • Overdoses  • Falls in elderly persons  • Cardiopulmonary resuscitation (CPR)  • Febrile patient  • Gastrointestinal bleeds  • Hepatic encephalopathy  • Ascites  • Common arrythmias  • Jaundice (continued)

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Table 6.1 (continued)  • Skin rashes (acute setting)  • Low urine output  • Gynaecology and obstetric emergencies  • Anaphylaxis  • Medication administration errors  • Neutropenic sepsis  • Congenital bleeding disorders  • Spinal cord compression  • Acute limb ischaemia  • Chronic limb ischaemia (ulcers and gangrene)  • Deep vein thrombosis (DVT) and pulmonary embolism (PE)  • Diabetic foot complications + sepsis  • Issues around COVID-19  • Oxygen management in wards  • Diabetes control  • Hypoglycaemic management  • Early warning score  • IV fluid prescription  • Arterial blood gas (ABG) interpretation  • Infection control on the wards  • Management of venous access line

The ethical case scenario is set up to assess your ability to deal with difficult ethical situations, how to ensure that you follow a safe approach and when and how to escalate a difficult case. My ethical scenario revolved around a colleague taking drugs. I was asked how I would deal with the situation. However, there are other ethical scenarios that may be presented. I recommend that you practice for the interview with a friend, where your friend can play the part of the interviewer and ask you questions. To prepare for the clinical scenarios, it is advisable that you consult a medical emergency book. Additionally, there are books specifically aimed at the foundation programme that contain guides that you can follow along with typical questions that are presented during the interviews. When you are practising for the interview be aware of your body language. This plays a key role during your interview. Try to

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avoid being fidgety, touching your hair, using excessively your hands, and avoiding eye contact.

6.4 All About the Big Day The interview can take place in two modalities: face to face or online. With the onset of the COVID-19 pandemic in 2020, most job interviews have shifted to an online platform. Whichever format is used, there are several things that should be performed or followed to ensure a successful outcome. As already noted, being prepared for the interview is crucial. Dress to impress is an important factor to keep in mind. This goes hand in hand with ensuring you maintain good personal hygiene. It is customary that for an interview you wear a formal suit or else if you are a female, a business dress. Try to avoid opting for a stripes or a flowery attire, as this is distracting especially if you are going to undergo an online interview. Ensure that what you wear is neat and clean. Your body language is another factor to work on. Making and maintaining eye contact is essential, this shows that you are confident and ready to engage in the interview conversation. If the interview is online, this might be tricky. You need to modify the technique, instead of looking straight at the interviewers on the monitor, you need to focus your attention on the camera. At the recipient end, you will appear like you are talking to them while keeping eye contact. Additionally, try to avoid being too fidgety while avoiding to look too robotic. Try to be as natural and as yourself as much as possible. Remember, you are allowed to smile during the interview, so no need to put in a stern face. On the flip side, do not allow yourself to get too emotional. While this may be your first job interview, and you are aware of the importance of acing it, you do not want to be too stressed. Being stressed and anxious may affect your speech as well as your overall outcome. Try to take in a deep breathe before starting off your interview, remember you have prepared for this, then go for it. If you are going to undergo an online interview, it may be a good idea that while you are preparing for the interview you film yourself. Then

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playback the clip to see how you sounded and looked. This will enable you to amend any unwanted behaviour that might have been portrayed. Remember to have a breakfast or lunch (depending on the interview appointment time) to ensure that you do not suffer from any hypoglycaemic episodes during the interview. I would also recommend keeping caffeine rich drinks to a minimum. The last thing you need is to have to fight your need to go to the bathroom in mid interview!

On-Site Interview If your interview is going to be held face to face in an interview room or a conference room, make sure that you arrive on site at least 30  min before your interview appointment. It is better to arrive early than late for your interview. Late comers will not only run into the possibility of missing their interview appointment but also might give the wrong impression to the interviewers with potential negative repercussions. If you are an anxious person, you may consider asking a family member or a friend to drive you to the interview site, unless you are going to opt to travel by public transport. In which case, make sure you plan your journey well.

