Every medical school course is divided into two main components, preclinical, which usually lasts either 2 or 3 years, and clinical, which is usually 3 years. Preclinical medicine essentially prepares medical students with the knowledge they need for beginning clinical practice. However, it is fair to say that the set up of each course is quite different. Preclinical medicine consists of around 20 hours a week 'contact time' made up of lectures, anatomy sessions, clinical skills and seminars, although this may be less on a problem-based learning course, where more group work may occur. Lectures cover all the physiology of the body systems in a well, and sick person. Anatomy sessions taught all the locations of the organs and structures in the body and their relations to each other. Clinical skills used plastic models and, often, each other to practice simple procedures and examinations. Seminars taught us practical communication skills, as well as reinforcing our lecture learning, or discussing ethical situations arising in medicine.
Over the two years we had had a couple of introductory hospital visits and GP surgery sessions, where we were able to observe, and sometimes interview selected patients in twos or threes, with some questions already provided. Prior to starting clinical medicine I had taken a full medical history only once, from a 'real' patient, and only once in an OSCE exam situation with an actor, and had learnt a handful of examinations. At the end of the two preclinical years, I was certainly anxious as well as excited about starting clinical medicine, but I had no idea what to expect, and I wasn't sure about how we would learn, because we were in hospital all year, rather than in the medical school.
So what changed once clinical years began? My anxiety was unnecessary; we were introduced to what the style of learning would be, and how to adapt to clinical teaching.
The main focus of third year is on taking a proper history, and doing a well-structured examination, and beginning to interpret the findings of these. The first term consisted of covering all the systems of the body in turn, focussing on important parts of the history, and practicing examinations over and over again, either with patients on the wards, or people who had come in from home. This might seem similar to clinical skills sessions in the lab, but when you actually hear a heart murmur or the crackles of pulmonary fibrosis, it's a great moment when you finally start to believe that the day where you qualify as a doctor isn't so far away after all. Another milestone in clinical medicine is doing all these things on your own, having confidence in taking the history and getting consent from the patient to examine them. Every day is now an opportunity to practice clinical skills. Siting your first cannula, or taking blood for the first time on a real patient, who actually needs it for their diagnosis or treatment, rather than on another student in the clinical skills setting, is a great feeling. It's a great way to feel part of the medical team, rather than the student getting under everyone's feet. However, all the staff are generally welcoming to the students, and often are quite happy to give you some off-the-cuff teaching, or listen to you present the history for a particular patient. You'll also learn more about ethics in the clinical setting that you ever could in the classroom, because listening to doctors discussing real-life situations makes ethics more applicable to everyday medicine. There are also opportunities to observe and take part in different clinics, observe an autopsy, and watch surgery.
How does the style of learning change? You'd be surprised in clinical years about the way you seem to turn into a sponge and soak up knowledge, just by talking to a couple of patients with different conditions. Sometimes a particular patient will make a real impression on you, and help you really remember a particular condition, and the signs and effects on the patient.
Obvious changes from the preclinical years include the structure of the timetable, almost certainly a 9am to 5pm, but often with more of a journey to hospital, and dressing professionally. On-call evenings are also added into the timetable, and these are a great opportunity to experience what medicine is really about. During one of my on-calls, I went to my first crash call, which was an experience I won't forget, teaching me both about resuscitation and talking to relatives about prognosis and changes in a patients' condition.
Overall, clinical medicine is a challenging, but fun way of learning about medicine, making it relevant to future practice, and it's introduced in such a way that you are prepared for it, but it is definitely normal to feel a little out of your depth beforehand.
Felicity Gilbert, third year medical student (Newcastle)
Received May 2010
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