‘Extracurricular activities’ pp. 1012–1015). Your aim should be to work effectively, which is as much about strategizing as it is about spending as much time as possible on the wards.The value of the clinical experience
Your responsibilities and professionalism
Ten tips for surviving clinical medicine
Taking control of your teaching
‘In the NHS, training and the delivery of patient care are inextricably linked. It is recognised that the majority of training should take place in a service environment and that quality training leads to professionals who deliver high standards of patient care and safety.’1
Learning medicine in a clinical environment is very different to the mainly lecture-based years. Now you have to begin drawing parallels between pathology and the real-life experience of your patients. Contrary to popular belief, being a good doctor does not require you to be the smartest individual! Other qualities are essential, which cannot solely be learnt from a lecture, and will develop throughout your clinical experience. Meaning that if you did not excel in your pre-clinical years, do not fret, you may flourish now!
Tomorrow’s Doctors (2009)2 is written by the GMC and outlines the standard of practice required by a UK medical graduate. Clinical placements are an important part of this and what makes a good doctor, as they provide many opportunities to learn crucial skills that are indispensable for your future career.
These skills are based on the UK Foundation Programme ‘Person Specification’3: the UK Foundation Programme is the 2-year programme medical students embark on after graduating.
6. Problem-solving and making a decision
10. Personal development: through teaching, research, and audit.
Students spend their preclinical time daydreaming about finally making it into hospital. However, it does not take long for the majority of students to become disillusioned to some degree. This may be because of the following:
• Medicine is difficult, and students feel as though they do not know what is happening.
• Often it is not obvious when learning is happening; students often live for the one day when the doctor imparts a list which they can scribble down in a notebook. They may feel this is the sum total of their leaning for the day; it is not, as you will gain far more than you think.
• Healthcare professionals unrelated to medical teaching can range from disinterested to hostile. Do not be put off.
• No one is forcing you to be present, and you might leave at the first sign of hunger or tiredness.
• The environment is alien and/or frightening; you do not know what to touch, where to stand, and patients ask you to do things.
• Even the most benign consultant can appear challenging or intending to intimidate when asking questions.
• Students often feel as though they have all the time in the world to learn what they need to know for finals; but your clinical placement will only be 6 weeks and become the extent of your experience in a given speciality.
• Healthcare professionals are busy, and certainly in the early years you cannot contribute and will mostly be in the way.
• Book work is comforting, but clinical work allows you to identify gaps in your knowledge, and helps you find things you can focus on.
Incorrectly or otherwise, consultants assess students based on their presence. If, on reaching the end of block assessment, you are having difficulty getting signed off, being seen by other members of the team would make your position unimpeachable.
This is why a consultant’s judgement is better than that of the senior house officer (SHO); as a result of seeing more patients and working for longer. By being present you are starting on the path of absorbing the knowledge and experience that will make you a better doctor (even if it does not seem evident for large parts of the day!).
It is often apparent to assessors in clinical exams which students have seen cases for the first time in their exam. Recall the student who reaches the end of their paediatric clinical exam but does not know how to undo the baby’s clothing; some things cannot be taught by textbooks.
Hanging around can pay off—leaving 1 hour earlier may mean you miss the opportunity to see the cardiac arrest. You will also find yourself often waiting for things to happen or for teaching to start. This is the time to capitalize by reading around a topic and using this handbook to improve your experiences in the clinical setting. It is necessary to ‘waste’ time in order to benefit from these valuable clinical experiences.
Making them more likely to interact and teach, giving them the impression of enthusiasm. Students arrive and expect to be taught, which is not always conducive with the primary function of hospitals and staff to treat patients. The more often you are around, the more likely you will be around to gain teaching opportunities. Being present on the ward allows you to learn how to interact with the rest of the team.
Allows you to focus your learning when off the wards, e.g. this will ensure you do not spend lots of time on Takayasu’s arteritis before you understand heart failure.
Being consistently present allows you to be a part of the team. Students are often unreliable because of other commitments (e.g. teaching, pub lunch); this is a barrier to them becoming a regular team member who is given their own tasks/responsibilities. If you have a role as a member of the team, you will be well prepared for your first job.
Insight into your professional future makes it easier to start making clinical career decisions earlier on if you have experienced different specialties.
The middle ground is working out for yourself the useful elements of hospital medicine. Once you have been a clinical student for a short while, you start to understand what you must attend and what might be less effective. Time in a clinical environment will make you a better doctor. Visibility will get you higher grades. However, you are only a student for a few years, and you do have a lifetime of work in clinical environments ahead of you. In the current environment, you also need to focus on extracurricular activities (see ‘Extracurricular activities’ pp. 1012–1015). Your aim should be to work effectively, which is as much about strategizing as it is about spending as much time as possible on the wards.
If your consultant has a clinic, it makes sense to attend this. They are less likely to spend time on the wards (ward rounds excepted), which should be factored into your decision-making. The key is to plan your learning; e.g. it is probably suboptimal to attend an all-day list of inguinal hernias. However, an hour spent reading about hernias and relevant anatomy before going to theatre will ensure that you gain the most from that experience. This still means you will have the rest of the afternoon to pursue other activities.
• Get to know the clinical team—this will make the clinical environment feel more human.
• Read and try to anticipate questions you might be asked.
• Developing your own syllabus and/or learning objectives will help structure your time and make you feel in control of learning. The pages in this handbook will help you through each individual placement.