Online Interview While online interviews are convenient as you do not need to travel for the interview, there are several factors to keep in mind. Before the day of the interview make sure that you have the video call application installed and working smoothly on your computer. I would recommend that you have a second device on standby with the video call application installed as well. Make sure that both devices work well. Prepare the room you will be using by eliminating any distracting backgrounds. A clean and plain background is recommended. Make sure that you remove any clutter that may be visible. Having a good lighting in the room is another important fact. Ideally you are in front of a natural light

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source such as a window. Try to avoid overhead lightning as this tends to cast shadows on your face. Ensure that on the day of the interview you keep the interview room locked to prevent anyone from entering the room during the interview. The use of earphones during the interview is recommended to ensure that no echo is present and you are able to hear the interviewers questions well. On the day, if you are using a laptop or tablet, make sure it is fully charged, although ideally you plug it directly to the electricity socket as well as to the internet cable. Make sure you have the contact email and phone number of the foundation office handy just in case an unexpected occurrence takes place preventing you from connecting to the interview call. Avoid having your mobile next to you while undergoing the interview to avoid unnecessary distractions. Following these steps will ensure that you have a successful interview outcome and making your dreams come true!

Further Reading Sathian B, Fatima H, Hussain SA, Menezes RG. Scientific publications and the curriculum vitae: a medical student’s Achilles’ heel? Nepal J Epidemiol. 2017;7(1):645–6. https://doi.org/10.3126/nje.v7i1.17756. PMID: 28970946; PMCID: PMC5607445. Waseem M, Schnapp BH.  Preparing a curriculum vitae for new graduates. AEM Educ Train. 2019;4(Suppl 1):S143–6. https://doi.org/10.1002/ aet2.10420. PMID: 32072119; PMCID: PMC7011422. Woo R, Krawczyk Oman JA, Byrn L, Wakim NM, Dyne PL, Cheaito MA, Epter M, Kazzi A. Writing the curriculum vitae and personal statement. J Emerg Med. 2019;57(3):411–4. https://doi.org/10.1016/j. jemermed.2019.04.019. Epub 2019 Jun 20.

7

Life After the Medical Course

7.1 Introduction Waiting for the final medical school exams results is an anxious, nail-biting period that every medical student loathes. Refreshing the online results page will be the commonest manoeuvre you will perform on the day the results are expected to be out. When they do appear, you will experience a momentarily numb period until reality sinks in. You have made it! You are now a medical doctor! The relief one feels after so many months of hard work and sleepless nights will be worth all that sacrifice. Most will then resort to posting their achievement on social media, text their family and friends, while making a call or two. This is great achievement that merits celebration. However, it soon dawns on you that now that the long-awaited dream has become a reality, you will need to call for work soon and start carrying out a doctor’s responsibilities. As much as you have observed this role being carried out and prepared to become a doctor, when the day comes for you to start your job, you will realise that you are never prepared enough. We all have experienced fear of the unknown as we walked through the familiar hospital doors but now carrying a bigger responsibility and a new title. This chapter will describe the typical journey of a junior doctor from the first day of work, to what is expected in the future. Although this chapter will be mostly based on a UK-­ based foundation and training programme system, other training programmes follow similar pathways. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 S. Cuschieri, A Pocket Guide for Medical Students, https://doi.org/10.1007/978-3-031-27342-1_7

