Subject Code/Name: MED4190 - Specialty clinical practicesWorkload: per week: varies between rotations and sites
- Paediatrics (perspective from MMC and Casey): get there at 8.30am for ward rounds and you can probably leave at around 2pm
- Women's health (perspective from Angliss): depends what you're doing, days can be long (including night shifts for delivering babies!), days can start early (for surgery), days can be short; highly variable
- Psychiatry (perspective from MMC and Kingston): get there at 8.30am for ward rounds and you can probably leave at around 12pm
- General practice: expected to do two full days of GP a week, there is 9-5 teaching two days a week, and one day off
Assessment:- Paediatrics: tutor assessments (11%), written case report (4.6%), oral case report (4.6%), contemporary issues in health group oral presentation (2.8%), logbook tasks (hurdle)
- Women's health: written case report (4.6%), oral case report (4.6%), observed clinical encounters (2.2% x 5), contemporary issues in health group oral presentation (2.8%), logbook tasks (hurdle)
- Psychiatry: written case report (23%)
- General practice: chronic disease assignment (23%)
- Other: attendance of 80% for all rotations (hurdle), evidence-based clinical practice quizzes (1% x 8 ) and forum posts (hurdle), health services management forum posts (hurdle, semester 1), health economics forum posts (hurdle, semester 2)
Recorded Lectures: No.
Past exams available: N/A, exams fall under MED4200, but I'll be discussing some exam study in this review too
Textbook and Website Recommendation: Paediatrics:
- Clinical Paediatrics for Post Graduate Examinations 3rd - Stephenson, Thomas and Wallace
- Illustrated Textbook of Paediatrics 4th - Graham and Lissauer
- Jones' Clinical Paediatric Surgery 7th - Beasley, Hutson, King, O'Brien and Teague
- Toronto Notes 2015 31st - Hall and Premji
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http://www.health.vic.gov.au/neonatalhandbook/conditions/-
http://www.rch.org.au/clinicalguide/-
http://muppits.mumus.org/clinical-cases/-
http://www.health.gov.au/internet/immunise/publishing.nsf/content/handbook10-home-
http://www.asthmaaustralia.org.au/Inhaler_technique_videos_for_HPs.aspx-
http://www.asthmahandbook.org.au/Women's health:
- Gynaecology by Ten Teachers 19th - Monga
- Lectures in Obstetrics, Gynaecology and Women's Health 1st - Kovacs
- Obstetrics by Ten Teachers 19th - Baker and Kenny
- Practice OSCEs in Obstetrics and Gynaecology - McNeilage, Vollenhoven and Weston
- Toronto Notes 2015 31st - Hall and Premji
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https://system.prompt.org.au/login.aspx-
http://geekymedics.com/how-to-read-a-ctg/-
https://www.thewomens.org.au/health-professionals/clinical-resources/clinical-guidelines-gps/-
http://medilinks.blogspot.com.au/2012/05/instruments-used-in-gynecology-and.html-
http://www.menopause.org.au/health-professionals/managementPsychiatry:
- Diagnostic and Statistical Manual of Mental Disorders 5th - American Psychiatric Association
- DSM-5 Guidebook - Black and Grant
- Kaplan and Sadock's Synopsis of Psychiatry – Behavioral Sciences - Clinical Psychiatry 11th - Ruiz, Sadock and Sadock
- Toronto Notes 2015 31st - Hall and Premji
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https://masteringpsychiatry.wordpress.com/ (there is a textbook in here too which is excellent)
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http://www.trickcyclists.co.uk/-
https://www.youtube.com/playlist?list=PLBF6D1605733BAACBGeneral practice:
- Clinical Examination A Systematic Guide 7th - O'Connor and Talley
- Clinical Orthopaedic Examination 5th - McRae
- Eye Emergency Manual 1st - NSW Department of Health
- Murtagh's General Practice 5th - Murtagh
- OphthoBook 1st - Root
- The ECG Made Easy 7th - Hampton
- Toronto Notes 2015 31st - Hall and Premji
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http://www.racgp.org.au/your-practice/guidelines/redbook/-
http://www.dermnetnz.org/-
http://elearning.dermcoll.asn.au/login/index.php-
http://lifeinthefastlane.com/ecg-library/-
http://www.ranzco.edu/index.php/ophthalmology-and-eye-health/eye-conditions-information-
http://www.ophthobook.com/ or
https://www.youtube.com/channel/UCSfq-96NwFRpmEZXxI7WIEw-
http://www.racgp.org.au/afp/-
http://copdx.org.au/copd-x-plan/-
http://www.dhhs.tas.gov.au/palliativecare/health_professionals/symptom_management_guidelines-
http://www.eyeandear.org.au/page/Health_Professionals/Education_and_Training/Lecture_series/I'd also recommend utilising UpToDate, eTG, and
http://radiopaedia.org/ as much as possible.