• Chose your clinical partner carefully. If you chose somebody who wants to attend, you will have to attend to keep pace. Negotiate with your partner, but remember you are responsible for your own learning.
• Develop a work–life balance.
You have no clinical responsibilities for patients. There are two circumstances under which a responsibility arises. You are responsible for your own conduct if you volunteer for something, e.g. siting a cannula, delivering an urgent cross-match to the blood bank, where the team will be dependent on you completing this task. Secondly, general responsibilities defined by the GMC’s Medical Students: Professional Values and Fitness to Practise. In particular:
• only work within the limits of your competence and ask for help when necessary
• accurately represent your position and abilities
• ensure you are supervised appropriately for any clinical tasks you perform
• respect the decisions and rights of patients
• do not unfairly discriminate against patients by allowing personal views to adversely affect your professional relationship
• report any concerns about patient safety to the appropriate person.
1. Temple J. (2010). Time for Training: A Review of the Impact of the European Working Time Directive on the Quality of Training. London: HMSO. 
www.mee.nhs.uk/pdf/JCEWTD_Final%report.pdf
2. General Medical Council (2009). Tomorrow's Doctors. London: GMC. www.gmc-uk.org/education/undergraduate/tomorrows_doctors.asp
3. The Foundation Programme. UK Foundation Programme Commencing August 2016 (FP 2016) Person Specification. www.foundationprogramme.nhs.uk
For many years, doctors have been known as one of the most trusted professions. An Ipsos MORI poll in 2015 of >2000 British adults reiterated this:1
• Doctors remain most trusted profession: 90%.
• Ordinary man/woman in the street: 62%.
In 2005, the Royal College of Physicians sought to define the role of medical professionalism in the twenty-first century. This report was called Doctors in Society: Medical Professionalism in a Changing World. They defined medical professionalism as follows:
‘Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust the public has in doctors.’
To supplement this definition they also described the ‘day-to-day practice’ doctors are committed to, including:
• working in partnership with members of the wider healthcare team.2
Therefore, in order to uphold the standards of professionalism, behaviour, and care this commitment needs to begin with medical students.
Learning professionalism is important to you now and for your future, as a doctor, and so has been incorporated in most medical school curriculums. It has been suggested that there are four key ways to do this:3
Much of the GMC guidance not only applies to qualified doctors but to you as medical students. This applies even more so when in clinical years. The GMC states: ‘Medical students have certain privileges and responsibilities different from those of other students. Because of this, different standards of professional behaviour are expected of them.’4 It is important to begin thinking about your responsibilities and professionalism as a medical student and future healthcare profession.
The following points on how to maintain professionalism are stated by the GMC in the ‘The doctor as a professional’ section of Tomorrow’s Doctors (2009)5:
1. Make the care of the patient the first concern.
2. Be polite, considerate, trustworthy and honest, act with integrity, maintain confidentiality, respect patients’ dignity and privacy, and understand the importance of appropriate consent.
3. Respect all patients, colleagues, and others regardless of their age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status.
4. Acquire, assess, apply, and integrate new knowledge, learn to adapt to changing circumstances, and ensure that patients receive the highest level of professional care.
5. Continually reflect on practice and, whenever necessary, translate that reflection into action.
6. Recognize your own personal and professional limits and seek help from colleagues and supervisors when necessary.
It is important to remember that we are all human and so mistakes will inevitably happen. As doctors are a highly trusted profession, at times the high expectations held by the public and patients may not always be met. This does not necessarily mean that the doctor is not committed to patient care. True professionalism is learnt and improved when mistakes are made but then reflected upon: an idea that should be instilled within medical students. This will ensure for you and for others in the future that when similar mistakes occur, the correct steps can be taken to ensure that the problem is resolved and patient care standards are upheld.
Hospitals are old-fashioned institutions that have a few unwritten rules which the uninitiated are unlikely to be aware of. Observing these rules will leave colleagues thinking that you are polite, professional, and competent. To play safe, introduce yourself to everybody in the clinical environment whom you encounter, but most importantly identify yourself to the most senior doctor and charge nurse. A confident, smiling introduction will leave a lasting impression of friendliness, enthusiasm, and effectiveness.
Although it is probably unfair, a medical student’s underconfidence may be interpreted as rudeness by other healthcare professionals or patients. You should therefore make an effort to say hello and smile at everyone you encounter. Humility pays dividends. Consider starting all requests with ‘I know you are busy, but I wonder if you could please help me …’. It is important to understand that everyone in the clinical environment is overworked and resources are stretched.
• Respect nurses since they can make you and equally break you!
• Beware the ward receptionist/clerk’s chair. Do not use or remove!
• You should never interrupt a conversation between colleagues when they are discussing a patient’s management. Keep your distance, keep quiet, and keep patient until it is your time to speak.
• Most patients are nice and interested in helping medical students. They will usually agree to help if asked in the right way—be polite, humble, and professional.
• Introduce yourself appropriately by name and title.
• Always pull the curtains around the bed and wash your hands before, in between, and after examining every patient.
• If you are with a doctor, why not help by pulling the curtain around and preparing the observation chart?
• Patients have little stimulation in hospital and often spend the day asleep. This causes trouble when you have been asked to take a history and examination. Most patients may not mind being interrupted, but reconsider if a patient is clearly sleeping deeply (e.g. snoring under sheets).