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7.2 What Comes After the Completion of Medical School? The transition from medical student to junior doctor occurs quickly, over a couple of weeks and everyone experiences a tough time during the initial days. When you are a medical student, you are cocooned, you do attend ward rounds and clinics, but you are just an observer. Now you have the responsibility of taking care of patients and following your senior’s instructions. The first couple of days on the job are usually orientation days and believe me, you will need them. Make sure that you optimise these days to your benefit by orientating yourself with the IT system, know how the printers work, familiarise yourself with the process of ordering and withdrawing of bloods, and ensure that you have filled in all forms that are required as a new employee. You would also need to learn the schedule of your new firm. Additionally, remember that although you will be working as a junior doctor, you are also enrolled to a foundation programme. This means that you must keep up with your personal development and the requirements set out by the programme to ensure that you finish this 2-year period successfully. The hospital environment is always busy, and it is up to you to ensure that you take a break, have lunch, drink water, go to the bathroom, and keep on top of the foundation programme’s portfolio. Indeed, to successfully be signed off these 2 years you need to demonstrate that you have acquired a set of skills and undergone self-development growth. This is accessed through a portfolio that consists of a set of assessment tools including case-based discussions, miniclinical examinations, direct observation of procedural skills, logbook of procedural skills, and teaching development assessments. Although one may portray these tasks as a “waste of time” let me stop you there and stress that you need to make sure that you keep up to date with these tasks. They do take time to complete while some tasks are time sensitive. Failure of completing the portfolio each year will lead to delays in your signing off from the foundation programme, meaning you will not be allowed to progress in your career. So, if I were you, I would start working on your portfolio very early on.

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 rom Interview to Getting into the Speciality F You Want It is customary that before actually finishing off your medical school you already know where you should be working (at least the speciality) if all goes well, and you pass your exams. After successfully passing your job interview, most foundation programmes would provide a list of hospital speciality rotation programmes for doctors-to-be to make a choice where they would like to work. Usually, the choices follow a ranking process according to the doctor-to-be standings which is published following the job interview. The rotation durations vary between programmes but tend to range from 3 to 4 to 6 months. Undergoing a medicine, surgery and accident and emergency rotation tends to be a must for all programmes, while the rest of the rotations can follow any other speciality. I do understand that the selection of your preferred rotations for your first-year junior doctor comes at a very awkward period as you have not yet passed your final exams and the last thing you want on your plate is being faced with this important decision. However, it is important to take some time and reflect which specialities you would like to work in. There is a huge difference from having an interest in a speciality and working in that speciality. Although let us be honest, working as a junior doctor in a speciality does not fully expose you to working in the same speciality as a trainee or specialist. Yet, I would still urge you to do your utmost to try to get first-hand experience in a speciality that might be on your bucket list as a contender for your professional career. Unfortunately, not everyone will be able to secure the rotation they wanted since this is very subjective to the ranking position you place as well as the available places for junior doctors in that speciality. Wherever you land, it is always an experience that you should cherish and learn from. Working as a junior doctor means that you will be spending a lot of time on the wards, making sure that patients admitted under your consultant are taken care of. This entails ordering of blood work (and bloodletting), ordering of imagining, chasing results, making sure that the patients are stable and receiving the treatment requested by your seniors among other tasks. If one wants to be blunt, a junior

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doctor might be portrayed as the “consultant’s firm minion,” but the job is still rewarding. Personally, I did not mind the ward work, but I was not a fan of the on-call duties. On-­call duties typically entail the junior doctor to work 36 h shifts which include covering night work on site. On-calls are not for the faint hearted, as although seniors will also be on-call, you are the first line medical doctor that nurses will reach out for anything that occurs on the wards. This may range from bloodletting to dealing with an acute onset chest pain or urinary retention or starting CPR. It is also the time where you learn the most, so try to make the most of it. Do not be afraid to ask for help from your seniors if you run into difficulty or uncertainty of what to do. This is especially applicable during the initial stages of your working experience. Seniors understand that you are just starting off, still new to the system and procedures. They have been in your exact position so they will be more inclined to close an eye if they are contacted for “basic” questions. The weekly work schedule tends to be busy with days arriving late at home or else arriving the next day (if on-call). It is essential to make time for yourself and for your hobbies. Do not just dedicate your life to work. It is easier said than done, I must admit, as apart from carrying out your ward’s duties, you need to be on top of your foundation programme requirements as well as attending the weekly lecture programme forming part of the same foundation programme curriculum. Apart from this, it is recommended that you start thinking of which speciality you would like to continue to work in and consider studying and sitting for the speciality entrance exam. Securing a place in a speciality training programme is becoming more difficult as years progress. This is adding additional pressure on junior doctors as they need to start working hard on enriching their CVs to make the cut, on top of their daily busy schedules and the foundation programme requirements. This will be discussed in more detail later in this chapter.