Lecturer(s): Many, depending on the series of lecture
Year & Semester of completion: Semester 1 and 2, 2015
Rating: 5/5
Comments: This is a very challenging year and unit. It is essentially one big unit divided into four topics: paediatrics, women's health (obstetrics and gynaecology), psychiatry, and general practice. I'll keep this general given that every student will have their own unique experience depending on their site, their rotations, their group, and how keen they are to get what they can out of it.
Basically the sites Monash have are (I may be missing some!):
- Central: Alfred (psychiatry), Cabrini (paediatrics), Peninsula (paediatrics, women's health, psychiatry)
- Monash: Monash Medical Center (paediatrics, women's health, psychiatry), Dandenong (paediatrics, women's health,psychiatry), Casey (paediatrics, women's health,psychiatry)
- Eastern: Box Hill (paediatrics, women's health), Maroondah (paediatrics, psychiatry), Angliss (paediatrics, women's health)
- A bunch of rural sites such as Bendigo, Mildura, Bairnsdale, Traralgon, etc
- Hundreds of GPs, although the teaching home base is in Notting Hill
Basically how rotations are allocated is that after giving preferences, the cohort is divided into three groups: metro, rural, Peninsula. Metro students have access to rotations in all metro hospitals other than Peninsula, rural students have access to rotations in the rural hospitals, and Peninsula students are at Peninsula for the year. I was a metro student who had rotations at MMC, Angliss, and Casey. Each site has their ups and downs in terms of a balance between practical skills and teaching and it's probably not up to me to make a comment on this for each site, but I think I was pretty lucky in getting good rotations.
The year is divided into two 18 week semesters, followed by one week SWOTVAC and then 5 exams in 5 days (more on that hell-hole in my MED4200 review!). Each semester you do two rotations, either paediatrics and women's health, or psychiatry and GP, each of 9 weeks duration. Some people may be in multiple hospitals during a rotation (especially psychiatry at MMC, or metro paediatrics), others might be at just the one (more-so in women's health), really depends.
From the outset, I want to make it clear that
this unit is bloody hard work and it's really important to study smart and keep on top of your study to make sure you don't fall behind. This sounds obvious, but this unit has a lot of assignments and Moodle tasks, and if you get caught up in them then it's very easy to lose track of your study. Personally, I made notes for my rotation before it started, and then added to them once I was in the rotation. So how my study went:
- Summer holidays: make paediatrics notes, also decided to make notes on ophthalmology, dermatology, and ENT because I knew GP was my last rotation and I wanted to ease off pressure as it was so close to exams
- Paediatrics: refine paediatrics notes, make women's health notes
- Women's health: refine women's health notes, make psychiatry notes
- Mid-year holiday: refine all notes thus far and start to revise third year material for MED4200
- Psychiatry: refine psychiatry notes, make general practice notes, continue revising third year material
- General practice: refine general practice notes, revise all notes from this and last year
- SWOTVAC: cram everything like there's no tomorrow, maybe consider revising clinically-relevant things year 1 and 2 if you have time for MED4200
To aid with the study, the Faculty provides you with a matrix, similar to the one in third year except about double in size. However, as I'll touch on later, I think that's the bare minimum to know. To enhance your knowledge, I'd strongly recommend a purchase of some sort of online MCQ/EMQ question bank. Some of the ones I have used over the years include:
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http://my.onexamination.com/Login.aspx (probably the best one)
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https://www.pastest.co.uk/product/medical-student-online?rbc=true&pnpid=915-
http://www.passmedicine.com/index.phpHere are some properties from my combined years 3 and 4 notes, the study is very much real this year:
As aforementioned, this unit has a few Moodle quizzes, these are evidence-based clinical practice quizzes and forum posts, health services management forum posts (semester 1), and health economics forum posts (semester 2). These are terrible, absolute pain in the asses to do every week. Definitely the bane of fourth year. However, as boring and tedious as these tasks are, they're hurdles and people have failed the whole year because of missing even a single quiz. Quick run-down of them:
- Evidence-based clinical practice: consists of four three-week blocks per semester. Each block consists of doing some readings (don't bother) and a video lecture (I'd recommend watching these, actually useful), answering a question in a Moodle forum about said readings (tactically pick a question that isn't about the readings, or one that is otherwise straightforward), and doing a quiz (usually about 10 questions).