• Protected mealtimes should never be interrupted. Do not underestimate the importance of nutrition as part of every treatment plan.
• Do not interrupt when patients are spending time with their relatives as this may cause them to leave prematurely.
It is essential to remember that as a medical student your first aim is to learn how to provide good patient care, not to be the main team member responsible for providing care. So even though you are playing an active part within the healthcare team, your main role is also to learn:
• practical procedures and skills
References
1. Royal College of Physicians (2005). Doctors in Society: Medical Professionalism in a Changing World. Report of a Working Party of the Royal College of Physicians of London. London: RCP.
2. Ipsos MORI Trust Poll, 5 January 2015. www.ipsos-mori.com/researchpublications/researcharchive/15/Trust-in-Professions.aspx
3. Baernstein A, Oelschlager AMA, Chang TA, Wenrich MD (2009). Learning professionalism: perspectives of preclinical medical students. Acad Med 84:574–81.
4. General Medical Council (2009). Medical Students: Professional Values and Fitness to Practise. London: GMC. /www.gmc-uk.org/education/undergraduate/professional_behaviour.asp
5. General Medical Council (2009). Tomorrow's Doctors. London: GMC. www.gmc-uk.org/education/undergraduate/tomorrows_doctors.asp
When on a clinical attachment it is important to make the most of your time there and be useful to your team. Fortunately, as a student on placement, anything you do to help the team will only aid your learning, and will therefore be useful for you too. Be proactive! If you get ‘stuck in’ and avoid playing a passive role on the ward then the junior staff will appreciate your presence and give you more things to do.
A simple way to do this is by helping to take on some of the duties of the junior doctors. Firstly use your common sense. If you see the probably exhausted junior doctor slowly drowning in a sea of notes, drug charts, and observation charts on the ward round: help them! Many hands make light work after all. You will instantly feel more involved with the team and find yourself with more opportunities to ask questions (meaning that you will not be left feeling hidden in the background).
• Write in the notes: different hospitals will have rules on whether medical students can write in the notes or not, so ensure you check this. Please remember: write in black ink (make sure it is legible), time and date, signature, and counter-signature from one of your seniors. If you are unsure about the format do not be afraid to just ask the junior doctor.
• Jobs after ward round: ask for a patient list prior to the ward round and make notes of the jobs that need to be done. After the ward round go with the team to discuss the jobs list and offer your help for simple things such as taking blood, inserting a cannula, or performing an ECG.
• Jobs: ask if there are any jobs from your team. They will really appreciate this, as it will free up their workload and possibly create some spare time to teach you by the bedside. However, do not work outside of your competencies. Remember to recognize your own limitations, both in knowledge and skill.
• Clerk new admissions: take a thorough history and examination before presenting your findings to a doctor.
• Is it possible to be too keen? Do not overwork yourself and take on too much, remember you still have exams to pass! If you have been shadowing the junior doctor all day, do not feel the need to stay for a late shift if you already have a lot on. The team understands that you need time to rest and to study. You will have all the time in the world to work lengthy hours once you qualify! So use your time wisely now. One of the best ways to feel motivated is to contribute to the care of the patients.
The more tasks you take away from the ward team the more time they will have to teach you and recognize your contribution when it comes to end-of-placement sign-off/evaluation/feedback.
• Practical procedures: you must learn to take blood and site an IV cannula at a minimum before finishing medical school. You should also learn to place a urinary catheter and perform ABGs. The earlier in your medical school career you can perform these tasks independently, the more useful you will be to your team. Much like business, it is a bit of give and take.
• Administrative tasks: there are lots of tasks which occupy doctors’ time which do not necessarily require a medical degree to complete. Although these will cause you much upset during the rest of your career, early on they create an opportunity to help the team while waiting for interesting things to happen. Obvious examples are printing blood forms, labelling blood bottles, assisting with discharge summaries (which should be appropriately supervised), updating the patient list, etc. If you are attached to the ward team for any length of time it can be helpful to update the ward list; this will also help you get to know patients and understand how their management progresses with time.
• Assisting with the ward round: it is easier to follow the ward round passively but this can give the impression of disinterest. Ward rounds are a team effort. This is one way of ensuring a smooth progression around the patients with minimal interruptions. Tasks within your skillset include drawing the curtains, and ensuring the observation chart and drugs chart are immediately available. You may be asked to document events of the ward round.
In an emergency situation, the following things will usually have to be obtained:
• Someone will take the ABG sample; you should only volunteer to do this if you are comfortable with running this sample and know where your ABG machines are.
1. A little introduction goes a long way. Apply this not only to patients, but to doctors and nurses too. Letting people around you know who you are means you are less likely to loiter in the background feeling uncomfortable and ignored.
2. Always be on time. Better yet early! Do not be the student who is routinely late. Make a good impression early on and your clinical attachment is more likely to run smoothly.
3. Be polite, confident, and smile! It can be quite intimidating entering a new ward and not knowing the ropes. Often you may feel like you are constantly in the way, but being friendly with all the healthcare team will make them more likely to help you!
4. If you do not know the answer to a question, do not be afraid to say so. This is often quite a daunting situation but do not worry! No one expects you to know everything; that is why you are here. If you do not know the answer just say so.
5. No question is a stupid question. The likelihood is that another one of your peers was too scared to ask it as well! Asking the question will only benefit all of your learning.