The Hierarchy of the Clinical Professional World Like every other job, there is a hierarchy to the medical profession, ranging from the junior doctor (foundation) to the consultant (attending physicians in the USA), as shown in Fig. 7.1. Although

7.2  What Comes After the Completion of Medical School?

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Consultant

Fellow (Senior registrar) Higher specialist trainee (Registrar) Basic specialist trainee

Junior doctor (Foundation doctor)

Fig. 7.1  The hierarchy of doctors (based on the UK system)

different countries or regions might label this hierarchy differently, the roles and responsibilities are similar. As already noted, the UK-based hierarchy system will be discussed with cross referencing to the USA system. A junior doctor, a.k.a. foundation doctor (intern in the USA) is the entry level to the medical world. At this stage, the junior doctor is protected in taking medical decisions on his/her own by mostly following the instructions of the seniors. Yet, a junior doctor will take patients’ histories, perform examinations as well as meet with the patient’s family members. Depending on which speciality junior doctors are assigned to, there are some procedures that they are allowed to perform. For example, if junior doctors are assigned to the Obstetrics and Gynaecology (Obs and Gynae) department, they are responsible for any suturing required post-partum. However, if the case is difficult, then it is important for junior doctors to seek senior help. At the end of 2 years as a junior doctor, you are faced with a big decision, “which speciality do I want to continue in?” Applications for “basic specialist trainee” (BST) will be available for second year junior doctors to apply as the end of this period approaches. Successful candidates will enter the BST (similar to junior residents in USA) phase, where these doctors

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start their speciality training and will take on more responsibilities as a doctor. At this stage, doctors will start off their entrance examinations for their speciality (unless already sat for part 1 during the second year of the junior doctor level). This BST period varies between different specialities, as well as from one country to another, however it usually lasts around 3–4  years. While some BSTs enter the speciality of their choice immediately, such as BST in Obstetrics and Gynaecology or in Paediatrics or in General Practice, those that opt for Medicine or for Surgery will have rotations across the different sub-specialities throughout their BST period. It is at the end of this period that these BSTs will have another major decision to make, will they remain as generalist or apply for a subspeciality, e.g., Neurology or Orthopaedic Surgery. The next step is “higher specialist trainee” (HST) also referred to as “Registrar,” which in the USA is like senior resident. At this level, the doctor would have entered the last period of the specialisation training and starts the preparation for the exit exams. The HST period will again vary depending on the speciality of choice, the country, and the ability to pass from the exit exam/s that are required to apply for the next hierarchical level. Once the training is over and the doctor has passed from the exit exam/s of the speciality, the doctor is certified as a “specialist.” Yet it is encouraged that these doctors enter a fellowship period, in order to further enhance their special interest. Different countries will term this stage differently from “Senior Registrar” to “Fellow.” At this stage, doctors are working on their own as a specialist, in consultation with the Consultant (Attending physician in USA). Doctors at this stage of their career will have to wait for the next available consultant post for their speciality to reach the top ranking position.

An Insight into the Medical Doctor Life A medical doctor’s life is not all glamour and sparkle as some TV series portray it. It is a very stressful job with lots of responsibil-