- Health services management: even after making weekly Moodle posts about this, I still don't know what it is or why we did it. Basically there is a weekly topic, and you're supposed to ask a senior clinician for their thoughts and then write a Moodle forum post summarising their thoughts and your own. As for how many people ever asked a clinician, I'd say <5%. Pointless waste of an hour a week imo.
- Health economics: this was a little better than health services management, although more tedious. Basically there are weekly readings about some economic issue in health that you have to make a Moodle forum post about. Some were interesting, others very dry. Not my cup of tea.
Now I'll go through the different rotations in the order I had them, and share my experiences, give some advice, and give you a taste of fourth year med
PaediatricsIf you like kids, this rotation can be really fun; if you don't, too bad
I enjoyed this rotation, spending four weeks of it at Casey and the other four at MMC. I had subrotations in general paediatrics, neonatology (ie. special care unit), rheumatology, nephrology, adolescent medicine, and emergency medicine.
The other week of this rotation, the first week, is a week of 9-5 lectures at MMC. This can be VERY overwhelming if you're not prepared, which is why I recommend pre-reading for your rotations so you can make the most out of them, especially because the quality of the lectures was very high and it'd be a shame to miss that opportunity. Furthermore, paediatrics is a rotation that has a LOT of content; it's essentially third year condensed (get it? because kids are smaller than adults hahahaha) into 9 weeks. The Faculty provides a list of conditions to know, but I honestly feel that you need to know much more than that unfortunately. The best way to fill in gaps in your knowledge is to do questions, there shouldn't ever be a case where you don't know anything about an option in an MCQ/EMQ.
In terms of other teaching, there are biweekly tutes, one discussing content and the other a bedside tutorial (of the same vein as third year bedside tutorials). These are run by senior paediatricians and are a bit of a mixed bag depending on who you get. I was extremely fortunate to have four weeks of tutes with Dr Hinds, who is a bit of a celebrity among us medical medical students, and I found them to be very useful.
Other than the intense workload of study, this rotation also has a few assignments:
- Oral case report: fairly straightforward, the more interesting the better
- Written case report: fairly straightforward, the more interesting the better
- Contemporary issues in health group oral presentation: this is an absolute pain. You don't choose your group and hence this can cause a few issues if you're with people who aren't keen to do well (I may or may not have had this issue...). This is essentially a presentation based on a topic, eg. childhood obesity, that you deliver to all the metro students in paediatrics and women's health. Hence, you either do this assignment during paediatrics or women's health, and the mark is used for both.
Now, moving on from study and assessment and onto my experiences. This was a really cool rotation if you're keen to stay late and get involved!