6. Practise examining and taking histories from patients. Practice makes perfect! Ask the nurses and doctors on the ward to point you in the direction of the best patients. Broaden your experience in clinical medicine, by seeing patients with many doctors; there are many approaches to history taking and examinations. Gain an understanding of the patient’s clinical course and speak to others in the MDT.
7. Get to grips with practical procedures. Take any opportunity that arises, be it venepuncture, cannulation, and so forth. Being confident with these early on is very important and will make OSCE examinations and future employment much easier
8. Be a team player. Your firm and other colleagues are all in the same boat so when a learning opportunity arises: share! Often your peers can be your greatest resource.
9. Active learning. You are responsible for your own learning! Striking a good balance between clinical and library work is very important; although being on the wards can be exciting, remember you still need to pass your exams! Always keep assessment forms ready, to be handed to your seniors whenever you can (at the appropriate time). Reinforce your clinical exposure with further reading, including material you might anticipate encountering the next day (e.g. likely cases in clinic, or operations on tomorrow’s theatre list). Set a target for every day (e.g. a single examination watched by your partner).
10. Enjoy yourself! Appreciate that you have worked long and hard to get to this position, so do not take it for granted. Although it is difficult to enjoy yourself with sick patients around, know that your contribution (whether administrative, procedural, or spending time with your patients) is contributing to their recovery. That ought to be your job satisfaction.
Entering clinical years may require you to make some changes to your life and schedule. But do not be scared, you can still have a life!
Although it may seem like the free time you have is limited (and will decrease now that you are entering your clinical years), it is important that you make the most of any available time you have to enjoy yourself. The last thing you want is to regret not doing so in the future when you are working. It can be quite difficult to strike the perfect work–life balance. But it is simply a matter of time management, if you work hard and plan ahead you can definitely find time to rest, play hard, and pursue your hobbies.
A three-pronged approach can be taken to make the most of your free time at home.
1. Use your time wisely: get organized and make a plan of things you need to get through in the day, be that work, or extracurricular activities.
2. Effective studying: entering clinical years may require you to change your original, mainly lecture-based way of learning. Try and find the best way for yourself.
3. Do other things!: your medical school will have and will be continually creating new sport teams, clubs, and charities that you may be interested in joining. Do not forget simple things such as going to bed early, going to the gym, watching a film, going out for a drink, seeing your friends, reading a book, etc.
Remember that free time is not necessarily just your time at home but you may also be faced with the situation where you have nothing to do when on placement.
• Find a doctor who is free to teach you and your firm.
• Take a history or examine a patient.
• Ask any of the junior doctors if they need any help with any of their jobs list. Use this to practise skills such as venepuncture and cannulation.
• Become familiar with the topics in this handbook.
You do not have to be on the wards around the clock. It is always a good idea to do book work to reinforce the clinical knowledge you are picking up on the ward. The doctors were all students once and recognize the need to study.
A clinical environment is necessarily inefficient, which means lots of free times for students while waiting for scheduled events.
Ad hoc free time (e.g. a patient did not attend (DNA) in clinic or a theatre patient was delayed) can allow you to do a few useful things:
• Reading. Relevant pages from this handbook, the Oxford Handbook of Clinical Medicine, or another speciality text. You never know when your consultant will quiz you on something you have read. Consolidate knowledge about previous patients or prepare for questions about your patient/case.
• Using people around you. Ask anyone nearby who is also free (e.g. consultant with patient) to quiz you on a topic of their choice. Most people will respond to enthusiasm.
• Use your partners. You may wish to practise your examinations with your partner, or perhaps prepare questions beforehand which can serve as a longstanding competition.
• Patient information leaflets. Cover a multitude of conditions with a reasonable level of detail.
• Smartphones. These need to be used carefully to avoid offending a consultant. Make sure you inform your senior if you are using medical applications as not all may be aware of what you are doing.
• Consider asking others before you leave (e.g. charge nurse, junior doctor). This is considered as being courteous.
Consider the following if you have a few hours spare (e.g. consultant sends you away mid morning before a fixed commitment in the afternoon):
• Speciality procedures. Turn to your specialty page to see if there are any other procedures you might be able to attend instead.
• Other clinics/theatres. If you are interested in a specific speciality, take the opportunity if it presents itself but not at the expense of your expected commitment to your firm’s activities.
• Day surgery. If you have a few hours, day surgery can be a nice compromise to other lists as they are more efficient and have a higher turnover of patients, allowing you to see three or four patients as opposed to one major or emergency case.
• Practical skills. Ask which procedures need performing (e.g. a patient needs their blood to be taken).
• You should only attempt venepuncture/cannulation/ABGs etc. if you feel able. You might want to visit the skills laboratory if you are less confident.
• ED. When you are feeling more confident, ask a clinician to see a few simple cases which you can discuss.
• Administration work. Might include assignments, research paper, reflective practice, or audit.
• Radiology reporting. Go to the radiology department and ask to sit in on reporting sessions—learn patterns from the experts!
• E-learning resources. Working through an online BMJ learning module for instance.
• Formal teaching. Check out departmental teaching/grand rounds.