7.2  What Comes After the Completion of Medical School?

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ity, after all doctors have the responsibility to care for a human being. Irrelevant of the stage in their careers, doctors will be faced with different hardships but also experience simultaneous gratification that comes with the job. Although different hospitals and clinics may have variations in their work schedule, most of the doctors work Monday– Friday, while others also have Saturday as part of their normal week. The normal working hours will vary depending on whether they work a standard 5 days or 6 days per week. On top of this, there will be the on-call roster that each doctor, irrelevant of the grade, needs to cover. The job requirements during the on-call duty will be dependent of the grade and the speciality. The on-call duty covers the out of normal working hours, so late afternoon, the night and early morning hours across the week, and Sunday. If Saturday falls within the normal working week, then the on-call will follow the same stratification as that of a weekday, if not then the whole day needs to be covered by the on-call doctors. The doctor’s work during the on-call will be tending to inpatients’ needs and to any emergency care. Elective consultations or procedures do not fall within the remit of the on-call. The distribution of work is another variable depending on the doctor’s grade as well as the hospital one is working in. Within each speciality, it is customary that the number of junior doctors and BSTs covering the on-call will be more than doctors at a higher grade (HST, Specialist). This follows the hierarchy of work and responsibility that each grade is expected to perform. The duration of the on-call again varies but generally a doctor goes to work on day 1 early morning, for example, at 8 a.m., will work the normal working day (e.g., till 2.30 p.m.), then the on-call starts till 7.59 a.m. of the next day. While some doctors will then go home to rest following the on-­call duty, others must remain at hospital to work another normal working day up till 2.30 p.m. There has always been a debate regarding the duration of a doctor’s shift, but that falls outside the scope of this discussion. Irrelevant of your grade, as a doctor you need to work and interact with a plethora of different healthcare professionals. Do not let your ego get in the way. For the optimal care of a patient,

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more than one professional is needed, whether the patient is in or an outpatient. Doctors tend to be the leading professionals in the patient’s management care plan; however, other healthcare professionals also have important roles to play. Another factor to consider is that inter-disciplinary consultations and management plans may be needed. One speciality may not be enough to tackle the patient’s medical problem, irrelevant whether the patient is inpatient or outpatient. Therefore, it is important that as a doctor you do not work in an isolated bubble but rather be proactive and ready to discuss and consult cases with other specialities. General hospitals tend to offer a variety of specialities under one roof, yet there are specialised hospitals that will only cater for certain types of pathologies or specialities only. In such cases, other hospitals might need to be roped in if a patient presents with multiple problems. Dealing with difficult patients or situations is another reality of a doctor’s life. Not every patient you encounter will be the same or hold the same characteristics. Some will need more explanations, while others might resist your expert opinion. In every case, a doctor needs to remain calm, composed, and compassionate, while doing no harm. The choice of words and behaviour should also reflect these values. Breaking bad news is a dreaded albeit essential feature of a doctor’s job. Time and experience will fine tune these skills, but it is important from early days, as a junior doctor, that you acknowledge that certain etiquette needs to be followed as part of the doctor’s daily life. Losing a patient for the first time, even after doing your best to prevent this occurrence, will be tough. I wish I could say it will get easier with time, but a life lost will always be a tragedy yet it is part of a doctor’s life. So is being called to certify the passing of a person, whether in hospital or in the community if you are working as a general ­practitioner. What makes it all worth it is observing your patients thrive, smile, and be happy after experiencing sickness. Although receiving “thanks” from your patients or their families may not be the commonest occurrence, when it does happen it will be the greatest satisfaction you will experience!

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7.3 Is Medschool the End of the Studying Journey? I hate to burst bubbles, but the end of medical school marks the beginning of your studying journey. As a doctor, you are continuously learning, and it is a must to keep up to date with the latest evidence-based medicine guidelines and findings. Apart from this, it is mandatory that every doctor chooses a particular speciality to continue working in. Whether you would like to work as a general practitioner or a physician or a surgeon or anything in between, you are obliged to continue studying, sit for the respective exams, and finally obtain a specialist accreditation. If you do not, you will be stagnant as a medical officer or a staff grade. This means that before finishing off your second year of the junior doctor period, you are encouraged to start thinking of sitting for speciality exams, according to which speciality you wish to pursue. Typically, each speciality will have the “entrance” exams, e.g., in the UK, surgeons need to first sit for the MRCS exams, while physicians need to sit for their MRCP exams. Once these are secured, then sub-specialisation will be required, i.e., sitting for the FRCS/FRCP, respectively. However, I do understand that not everyone will be certain or know which speciality to follow in the initial stages of your career. Indeed, this aspect will be discussed in more detail later in this chapter. Different specialities follow different training programmes, durations as well as requirements to achieve the specialist accreditation, apart from the fact that every country will follow different procedures. So, it is important to familiarise yourself with the country’s requirements and the speciality you wish to pursue. Training programmes usually oblige their trainees to undertake several tasks, a dictated number of hours performing certain duties as well as completing logbooks. Additionally, trainees need to sit for specific speciality examinations to mark off the end of their training. Sitting for exams mean that you need to revert to books and to the studying mantra. The issue with studying at this point in your career is the fact that unlike in medical school, where studying was done mostly on fulltime basis, studying for your