- Casey: spent a lot of time in general paediatrics, neonatology, and the emergency medicine. General paediatrics was a little dull, lots of common conditions such as bronchiolitis, exacerbations of asthma, urinary tract infections, etc. Neonatology was awesome! It was pretty much my first experience with babies and I guess what I got out of this was that "babies are saaahhhhhhh cute!" Most of the babies were fairly healthy, a few had sepsis and jaundice for investigation, but it was a great experience. Emergency medicine wasn't really supposed to be a rotation for us, but I was keen and decided to do some after-hours stuff with the registrar a few times, very rewarding experience! You get the chance to clerk kids, diagnose them, and recommend some investigations to the registrar. I'd highly recommend going out of your way to do more stuff if you're keen on it, there are heaps of opportunities.
- MMC: subrotations in rheumatology and nephrology, adolescent medicine, and emergency medicine. Rheumatology and nephrology had a reputation for not having many patients and hence having the med student leave at about 10am, however I was there on a pretty busy week. Saw cases of glomerulonephritis needing renal transplant, congenital nephrotic syndrome, acute rheumatic fever, hypermobility syndrome, pyelonephritis, etc. The team was also fantastic and I had a great time. Adolescent medicine, on the other hand, wasn't so great. Essentially the patients here have eating disorders, and whilst it was great to get exposure to these patients, there wasn't much I could contribute to what was going on; the team was nice though. The best thing about paediatrics at MMC is the emergency medicine week. Here, you pick 4-hour shifts and then pretty much work as a paediatric resident! Amazing opportunity to take histories, perform physical examinations, make diagnoses, and initiate management and treatment with the guidance of a senior physician. Saw a variety of cases, and as with Casey, I went out of my way to go on weekends and after 12am, had an absolute ball!
To guide your clinical experiences, there is also a hurdle logbook. However this is only one page in length and most of it can easily be done during the emergency medicine subrotation. Not really a stress.
Overall, paediatrics was very good! Probably not as good as some of my rotations last year, but still very interesting and exciting. And babies, so darn cute!
Women's healthI was expecting to hate this rotation, but I was blown away by how interesting it was! There are really two parts to women's health: obstetrics and gynaecology. The former deals with pregnancies, births, and the postpartum period; whilst the latter deals with non-baby related conditions (endometriosis, fibroids, cancers, etc.). I got pretty good exposure to both, and similarly with paediatrics, the more time you put in to this rotation, the more you can get out of it. This rotation had a similarly bulky week of lectures to start it off, and again I can't emphasise enough how important it is to not get lost during this valuable teaching period.
Being in a small outer-suburban hospital at Angliss, I got to know all the consultants and registrars quite well, which made the atmosphere a really friendly one. The teaching, which consisted of tutes and clinics, was excellent. They were very informal and we could discuss everything and anything, which was great for focusing on tougher areas of the course and having a bit of fun at the same time.
Unlike my surgical experiences in third year, I enjoyed surgery in this rotation! There weren't many different types of procedures and there was plenty of opportunity to get involved in assisting in both gynaecological surgery and in Caesarean sections. Speaking (or writing) of which, this rotation presented a unique privilege: being present at births. Surprisingly, having a baby seems nothing like it's made out to be in movies, labour can last hours (or even days!) and honestly I don't see how men can complain about ever being in pain haha. It was amazing to see births and even deliver a baby, a room full of anxiousness and worry becomes one of complete elation, it's almost magical to witness. I was fortunate to see normal vaginal births, forceps assisted, and ventouse assisted; would highly recommend trying seeing all three as it really ties a knot in the theory. The best way to achieve this is to be nice to the midwives, as they pretty much control the show!
One of the best parts of this rotation is "mentor week". During this week we stray from Angliss and join a private obstetrician and gynaecologist in their rooms for a week. I had the privilege of joining a doctor at a private hospital who did a lot of work with IVF, and had a fantastic time learning about it and assisting in his surgeries. It was very eye-opening to see how private practice work and we had a lot of interesting conversations about medicine and life. He's probably the reason I'm choosing to do an Honours degree next year (if I pass!). I kinda wish we were allowed to do a "mentor week" for every rotation for years 3 and 4.
In terms of assessment, it's very similar to paediatrics with the written and oral case reports. The addition are the observed clinical encounters. These are very similar to the MCRs of third year, except with an obstetric and gynaecology focus. The "encounters" are an antenatal check, postnatal check, bimanual vaginal examination, speculum, and Pap smear. These were sometimes stressful to get done, but otherwise all part of good learning.