Preclinical students tend to be mainly dependent learners and as they progress through clinical years become more self-directed ready to be independent practitioners in the future. Teaching here is not only used to acquire and broaden knowledge but also to help you apply it to a clinical context and learn the new skills necessary to support you in your transition to working life. Teaching while on placement can happen in a wide variety of environments, and will frequently occur without you even expecting it! Long gone are the days of mostly scheduled lecture-based teaching. It allows you to:
• role model—observe, first-hand, doctors and their team on the job and learn how things should be done, e.g. things which students often neglect: writing in the notes, doing discharge summaries, referrals, investigation requesting, and prescribing
• take histories from, and examine real/simulated patients; this allows you to familiarize yourself with common presentations and signs
• observe and develop your communication skills
• interpret data and problem-solve
• practise and perform clinical skills.
There are a number of ways teaching can be delivered to you:
This has traditionally been thought the most effective way of teaching in the clinical environment as it promotes ‘real’ patient contact and so improves students’ clinical and communication skills. Patient-centred teaching can happen in:
A planned session that is not interrupted by clinical duties (‘bleep-free’):
• Simulation/role play sessions.
• Bedside teaching can also be organized as protected.
It is also important at the undergraduate level to begin developing your own teaching skills, as teaching is very important to patient care. Many medical schools therefore, as part of their curriculum, encourage this by having teaching modules and assessments.
By spending time in a clinical area you will naturally pick up a lot of information. While this will broaden your knowledge base, it is essential to consolidate your leaning. An easy way to do this is to arrange teaching during your hospital attachment, in addition to the formal sessions in your curriculum.
Anyone! The GMC’s Good Medical Practice states: ‘You should be prepared to contribute to teaching and training doctors and students.’1 Hospitals are full of professionals looking for the opportunity to teach students. All you have to do is ask. Do not think you are limited to only being taught by doctors. You may approach any healthcare professional, including nurses, pharmacists, physiotherapists, and radiographers to mention a few. You can learn from all of these different perspectives and build that knowledge in to your practice. It may seem intimidating to approach a healthcare professional to ask for teaching; however, most are more than happy to help. Do not forget that they will benefit too, as some may ask you to fill in a feedback form to use for their portfolios.
The best way to go about this is to spend a little time on the ward, perhaps go on the morning ward round and befriend the junior doctors. If they are looking particularly busy and stressed then it is best to leave it for another time. However, when they have a free moment do not be afraid to ask them if they could teach you something. Ideally, you should have a topic or examination in mind that you would like help with. Having a junior doctor watch you examine a patient can be an invaluable experience because they have only recently completed medical school OSCEs and know what is required of you. Most hospitals will create a ‘firm’ or ‘team’ of students and attach you to a consultant who will offer you teaching on a weekly or fortnightly basis. In this case, you may need to liaise with the consultant’s secretary to ensure your teaching is going ahead. Do try your best to attend these teaching sessions, as you will learn an incredible amount from the consultants and it cannot hurt to make a good impression! You will have to be flexible with your timetable and occasionally you may reschedule but do not let this deter you.
Before your teaching takes place, have a think about what topic you would like to cover. It is best to let the doctor know in advance so they can prepare. This will give them time to collect any interesting patients or cases to make your teaching more useful. You can also show them your learning outcomes on the university curriculum and work through each of them.
This takes place on the ward, focused on a patient. In general, this tends to be practical, where you are observed examining a patient or taking a history. You may be asked to find patients in preparation for your teaching. If you go on to the ward and ask any of the nurses or doctors they will be able to let you know who to approach. You will need to take consent from the patient before your teaching. Most will be happy for you to examine them as long as you let them know when it will be and that it would benefit your learning. If possible, try to run through the examination or topic of choice before the day. It will make the teaching more interactive and useful for you if you have a little background knowledge. You can ask the doctor to watch you examine a patient and mark you as if you are doing an OSCE. By practising in situations where you are being assessed, you will become used to the pressure and may help your exam performance.
These may take the form of a presentation or a case-based discussion. A case-based discussion is centred on a clinical scenario and can help put learning into context. In this kind of learning you will more than likely be asked questions on the subject, in order to make the teaching interactive. Therefore, it will save you some embarrassment if you do some pre-reading and are able to contribute! The important thing to remember is that this is your chance to learn what you think is important. These tutorials can be tailor-made to your learning requirements.
You can learn a lot from a good ward round. This is dependent on the consultant and how busy the ward round is. You will see many patients during the round, with a variety of medical conditions. This is the perfect opportunity to observe the management of these different conditions. Try to take advantage of this opportunity by listening carefully while the history is read out and ask questions. Do give honest feedback after teaching sessions. Your thoughts and comments can really help develop their teaching styles and benefit future sessions. For example, if you would like more case-based discussions then either let them know or write it down in a feedback form. That way, for the following teaching the doctor will be able to prepare a case in advance, improving your learning and making the teaching more interactive.
Reference
1. General Medical Council (2013). Good Medical Practice. London: GMC. www.gmc-uk.org/-/media/documents/good-medical-practice---english-1215_pdf-51527435.pdf
Don’t take a back seat! You are in control of your learning once you reach clinical years.
If staff members do not know who you are, they will question you and ask the purpose of your visit. Do not take this personally, as this is for patient safety. Or they may just ignore you and not share their pearls of wisdom with you—this defeats the purpose of you being present in clinical areas. You will get a lot further if you are on friendly terms with everyone.
You will definitely be expected to attend ward rounds during the week. This can be a tedious experience if you are just following the group around and not engaging with the team. On some wards you will luckily have a helpful junior or middle-grade doctor who will involve you. If not, then be proactive! Ask if you can write in the notes. Ask if you can present the patient.
