https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/professional-behaviour-and-fitness-to-practise).The jump from A levels to preclinical medicine is a significant one. Previous revision strategies such as cramming and rote learning are unlikely to lead to success in your preclinical exams, or provide a solid foundation of medical knowledge for your future clinical career. Preclinical medicine requires a different approach to learning. The sheer volume of information in the medical disciplines (biochemistry, anatomy, etc.) may seem overwhelming at first, but you will learn how to navigate this and find what you are looking for. Graduate entry courses are similarly demanding, as the content of two preclinical years is condensed into one. You may go from being a straight A* or a first-class honours student to achieving the equivalent of B or C grades in your preclinical exams. This is normal, as you are now among a selected group of peers. Preclinical years set the foundations of medical knowledge for clinical medicine that follows; dedicate time to study during these years and the step into clinical medicine should be more natural and intuitive, and you can focus on developing your clinical skills, rather than trying to understand the subject matter of medicine.
During your preclinical years, you will be expected to learn the basic sciences: biochemistry, anatomy, pathophysiology, physiology, and pharmacology. You will also learn ethics, psychology, professionalism, communication skills, law, and sociology in the context of medicine. This knowledge is important for your clinical years and for the rest of your career. While you may look longingly at your stethoscope and wonder when you will learn how to diagnose, treat, and manage patients, it is important to learn these disciplines that underpin clinical practice. Medical schools provide both formative and summative assessments:
These do not count towards your final grade. These ‘mock’ exams are especially useful in the first semester when you are finding your feet and familiarizing yourself with university exams. They may provide an early indication of your own progress, which will help you determine if your approach to learning in a new environment is appropriate. Some medical schools use them as progress tests to flag up any concerns to you or your tutors in case additional support is warranted.
These count towards your final grades. You must pass all summative assessments to pass the year. Your medical school will have detailed information in the year handbook about how each type of assessment contributes to your overall grade. The year handbook is usually available on the medical school portal system or your medical school may give you a paper version at the start of the year.
You will be assessed using a number of methods depending on your medical school and this may change from year to year. The most common examination format is multiple choice questions (MCQs). Others include extended matching questions (EMQs), single best answers (SBAs), short answer questions (SAQs), essays, and viva oral exams. Some medical schools assess anatomy with an anatomy spotter and viva, use objective structured clinical examinations (OSCEs) in preclinical medicine, and assess group presentations for PBL.
MCQs are often the choice of assessment for preclinical exams. Medical schools often have a bank of MCQs that they use every year, and the question bank is well protected. However, there is a range of books and websites with banks of MCQs available. It is important to read the question properly and practise your examination technique.
EMQs present a theme: a list of structures, drugs, or receptors and ask you to select the best response to a several stems. Example EMQ:
Out of the list above, isolated injury of which nerve would cause weakness to elbow flexion and supination of the forearm?
ANSWER D. Elbow flexion is the action which bends the arm at the elbow and supination is turning the arm so that the palms facing upwards.
Mr Smith dislocates his shoulder and experiences weakness to his deltoid muscle, select the nerve from the above list which is most likely to have been damaged.
ANSWER C.
SAQs are a form of written examination. Read the question and answer the question succinctly—do not simply write down everything you know. If your response is not relevant to the question then you will not gain marks and you will waste time in the exam. Here are some examples of the style of SAQs:
• Name two diseases of the basal ganglia (2 marks).
• Describe the pathophysiology of asthma. Describe and explain the pharmacological treatments for this disorder, and their mechanisms of action (8 marks).
Some medical schools examine anatomy through anatomy spotters and/or viva examinations. You will be expected to identify structures in specimens that have been dissected, and sometimes a range of clinical images (using techniques such as computed tomography (CT)/magnetic resonance imaging (MRI)).
Your medical school may provide you with a description of the requirements to achieve each grade/percentage range. You will have written essays at school and know the basic structure of an essay (introduction, main body of argument, and conclusion). At university, your essays will need to be referenced in a formal manner and will be checked by plagiarism detection software. You will need to practise how to summarize conclusions or findings from other studies/sources and paraphrase them to avoid plagiarism. Vancouver and Harvard are types of referencing conventions that are commonly used. Consider using a reference manager program to make referencing easier for you.