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specialisation exams needs to be juggled with working in hospital or clinic including covering the on-calls and most will also have a family to tend to. There is also the fact that you will becoming older, and most will start struggling to maintain the same mental strength and endurance as when you were younger. Undergoing research and publishing research articles are increasing seen as essential by training programmes in most places. So, on top of your obligatory studying for your exams, you are expected to dedicate time to the conduction of research. While some individuals find this task easy and fun to carry out, others might struggle. Let us face it, most medical schools do not prepare their students to be independent researchers, nor are they equipped with the skills to conduct research and write a scientific article. While some will perceive this as outside the scope of medical school, I beg to differ. As time passes, the mantra of “publish or perish” is no longer just applicable to university appointed academics and research officers but also to medical students and doctors. Publishing of research is becoming a requisite to successfully secure a job and a successful specialist training progression. Therefore, I strongly believe that medical schools should equip their students with hands-on research experience, even if on an elective basis. It is not the first time that I encountered both medical students and doctors requesting me to aid them in the writing of a scientific article or to undergo a simple study. So, the need for such training is definitely of essence. More ambitious doctors might additionally opt to follow a master’s degree and later a PhD degree. Doctors following these academic qualifications are obliged to undergo research. Although some master studies follow a class-room approach including end of the year exams, others are more research based but ultimately, all master studies require candidates to present a research thesis at the end of the degree. Those following a PhD degree will be ­conducting a research study according to their research question and their hypothesis. If you are wondering whether following a masters and PhD degrees is a requisite for a hospital/clinic-based speciality, the answer is “No.” But with the growing competition to secure training posts and specialist jobs, having additional qualifications under your belt might be a good idea. I do under-

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stand that pursuing such a degree requires more commitment and time away from “living your life.” This is a personal choice, but you need to balance out the pros and the cons. Whether you are ready to sacrifice a couple of years to further your academic qualifications or not is your prerogative but remember having a PhD opens a lot of additional doors. While you may not be envisaging yourself following an academic career just off medical school or during your specialist training, later your view might differ. A PhD is a prerequisite to having a permanent job with a university. We are all humans, and things happen in our lives, having a backup plan might not be a bad idea. However, I leave this decision in your hands.

7.4 I Do Not Know What Speciality I Want to Pursue: Should I Worry? Some of us have had a calling for a specific medical/surgical specialty from early days, some even before entering the medical course, others might struggle to pin-point which specialty makes them tick up till the eve of BST or HST selection process. Everyone struggles in making this important life changing decision even those who think they know which specialty they want. There is a huge difference between what you perceive a specialty is all about, to what it truly entails. I for one can relate to this perfectly. From a young age I always knew I wanted to become a medical doctor, I even recall role playing with me as a doctor, and I was examining my teddy bears! As I started medical school, I set my heart to becoming a surgeon, as I was fascinated (still am!) at how life changing and potentially saving a surgeon’s job is. On finishing off medical school, I bought the necessarily surgical trainee core books and started to study in preparation to sit for the part 1 MRCS exam (surgical exam). However, working on the surgical wards, while working neck and neck with surgeons of both genders, I started realising that as much as I love the subject and my heart wanted it, my body was not in line with what the work really entitles. I was in denial for almost a year until my husband (boyfriend at the time), a fully