It would be much more educational for you as a future doctor and also demonstrate your proactive engaging nature if you offered to present some of the patients on the ward round that you may have seen earlier or review their history, examination findings, and investigation results prior to the ward round. If you see an interesting patient on the ward round then go back afterwards and examine them yourself. Compare your findings with what is documented. Remember, if you see a patient with an unusual condition then use their case for your portfolio.
If you are on surgery, then go in early and ask if you can ‘scrub in’ to theatre. They may even let you assist. If you are on anaesthetics, again go in early while the patients are consented and ask the anaesthetist if they will show you how to insert airways and intubate. If you show enthusiasm they will probably let you try as well. Practising and polishing up skills such as cannulation or insertion of a catheter will only serve to help you in the long run.
Top tip
If you are particularly interested in an area then let the team know and ask if there are any audits you can get involved in. It is a good idea to start doing audits in medical school, not only because you will gain experience of how to do them but also to help with your CV in the future. A good audit poster can be submitted to a conference. A great audit may be presented at a regional and national conference, all of which will make your CV stronger for after medical school.
Ask the junior doctor if you can join them for an on-call shift. There are two different types of on-calls. Ward cover is where the doctor will be in charge of most of the medical or surgical wards. They will be bleeped for any sick patients or jobs needing doing. Admissions shifts are where doctors see new patients, coming in from either the ED or via GP referrals. They will clerk them, order any investigations, and make management plans. Depending on what you want to get out of your time there, pick an appropriate shift.
Top tip
Clerking is an exciting way to learn. You will get the chance to engage all the knowledge you have to work out what is going on with your patient. It is almost like being a detective! Once you have seen a patient with a specific condition, it is a lot easier to remember the management of it.
If you come across something you do not know much about or have not heard of before, then when you go home spend half an hour reading about it. Doing a little each day will really help you in the long run. For example, if you see a patient with chest pain then read about the causes and investigations you would do.
Even though you are not yet qualified, get into the habit of maintaining a certain level of professionalism. Take note of any members of staff you think excel at this as well as ones who do not. And try and mimic the ones who do it best—that is the best way to learn these soft skills that go a long way in making you a successful clinician.
Learn how to do all the nitty gritty jobs. Unfortunately, a large part of our job is to fill out paperwork and make phone calls. Although this does not sound very exciting, it will make your life a lot easier once you have graduated if you have a little understanding of the logistical aspects of being a doctor. This means knowing how to write discharge summaries, phone the X-ray department, phone the laboratory, and chase results. Learn how to bleep. This may sound simple but it really is the main way we communicate with each other in hospital. Get used to doing it early on.
Learn how to handover a patient. This is really important for when you start working as it is a crucial part of the job. Listen to how patients are handed over on the phone and in person. Even better, ask if you can do it. For example, if the doctor you are with is handing over a patient to the specialist registrar, then ask if you can do it. Read the history carefully, look through the investigations and see what medications they are on. Try to anticipate any questions the registrar may ask you. Try using the SBAR method of framing critical conversations (i.e. Situation, Background, Assessment, and Recommendation; see Box 6.1) developed by the NHS Institute for Innovation and Improvement.
Box 6.1 SBAR tool
• Identify yourself and the site/unit you are calling from.
• Identify the patient by name and the reason for your report.
• Give the patient's reason for admission.
• Explain significant medical history.
• You then inform the consultant of the patient's background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results, and other relevant diagnostic results. For this, you need to have collected information from the patient's chart, flow sheets, and progress notes.
• Clinical impressions, concerns.
• Explain what you need—be specific about request and time frame.
If you find a patient with a really good murmur, then let your colleagues know about it so they might be able to listen as well. If you find out about some teaching then let everyone know and everyone can benefit from it. Medicine is really all about being in a team and we need to look out for each other. Chances are if you help someone out they will do the same for you! The key thing to stress here is if you do not ask then you do not get. You may feel as if you are being pushy and sometimes might not get what you want. Just remember to always be polite and be sensible with what you are asking. Take an active role in your learning.
Wards rounds are when all the patients are reviewed and management plans are made for their future care. They provide the opportunity for patients to meet the consultants and vice versa. It also gives staff the chance to interact with each other and to make decisions in a multidisciplinary manner.
This usually depends on individual units, and timings can vary not only between specialities, but also between consultants. Depending on how many patients there are to see, they may last anywhere from 30 min up to a few hours.
There will normally be a consultant who will lead the ward round, accompanied by one or two junior doctors. They may be foundation doctors to registrar level. The nurse looking after the specific bay of patients will also be on the ward round, to inform you of the progress of the patient and any salient points from the last medical review.
The junior doctors will prepare the notes and give the consultant a brief summary of the patient’s care to date. Then they will show the consultant any recent investigations such as blood results or scans. While the consultant reviews the patient, the juniors document the consultation in the notes.
A great opportunity to learn and impress your consultant would be to go in a little bit early and prepare one of the patient’s notes for the ward round. This would mean familiarizing yourself with the history and current investigations so you are able to present the case on the ward round.
You may be asked to scribe for a few patients on the round (see Box 6.2). A simple way of remembering what to include is the mnemonic SOAP:
• Subjective: what does the patient say? How are they feeling? How do they look to you (e.g. unwell, tired, alert, lying in bed vs sitting out)?