In the past, OSCEs were a type of examination reserved for the clinical years. However, some medical schools have introduced OSCEs in the preclinical years to bridge the gap between preclinical and clinical medicine. They are commonly used in the preclinical years to assess basic clinical skills (such as taking BP, peak flow, or doing a clinical examination in a healthy adult) and communication skills. OSCEs at this stage are helpful to practise performing in this context, especially when under pressure and with individuals watching. Tips for preclinical OSCEs include the following:
• Time management: while you might be unfamiliar with using a tuning fork, move on swiftly through the various components of a neurological examination. OSCEs are like driving tests, you have to exaggerate to draw attention to the boxes you are ticking. You will gain a few marks for introducing yourself, obtaining consent, and washing your hands. The majority of marks are for carrying out the required tasks in the time allocated. A few marks will be awarded for summarizing your findings. You may be asked a few questions at the end.
• Practise examining your flatmates and friends. This will result in a confident and well-rehearsed sequence of examination. It does not instil confidence in the examiner if you are hesitant or seem unfamiliar with devices used in the examination (such as a tuning fork). This is valid; in clinical medicine, you must instil confidence in your patients in the way you approach them.
You may be asked to give a presentation as part of a summative or formative exam. Most preclinical students become increasingly confident with the use of PowerPoint, Prezi, or Keynote to create and deliver presentations.
• Structure your presentation: an introduction, the main body, and a summary slide is a general structure you may want to adopt.
• Timing: stick to your time limit. Too short suggests that you have not thoroughly researched the topic. Too long suggests that you cannot concisely present information. You must practise at least once to ensure the length of your presentation is correct—time yourself.
• Less is more: present the main points on the lecture slides and then elaborate on them. A slide full of text will result in your audience being disengaged and simply reading the slide with you. Images and figures are much more captivating than text, and you can talk naturally over them.
Producing an academic poster and presenting it is a useful skill that some medical schools introduce in the preclinical years. If you have been involved in research, ask your supervisor if it is feasible to enter an abstract of the poster to a medical conference. Later, when you apply for academic foundation jobs or even specialty training, poster presentations at medical conferences will strengthen your application. Therefore, make use of the opportunities that your medical school provides.
As a medical student, the standard of behaviour expected is different from that expected of other students at university. You will be responsible for patients in the near future, so it is important you instil trust with your conduct and act in a responsible manner. Most medical schools provide preclinical students with opportunities to go to hospitals or GP practices during the preclinical years. This sets the tone for how you are expected to behave. Remember to lead by example and that you have been selected to act as an ambassador for your university. The General Medical Council (GMC) has recently set out guidance for the standards expected which can be found via its website ( https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/professional-behaviour-and-fitness-to-practise).
The main challenge of preclinical exams is covering the volume of information, while identifying, understanding, and retaining the key concepts in each discipline relevant to clinical practice and commonly assessed in examinations.
Some tips include:
Your year handbook often has learning outcomes or objectives. These tend to be broad, such as ‘understand the gross anatomy of the heart and blood vessels’. This is different to your A levels where a detailed syllabus is provided. Make a detailed plan of all you need to cover and when you are going to revise.
The most important strategy when revising for preclinical exams is starting early. After making a plan, you will appreciate the sheer volume of information that you are required to know for your preclinical exams. Therefore, start early in the semester and do not leave all your revision to the week before your exams.
Small chunks of information are easier to digest than attempting to learn a whole module. Try short periods of revision of 20–30 min with breaks in between to maximize your efficiency. If you spread out your revision, you will be able to manage your time effectively. This means you can still keep up with hobbies and sports and are less likely to burn out at a critical time (just before the examinations).
Diagrams, writing bullet points, explaining a topic to a fellow student, or listening to podcasted lectures are examples of different types of learning styles. Find the one that works well for you.
‘Mnemonic’ originates from the Ancient Greek word meaning memory. Some find mnemonics useful for aiding in the recall of facts, at least initially. Learning large numbers of these, simply because they exist, is unlikely to be helpful.
Here are some examples of the style of questioning in preclinical exams.
(a) vasoconstriction through inhibition of cGMP-specific phosphodiesterase type 2 (PDE2)
(b) vasoconstriction through inhibition of cGMP-specific phosphodiesterase type 3 (PDE3)
(c) vasodilation through inhibition of cGMP-specific phosphodiesterase type 3 (PDE3)
(d) vasoconstriction through inhibition of cGMP-specific phosphodiesterase type 5 (PDE5)
(e) vasodilation through inhibition of cGMP-specific phosphodiesterase type 5 (PDE5).