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fletched spinal orthopaedic surgeon, asked me point blank whether I was up to follow a life of a surgeon? would I endure the hardship it carries with it? and will I be truly happy? As much as it hurt to have him challenge me on the subject, deep down I knew he was right, even if at the time I was not really pleased. This put me in a dilemma and triggered a soul-­searching exercise. What am I going to do with my life? I had been so set and focused to becoming a surgeon for so long that I never considered any other specialty. I sincerely did not know what to do! The first 2 years of a doctor’s working life are there to give you a taste of what different specialties are all about. But time quickly dissolves, and you need to start taking hard decisions as to which specialty you will be applying for and starting your basic speciality training in. Considering the level of competition each specialty carries, you always need to have publications, exams, certificates, or degrees under your belt relating to your speciality of choice. Having this knowledge, I realised I needed to enrich my CV, especially now that I was not certain which specialty I wanted to follow. I opted to start a postgraduate diploma (which later I converted into a master’s degree) in diabetes. The rational for this choice came about following the fact that type 2 diabetes is a national disease in my country, so I reckoned having a degree in the subject should help me in whichever direction I ended up taking. Another reason was that having a medical based degree can be of aid in several specialties, it does not have to be just for medicine, but also applicable for general practice, public health, emergency medicine, among other. On starting this diploma, little did I know that this will open more opportunities later in my life including being the basis to my PhD degree. My career speciality dilemma continued even after applying for various BST positions and sitting for their respective interviews. Although I was fortunate to be given a position within the four different basic specialist training programmes I applied for, I still was not certain about my first choice to which I was automatically assigned to. Within a couple of weeks working in the speciality, it became obvious that I was unhappy, and it was not for me. The only option was to continue working in that speciality for a year and re-apply for another basic specialist training programme the next year. I am not the exception of having such an experience, as every year several doctors change training programmes. In my case, I was lucky that at the time of my BST applica-

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tion process, there was an opening at the university for a fulltime position, which I applied for and was a successful recipient. This career change was another dilemma that I had to face, as it was a very hard decision to take, changing the course of your life from a clinical based doctor to an academic research-based doctor. Indeed, there have been several doctors that attempted to follow an academic career but after a couple of years opted to change back to clinical based work. As for my career choice, now, I believe it was the best thing that happened to me. I must admit it was a hard thing to do, and it took me years to accept this career change, although I did spend 8 years working on part-time basis as a medical officer at the local accident and emergency department that kept me in-touch with the clinical world. It is therefore normal to experience uncertainty as to which speciality suits you and your ambition. Do not be alarmed or consider yourself a failure if years down the line you might realise that you are in the wrong speciality. Changing specialities or career options will take you back in the speciality hierarchy and in the training program, but your happiness as well as job satisfaction is what is important. Then there is another potential issue that you might face. You might want to follow a particular sub-­ specialty, but no positions are available. This does not mean that you give up on your dream, but rather keep on persevering until you make it.

7.5 An Overview of What Each Speciality Offers You Once your first 2 years as a junior doctor are over, it is expected that you enter a basic specialist program. This does not necessarily mean that you will continue your training in the same hospital that you had been working in. Indeed, not every centre/hospital offers every speciality, let alone a training program. I am lucky that I come from a small country where our tertiary hospital offers training in almost all basic specialities. The basic specialities, as illustrated in Fig. 7.2, can be considered as the core specialities that a doctor can apply for, i.e., medicine, surgery, general practice, anaesthesia, radiology, psychiatry, obs and gynae, paediatrics,

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Foundaon program

Basic specialist trainee

Higher specialist trainee / registrar Internal medicine

Medicine Cardiology

Neurology

etc Surgery Vascular

Orthopaedics

Plascs

ENT

Junior doctor

Anaesthesia

etc

Radiology Family Medicine Obs & Gyane Psychiatry Paediatrics

Special interest in a particular field

Pathology Emergency medicine Public Health

Fig. 7.2  A representation of the speciality hierarchy from junior doctor to basic specialist trainee to higher specialist trainee. The black bracket is illustrating that the various doctors following certain specialities at a basic trainee will go on to higher specialist trainee in the same speciality without the need to sub-specialise or else would follow a special interest in a particular field within the speciality