• Objective: what are their observations, examination findings, and investigation results?
• Assessment: what is your impression after considering the subjective and objective findings? What is the diagnosis? Is the patient on the ward clinically stable, improving, or deteriorating?
• Plan: write down all the jobs you need to do for this patient. What is going to happen in the next few days? What needs to be done to aid in the patient’s discharge planning?
1. Write the date, time, and location of the ward round.
2. Write the consultant’s name who is taking the round.
3. A good habit to get into is to write a brief summary and problem list at the top of the page so that anyone seeing the patient at a later date has an idea of what is going on.
Box 6.2 Example of ward round entry
dd/mm/yy WR DR BONES
Time
Ward 2
84 ♀ admitted with: cough + SOB
Problems:
Treated with IV clarithromycin and amoxicillin —day 3
S: Cough improved + not SOB now
O: Obs: stable and apyrexial
BP 105/86
Sats 98% on 1 L O2
RR 18
Pulse 82
Temp 36.2
Bloods: normal, blood cultures negative
O/E: looks comfortable at rest
CVS: HS 1+11+0, rad 80 bpm and regular
GI: abdo SNT, bowel sounds present, bowels opened today, catheter in situ
Resp: equal expansion, resonant percussion, vesicular BS + 0
Impression: resolution of LRTI
Plan:
1. Convert to oral antibiotics and monitor for 24 hours
2. Wean off oxygen and TWOC (trial without catheter)
Ben Bloggs FY1 #1234
After the ward round, the junior doctors sit down together and split up the jobs. This is a perfect opportunity for you to practise some clinical skills such as venepuncture and cannulation. If you are a bit nervous at the start it is perfectly acceptable to ask for supervision. You will be a massive help to the team by doing these kinds of odd jobs. You will meet many different people working in the team on the ward, and it will be handy to know a little about each of their roles:
• FY1: stands for Foundation Year 1. This doctor is the most junior in the team, in their first year post graduation. Their role in the team is to carry out jobs from the ward round and keep the patients stable. Most importantly they have to know when to escalate and ask for help.
• SHO: an old term that is now used broadly for the grades of Foundation Year 2 trainee up to Core Trainee/Specialty Trainee Year 2 in the specialties. They are often in the ‘lower tier’ of the rota. They work closely with the FY1 and are useful where senior input is required.
• Registrar: also an old term still in use, and can refer to anyone in training from Specialty Trainee Year 3 to 8, depending on the specialty. The registrar is usually the most senior doctor present on the ward on a day-to-day basis. They will be responsible for much of the important decision-making throughout the day. Registrars seeking additional training or who may be out of formal training are also referred to as Associate Specialists and Clinical/Research Fellows.
• Nurses: invaluable to the smooth running of a ward. Get on their good side and they will really help you out, e.g. they will let you know of any good patients to see or clinical skills you can practise. Your medical school may require you to get certain clinical skills signed off. Carrying out observations and setting up IV infusions and SC injections are just a few of the jobs the nurses do. If you need to get any of these skills signed off then the best person to ask for help is the nurse on the ward. You can differentiate their grade by the colour of the uniform (e.g. dark blue signifies senior nurse).
• Pharmacist: most wards will have a pharmacist attached to that ward who will check that correct medications have been prescribed for patients and help out with any drug queries. They can offer to give you a tutorial on a tricky subject, e.g. antibiotic prescribing.
• Physiotherapist/occupational therapist: in the notes for many patients it will be written to arrange an OT/PT review. This will be for patients who need help with their activities of daily living and mobilizing. They play an integral role in rehabilitating patients.
• Ward clerk: carries out all the administrative duties.
• Student: do not forget that you are also a key member of the team! Never demean yourself by saying that you are just a student. If you are enthusiastic and willing to get involved, you can be a great asset.
• Learning how to take a medical history is an important skill to master early on in your studies.
• The ward is the perfect opportunity to practise as it will be full of patients with different presentations and conditions.
• There are several key examinations to become confident in—each specific to the placement you are on (e.g. cardiovascular, gynaecological, and neurological).
• Top tip: go and examine a patient with another student. One of you can take the history and the other can examine. You can mark each other and afterwards give feedback. This is a great way to prepare for OSCEs and get used to someone observing you while you are examining a patient.
• Top tip: practise identifying the positive findings on examination as this is tested in final year OSCEs. If you consciously make an effort in earlier years, it becomes easier later on. Ask FYs on the ward for any patients with positive/interesting signs.
• ECGs are among the most commonly ordered investigations in the hospital.
• They are also something many medical students struggle with.
• Learn a systematic way of interpreting ECGs and get used to looking at them.
• Top tip: interpret an ECG before looking at the patient’s notes. Then explain your findings to one of the doctors on the ward and see if they agree with you. Afterwards, if you read through the notes it will help you build a picture about how different conditions may affect an ECG.
• Observe any interesting procedures:
• If you are lucky you may observe an unusual procedure on the ward, such as lumbar punctures or chest drain insertion.
• Clinical skills (see Chapters 45 and 46):
• Venepuncture: the ability to take blood is absolutely essential as a medical student and for the rest of your career. Even consultants are called to perform this task at times.
• Cannula insertion: if you can do this you will become extremely useful on the wards, and thus gain favour with nurses and doctors, and also actively participate during an emergency!