ANSWER E. Vasoconstriction is contraction of smooth muscle, whereas vasodilation is relaxation of smooth muscle. cGMP-specific phosphodiesterase type 5 is an enzyme. You will need to learn the mechanism of action of common drugs. In this example, knowing that sildenafil causes vasodilation can help you deduce its side effects such as headaches and flushing which will be helpful when you later consult in the clinical years; it may be the cause of a presenting complaint of headache. This example shows how basic science knowledge underpins clinical decision-making.
ANSWER A. This question requires factual recall.
Tip
There is little certainty in medicine. There may be answer options which contain words such as ‘always’ or ‘never’—these are unlikely to be correct. Answers which contain words such as ‘often’ and ‘usually’ are more likely to be correct.
ANSWER E. As well as the traditional basic sciences, you will also be examined on medical ethics, medical psychology, professionalism, communication skills, medical law, and medical sociology.
Tip
Trust your instinct. Your first answer is usually the correct answer. If you overthink and imagine the examiner is tricking you, you lose marks on straightforward questions.
ANSWER B. The radial nerve does not always run in the cubital fossa. However, the ulnar nerve is found in a groove of the posterior aspect of the medial epicondyle of the humerus, never in the cubital fossa. Therefore the answer is B. Impingement of the ulnar nerve is also known as cubital tunnel syndrome.
Tip
Remember to read the question properly. If you miss that the question stem contains the word ‘not’, you may select the wrong answer. Skim reading questions can lose you marks when you have done the hard work and know the answer. In dealing with these types of questions, you may find it helpful to tick all the options that you know with confidence the cubital fossa does not contain. Then decide between the options that are left. In a time-constrained examination situation, you may accidentally misread the question and select one of the structures that the cubital fossa does contain, whereas the question is asking for which one is not part of the cubital fossa.
(a) Ventricular preload load in relation to end-systolic volumes.
(b) Ventricular preload load changes in relation to changes in stroke volume.
(c) Ventricular preload load changes in relation to venous return.
(d) Venous return changes on relation to end-diastolic volumes.
(e) Venous return changes on relation to end-systolic volumes.
ANSWER B. The similarity between each statement shows that you really must know your physiology and MCQs are by no means easier than written papers. These questions are sometimes called SBAs.
Tip
If you do not know the answer to the question, star or highlight the question and move on to the next. Attempt all the questions and pace yourself. You can attempt difficult questions later, with the knowledge that you have answered the easier questions first. You do not want to be left with barely seconds to answer easier questions.
Your medical school handbook will provide you with detailed information about the types of exams your medical school has chosen for assessment, how your preclinical exam results are used, and information about failing and extenuating circumstances.
This has the closest resemblance to an A-level syllabus at university. These objectives or learning outcomes are broader than the syllabus provided for your A levels. However, they help you manage your learning and revision. It is easy to get overwhelmed when you think that you have to learn all of biochemistry, anatomy, or pharmacology. Work your way through the learning objectives during term time, ticking off objectives as you go along. This way when you get to Christmas and Easter, you will have a general idea of the depth and breadth of the modules.
Your medical school may provide past papers on the student portal. Often medical schools have a limited bank of questions, so they are unlikely to publish large numbers of these, particularly MCQs. Moreover, your medical school may provide past questions but without mark schemes or examiner reports. Ask your undergraduate tutors or senior colleagues if you are unavailable to source them. Find all the past papers and practise completing them in the time allocated. Make your own mark scheme with your colleagues. Revisit these past questions, as it is likely the odd question may resurface in your exams. Practising using past papers will give you confidence and settle your nerves before you sit your first preclinical exams.
You will have a suggested reading list and your medical school library should hopefully stock more than one copy of the recommended texts. These books are likely to be loaned out during peak times in the year. Buying all the recommended textbooks can be expensive and is usually unnecessary. You may be able to photocopy relevant pages of some textbooks, which can be annotated as you wish. The core topics such as anatomy, physiology, and pharmacology are likely to need regular reference, and a textbook in each is usually advisable. Senior students often sell their preclinical textbooks, so look out for the second-hand book sales.