The big downsides to this rotation were the logbook and the attendance requirements. The logbook is a little insane and a big stressor, there are a lot of components to it and there can be a lot of luck in terms of getting things done. For example, during my night shifts on the birth suites, I had 5 consecutive days without any births, which was apparently a record according to a senior midwife there haha. As for attendance, you had to record morning and afternoon attendance every day. This was a little ridiculous because sometimes there was just nothing happening and you had to stay around to get a signature, bit of a waste of time.
Overall, a good rotation, much to my surprise! Being in a small hospital was a good thing for this rotation, we got to know everyone well and it was a really good environment.
PsychiatryProbably my least favourite rotation of the year, but probably the one that I felt I most needed to have. Mental illness is something of a "hidden" burden in our society, it's an umbrella for multiple conditions that effect more people than we can imagine, and it was a very valuable and enlightening experience to see it at its extremes.
My rotation was divided into three subrotations: acute ward, aged care, and adolescent medicine, although other people had different rotations.
- Acute ward: this is eye-opening. The patients here are acutely unwell with a variety of psychiatric illnesses such as major depressive disorder with suicidal features, acute mania as part of bipolar I disorder, psychosis as part of schizophrenia, etc. It's a confronting place to be and I honestly couldn't wish admission there to my worst enemy. There are times where you feel a little unsafe (even not in the seclusion areas, although luckily police were nearby) and times where you feel out of your depth, I was told that was to be expected and was normal. It was a good learning experience to see how psychiatrists managed patients who were acutely suicidal or manic (or whatever else), as it's something that is incredibly difficult to do. Unlike most areas in medicine, many patients in psychiatry here don't want to take their medications because they don't know that they're not well, this poses a unique challenge and it was fascinating to see how they dealt with this problem (with a variety of outcomes haha). Another issue worth mentioning here is drugs. The ward was infested with amphetamines, and it was startling to find out how they got there. For example, smuggling drugs inside of McDonalds burgers!?! The problem with drugs was very evident, with many patients suffering from addiction. This is a real issue as it prevents them from recovering from their mental illness and in fact makes things worse, which is a terrible vicious circle to get trapped into.
- Aged care: this is pretty much acute medicine but for the elderly. Given the demographics, there was less mania and more dementia-ish presentations mixed in with some depression and psychosis. I was really lucky during my rotation here because the registrar transitioned to becoming a consultant, so because we were already friendly beforehand nothing changed when she became the boss! We were able to get a bit more involved with the team here, able to talk to more patients (and by ourselves, something they don't let you do for safety reasons on the acute ward) and join them for walks and stuff. Had opportunities to see electroconvulsive therapy (ECT) here, which busted all the myths I had heard about it; it's actually a very safe method of treatment with a lot of evidence of efficacy. Overall, not as confronting, but it was valuable to experience some issues the elderly face and how to overcome or prevent them.
- Adolescent medicine: covered older people, younger adults, and now kids. These patients had similar issues to those I saw on adolescent medicine in paediatrics, except they were medically stable. Conditions encountered include borderline personality disorder, major depressive disorder, drug-induced psychosis, and various eating disorders. The frustrating thing about this part of the rotation was interacting with the patients was difficult for a bunch of legal reasons, which was completely fair enough and understandable, but puzzling as to why they sent us down there for three weeks if we weren't going to do anything. In the end we found that the best way to interact with them was by playing table tennis with them and getting to know them that way, which kinda worked out. Something important to mention in this subrotation was how eye-opening and shocking some of the stories these children had. It's absolutely horrible what some of them had been through, and there were definitely days when you left hospital feeling pretty down just from hearing about what they had to endure.
I guess the one thing I really didn't like about psychiatry, other than the limited patient interaction, was just how under-resourced it is. Despite all these feel-good R U OK? days and whatnot (which in all honesty, I feel don't help that much), there isn't enough funding for research into new drugs and we're still using medications that were made too many year ago. Furthermore, despite having acute wards, many of these patients don't get better, which is a really sad thing.