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pathology, emergency medicine, and public health. After completion of the basic training, which typically varies between 3 and 4 years, the doctor is now set to continue in a certain subspeciality, for example, if a doctor is a BST in medicine, then can opt to continue in neurology, internal medicine, or any other medical subspecialty. Same goes for surgical BSTs, these can opt to continue in orthopaedics, plastics, ENT among other surgical sub-­specialties. For other specialities, doctors might opt to have a special interest and continue training in a particular aspect such as interventional neuroradiology, or child psychiatry, or paediatric cardiology, etc. There are grey areas that overlap between specialities, so when deciding which speciality is the ideal one for you, it is important to keep these in mind. As a rule of thumb, you can divide the specialities into whether there is surgery or procedures involved as part of the work plan or not. What I mean with procedures is the need to undergo certain medical invasive tasks such as intubation, spinal taps, putting a chest tube, suturing, etc. which does not necessarily mean opening a human body to remove or replace structures. Table 7.1 provides an overview categorisation of specialities into three broad job requirements. Whichever speciality you will Table 7.1  Categorisation of specialities dependent on the work requirements Consultations—ward rounds—lab/ office based Procedures Non-interventional radiology Anaesthesia Nuclear medicine Emergency medicine Pathology Family medicine Psychiatry Internal medicine Public health

Neurology Oncology Paediatrics Interventional radiology

Surgery Cardiothoracic Dermatology ENT General surgery Neurosurgery Obs and gynae Ophthalmology Orthopaedics Urology Vascular

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opt for, the majority will involve direct contact with patients through ward rounds and consultations during clinics. There are some exceptions to this such as those doctors working in ­pathology, where they will not be dealing directly with patients but rather working on samples from patients. Similarly, those working within public health have an office job with direct interactions with different entities including workplaces, schools, and policy makers. Whichever speciality you opt to follow, all will require you to work as a basic specialist trainee and continue progressing through the speciality hierarchy until 1 day you will become a consultant. Each speciality requires doctors to work the normal weekly schedule along with the on-calls. The frequency of the on-calls is very variable and dependent on the hospital/clinic you are stationed at. The weekly schedule will vary depending on the speciality, with those within surgical specialities (including Obs and Gynae) having a substantial portion of their week dedicated to surgeries (day cases, elective or trauma if following the orthopaedic speciality), with the rest of the days dedicated to clinics. Surgical based specialities rarely have a whole day dedicated to just a ward round, unlike the medical based specialities. Conversely, those following the anaesthesia speciality will be scheduled to work in the theatres almost daily unless they are covering the intensive care units. The family medicine and dermatology ­ specialities typically follow a daily clinic schedule with occasional planned procedures. Working in the radiology speciality will require doctors to undergo different tasks, from performing ultrasounds on patients, to reporting of X-rays, CT-scans, and MRIs, to performing and reporting of contrast scans, while some will also undergo interventional procedures. The duration to reaching the ultimate position of consultant depends on several factors, from the length of the training programme (which varies between specialities and sub-specialities) to the need for a consultant in the hospital (you may need to change hospitals or countries to secure this position quicker). Reaching the top hierarchy, i.e., making it to consultant, as you look back at all those years of hard work, you will feel a sense of relief and gratification to having made it!

Further Reading

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Further Reading Magauran CE, Brennan M.  Being a “good doctor”. J Palliat Med. 2008;11(3):506–8. https://doi.org/10.1089/jpm.2007.0206. PMID: 18363496. Williams D, Ledger A. Starting work as a doctor: challenge is essential. Clin Teach. 2020;17(1):36–40. https://doi.org/10.1111/tct.13012. Epub 2019 Apr 15. PMID: 30985078. Yardley S, Kinston R, Lefroy J, Gay S, McKinley RK. ‘What do we do, doctor?’ Transitions of identity and responsibility: a narrative analysis. Adv Health Sci Educ Theory Pract. 2020;25(4):825–43. https://doi. org/10.1007/s10459-­020-­09959-­w. Epub 2020 Jan 20. PMID: 31960189; PMCID: PMC7471202.