There are a few MCQ question banks online. It is useful to practise questions with a simulated time limit, and feedback is often provided (score by specialty of discipline). Questions may vary from the questions that you will actually get in the exam, and factual inaccuracies in the questions do exist on occasion. If you subscribe online, their mobile app version is often free to download.
Examples of online medical question banks
• Medical Educator: www.medicaleducator.co.uk
• Multiple Choice Questions: www.mcqs.com
• Leeds Medical Student’s Representative Council: www.mcqs.leedsmedics.org.uk/index.html
• BMA OnExamination: www.onexamination.com.
Preclinical exams often test your ability to learn independently. However, if you are struggling to understand key concepts in the disciplines, ask your lecturers or undergraduate tutors for help. Most reply swiftly to an email when you ask a specific question. Try to refrain from asking ‘Will this be on the exam?’ or asking questions that are too broad. Tutors and lecturers are often passionate educators and most educators want to teach, not provide you with the minimum to simply pass exams.
May provide a useful source of advice, having been through the same course and examinations. It is very likely you will meet more senior students through societies or in the library etc. Most will happily impart wisdom and provide useful practical advice and guidance. They will be well placed to recommend books and useful strategies that may be fairly specific to your medical school (e.g. there may be an influential lecturer on your course who has written a book and tends to write questions around its content).
These can offer you the reassurance that you have revised effectively. Medical societies often provide these courses taught by more senior medical students for free and will give you handy tips specific to your medical school exams. However, intense weekend courses are unlikely to give you all the knowledge you need to pass preclinical exams and they are no substitute for dedicating time to study. Basic science questions feature later in clinical exams and will form the basis of your clinical knowledge, so learning concepts thoroughly is the only advisable approach.
There are a range of companies who provide MCQ or anatomy apps, in addition to online subscriptions. If you are on the train home or travelling to clinical placements in your preclinical years, these may be an efficient use of time. The BMJ OnExamination app provides an extensive bank of MCQs and EMQs in the basic sciences to complement its online resource. The One2One Medicine Preclinical app is a free app with over 500 questions. The TeachMeAnatomy app provides both detailed anatomical images and numerous MCQs. 3D4Medical provide a range of anatomy apps such as Essential Anatomy. Medical students have developed some of these apps themselves.
During each semester and in the run up to your exams, you may experience bereavement, illness, or run into financial difficulties. Various terms such as extenuating or mitigating circumstances are used to describe these unforeseen circumstances. If events have affected your ability to study then you should consult the pastoral support available at your medical school. Moreover, you can discuss the impact that it has had on your studies. They may be able to offer an extension for essays or offer the option of deferring your exams. Some medical schools operate a policy of ‘Fit to Sit’. If you choose to sit an exam, you have declared yourself ‘Fit to Sit’ at the start of the exam. Therefore, if you fail that exam, circumstances such as bereavement, will not be taken account. However, if you have a chronic illness during the semester and choose to sit the exam and fail, you cannot claim in retrospect that your chronic illness affected your ability to study. Seeking help early is a sign of professionalism that you possess insight into your health and well-being. This is important in your future medical career. It is worth discussing any such issues with your personal tutor, the welfare officer, and the occupational health service.
You may fail an examination or two during your preclinical years. This may very well be the first time you have failed something. The key thing is to pick yourself up, reflect on where you went wrong, and make a plan on how to prepare for your resit. Failing examinations can be stressful, but most people manage to persevere and pass their resit(s). Quite often, it is the sheer volume of work that has left you unprepared to sit the exams, rather than a question of intelligence. Some medical schools provide resit classes to help you pass. Make an appointment with your undergraduate tutors to discuss certain topics that you find difficult.
You will fail in some form during your medical career—whether it is passing your first professional examination such as membership exams, getting the speciality job of your choice, or publishing research. Unfortunately your patients may not recover as expected or respond to treatment even if your management was correct, possibly leading to their mortality in spite of your best efforts. Therefore it is important to learn how to cope with failures. Medical schools normally only allow two attempts at a preclinical exam. So take failing an exam seriously and study hard for the resit. If you fail after the third attempt, you may be required to withdraw from the course or take a year out to sort out any issues. This happens to a minority of students but the lesson here is that no one is immune to some sense of ‘failure’. Leave yourself no other choice but to get back up again and try until you succeed. Do not allow one poor mark, bad experience, or obstacle at one time to define your whole career!