In terms of teaching, this unit was focused around intermittent lectures spaced throughout the rotation and tutes which ended up being discussions on whatever came to mind. There was little structure, but I thought that worked pretty well. Our supervising doctor was pretty amazing and had a lot of fascinating insights into the world of psychiatry.
The assessment in psychiatry is daunting, it's a massive 5000 word case report. This is a mammoth compared to the 1500 word case reports in paediatrics and women's health. It's stressful finding suitable patients and then even more stressful trying to interview them. Took me a good week to get it done (with trademark procrastination), but I'd advise people to try and get it done as early as possible in the rotation. Get it out of the way!
Overall, my least enjoyable rotation, but as mentioned, the one I needed to have. Not just as a medical student, but as a human being. Very important knowledge gained from this experience.
General practiceHonestly a great way to end the year, my favourite rotation! General practice was awesome to have at the end of the year because I was theoretically at the peak of my knowledge and could apply it to the wider community haha!
This rotation was the best for a number of reasons:
1. It was very well organised. Everything was perfected.
2. The teaching was outstanding. Teaching throughout the year was very good, but in this rotation it was just better.
3. The days at GP were fantastic.
Touching upon the teaching in a bit more detail. The rotation was divided into 9 topics (eg. emergenices, palliative care, ophthlmology, dermatology, etc.), each a week in length. The tutes were run by senior GPs and were very good, a mixture of case studies and mock patient interactions. The best tutes were in the week based upon emergency medicine, whereby we had an interaction with a mock patient (an actor) in our own room and our tute group watched us live via a video stream. It was fascinating to see how we each handled the pressure! Lectures were also very thorough, delivered by either GPs or specialists (eg. ophthalmologists, dermatologists). Lectures in this rotation were held Monday and Wednesday mornings, with tutes based on them in the afternoon. Hectic full days, but well worth it.
I'd strongly recommend attending the John Colvin Lecture Series as an adjunct to the teaching here. These are held at the start of the year at the Royal Eye and Ear Hospital in the city and are run by ophthalmologists on Saturday mornings. Fantastic teaching and all the students there are clearly keen to learn. A very good learning environment if you can be bothered going. More information
here or
here. There are also dermatology and ENT lectures (Brian Pyman Otolaryngology and The Victorian Faculty of Australasian College of Dermatologists Lecture Series) held on later Saturdays, but I unfortunately couldn't go to them.
On Tuesday and Friday I had my GP placements. Similar to mentor week of women's health, you're with a GP in their private rooms and seeing patients. I had a great time! One of my GPs allowed me to have my own room for parallel consulting, which was an invaluable experience. The only issue I found with this is that because I was so close to exams and in a rotation with a couple of public holidays (a holiday for an AFL match? I mean, really?), it was stressful trying to do the required 108 hours of clinic time, but I managed it in the end. The best thing about clinic is the opportunity to weave all your knowledge together, and it's rewarding when you realise how far you've come and have learnt.
In terms of assessment in this rotation, there was yet another case report. Here you choose a patient, interview them a few times and then write up ANOTHER 5000 words. Because this was my last rotation, I tried to get this done as soon as possible, just so I could focus on the study. Frustrating assignment, but my patient was lovely and she had a very interesting story to tell, so it was ok haha.
Overall, another great rotation! Felt like everything "came together" as I applied my knowledge and skills from my last 4 years, something which I enjoyed doing
Overall impressionFantastic year, so many amazing memories and so much knowledge acquired. I think the year would be better if there were less assignments given the exams at the end of the year (more on that in my MED4200 review), but still a really fun year.
As with previous years, there are still med soc events, med ball this year happened to be on my birthday so that got a bit rowdy
Just got back from of our end of year celebration, which was another memorable night. Plenty of other social events on the calendar too, but not as many as in previous years due to study load. Important to have a balance though, as some people in my year kinda lost themselves with so much going on, and I think it's really important to remember why you're doing medicine because although the light at the end of the med school tunnel is so close, it can sometimes feel very far away.
Feel free to ask me any questions!