(See 
Chapter 5). If intercalating, all summative assessments from preclinical years will be used in combination with your intercalation year percentage to determine your degree classification for your intercalated degree of Bachelor of Arts (BA), BSc, or Bachelor of Medical Sciences (BMedSci):
• First-class honours degree: more than 70%.
• Upper second-class honours (2:1) degree: 60–69%.
• Lower second-class honours (2:2) degree: 50–59%.
Your medicine degree (Bachelor of Medicine, Bachelor of Surgery (MBBS)) is not classified with the conventional classification of first class, 2:1, or 2:2. All summative assessments from preclinical years and the clinical years will contribute to your final grade. The top performing part of your cohort will graduate with a degree of MBBS with Honours. It varies between medical schools how they calculate Honours, so consult your year handbook or ask your undergraduate tutors for the specific percentage or merits that are required. Distinctions are usually awarded to the top 5–10% of your year. You will graduate at the end of your 4/5- or 6-year course with any of the following on your degree certificate, depending on your medical school:
Summative assessments from both the preclinical and clinical years are usually used to determine your decile. Deciles range from first decile (top 10%) to tenth decile (bottom 10%). When you apply for junior doctor jobs in your final year, all summative examinations from year 1 to year 5 (or year 6 if you intercalated) will be used to calculate your decile. Each medical school has a unique method of calculating how you are ranked in your cohort and this method may vary from year to year. Some modules or components are deemed to carry more weight and importance than others. Most medical schools tend to put greater weight on clinical years compared to preclinical years when calculating deciles. Your medical school should provide information in your handbook.
It is estimated that approximately 8% of preclinical students drop out of medicine within the first 2 years. Some premedical students decide that they no longer hold aspirations to train as a doctor and no longer want to continue with the course. Medical schools usually offer exit qualifications at the end of least 3 years of study. Degree qualifications with a BSc or BA are offered and the standard degree classification usually applies.
Revising a whole module on the Sunday before the exam is impossible. However, scheduling time to learn a few metabolic pathways and the mechanism of action of a few drugs is more manageable and you are more likely to commit the detail to memory. University gives you freedom to manage your time. Do not spend all your time socializing or overcommit to any single activity. If you dedicate some time to studying early on, you will not have a pile of disjointed lecture notes to scramble through at Christmas and Easter.
There are aspects of the course that require rote learning, or require you to simply memorize detail (drug names, for example). You must revisit topics more than once until you are satisfied that you have retained those details.
Calculate how much time you require per question. If in an exam you are struggling to answer a question, highlight the question and return later. If you spend a disproportionately long time on one question, you may not have time to answer easy questions later on in your exam.
There is no guarantee that the same questions will come up in the exam. Therefore, do not focus on the content of practice exam questions. However, practising exam questions will help you apply your knowledge and refine your exam technique.
Exercise, play a musical instrument, or see your friends. Taking regular breaks will make you more productive. After your break, you will return with renewed enthusiasm for understanding abstract principles compared to if you had stayed at your desk staring at the same page for 2 hours.
The midnight oil burns ardently for many medical students. However, it is important to take care of yourself and sacrificing sleep is counter-productive.
At times, passing your preclinical exams may seem challenging. However, the vast majority of students make it through to the clinical years. The key strategy is to work steadily throughout the year.
It can be stressful when presented with 120 MCQs to answer in 120 min and you may misread a question. You may misread the question stem that has asked you to select which statement is false and instead selected an option which is true. A handy tip is to mark each MCQ that is false with a cross and each MCQ that is true with a tick. Then read the question stem again to check you need to select an answer that is false.
You may meet some people who claim to do no revision or find preclinical exams easy. If you glance back at the example questions in the chapter, you will realize that you cannot pass your preclinical exams with cramming or doing no revision. Medical knowledge is not innate. It requires hard work, understanding of abstract concepts, and time to accumulate and commit these facts to memory, so you are able to demonstrate your knowledge in the exam.
Everyone learns in a different way and has different strengths. You are likely to be competitive, but comparing yourself continually to your peers is more likely to be harmful. It might take you much longer than your flatmate to learn something or you may be disappointed that your best friend beats you in every exam. Later on in your career there are more exams to come and more chances for you to excel. You have not worked this hard to compete with anyone, your greatest strength and weakness is yourself. If you look at the bigger picture, you will quickly realize that there will be many opportunities for you to hone your skills. This is where patience is a virtue.