• Catheterization: nurses can perform these so if you do not have a doctor around, ask one of the nurses to show you.
• ABGs: you may have access to simulated arms to perform this, which is a great way to practise. If not, request to be taught by a doctor.
Outpatient clinic services are used for patients who need specialist follow-up but do not necessarily need to stay in hospital. They bridge the gap between primary and secondary care.
You will mainly be attending clinics during your later years of medical school where you are required to become experienced with specialist subjects. By this point, you will have definitely encountered cardiology, gastroenterology, respiratory, and neurology. It is of course important to attend clinics in these specialties as you will see conditions and treatments you would not otherwise see on the wards. However, you now also have the chance to see other sides of medicine and surgery, such as dermatology, oncology, paediatrics, and psychiatry, to name a few.
The clinic will be held in the outpatient department of the hospital. It will usually consist of the consultant or sometimes junior doctors running the clinic. Clinic appointments often run behind so patients will have had a bit of wait before going in. It is important to remember this as it can help explain why some patients may seem a little annoyed when they come in. A simple explanation and apology at the start of the consultant is usually enough.
In general, you will be assigned to a certain specialty for a length of time and will go to their clinics. It is not necessary to attend every clinic on offer, as not all of them will be relevant for you.
• Do try to attend general clinics, where you will get an overview of a topic. Here you will learn about management and monitoring of common conditions. Clinics are a great place to learn about chronic diseases and to see disease progression. You can sit in on specialist clinics if you have a particular interest in a topic but if you do not then it may not be very useful for you. As a medical student it is most important to cover all the basics.
• Do try to attend a new patient clinic. Here you will get the chance to listen to the patient’s story and challenge yourself to figure out the differential diagnoses and appropriate investigations. There is great opportunity here to follow a patient’s journey from diagnosis to management. Certain doctors will do teaching clinics. These clinics tend to take two or three students at a time and are designed specifically with you in mind. You will learn a great deal in these clinics as the doctors are prepared for you. In general, as only a few students are allowed in these each time, you will be assigned a time to go or have to sign up.
• Do know where the outpatient department is situated and with whom you are sitting in with.
• Do check with the outpatient reception the day before that the clinic is going ahead as scheduled.
• Do read the GP referral letter. GPs will write to the consultant asking them to review the patient and explaining why they need specialist follow-up. Once you read a few of the letters you will start to see what makes a good referral and what does not. The key to a good referral letter is to clearly explain the patient’s history, any relevant investigations, treatment already tried by the GP, and why they feel the patient needs to be seen.
• Do read up on the topic of the clinic before attending. For example, if you are going to an IBD clinic then read about ulcerative colitis and Crohn’s disease beforehand. Having some background knowledge will make the clinic more interesting for you and you will not be embarrassed if the consultant starts asking you questions! Seeing the management of a condition in clinical practice will help you remember it in the future.
• Do read through your learning outcomes for the topic of the clinic. Then while you are there you have an idea of what you are trying to achieve. You may be asked by the consultant if there is anything specifically you would like to know and this is a perfect time to ask if you are prepared with knowing your learning objectives.
• Do bring your stethoscope! You will be expected to examine patients or the consultant will ask you to listen to an interesting patient’s heart. Do not be caught out by forgetting your stethoscope at home.
Be sure to arrive 10–15 min early so that you can ask the consultant’s permission to sit in and make a good first impression.
• Do be proactive in clinic. Just watching the clinic run can get quite tedious after a long time. So make the most of your time there and ask if you can take the patient’s history before they go in to see the consultant. Spend about 10–15 min taking a history and examining the patient. Then you can present your history and differentials or management plan to the consultant. Compare your findings with the consultant’s interpretation. You could also ask if you could examine the patient; you may get the opportunity to perform a specialized examination that you may not be able to do on wards.
• Do bring with you any clinical skills booklet you have that needs signing off.
• Do ask questions! You need to understand the logic behind treatments.
• Do bring a textbook with you to read in quiet moments. Sometimes patients do not attend appointments so you may have a prolonged wait in which it can be useful to read up about the last patient you saw. Another option at this point includes asking for teaching on any relevant topic from the consultant or other doctors present.
• Do watch carefully how the consultant and patient interact. This is a time to pick up any good habits you observe. You may end up observing the consultant breaking bad news. Pay careful attention to the words used to explain the news to the patient and the tone of the conversation. This is a very important skill to learn, and patients will always appreciate the doctor who was sensitive during their difficult hour.
• Don’t stay in a clinic if you are finding that it is not useful. You may find that at certain times your time may be better spent elsewhere, e.g. on the wards or doing some reading on another topic. Politely excuse yourself from the clinic, asking permission from the consultant to see whether there are other opportunities such as the ward or theatre where you would be able to gain some extra experience. Similarly, if you have an appointment you must attend which falls midway through the clinic then it is a good idea to let the consultant know at the beginning what time you will have to leave. Large numbers of patients are seen in clinic every day, so the consultant may not have time to go through each patient with you or answer any questions. Unfortunately this can really hinder your learning in the clinic. If you find yourself in this position then you can either try to make it a useful experience yourself or ask to be excused. One way in which to help yourself learn in this situation is to take a notebook and document the history or consultation as it goes. Try writing as if you are actually writing in the notes and have a think of what your plan would be. Ask questions after the consultation or at the end of the clinic.
• Don’t be offended if a patient requests that you are not present for the consultation. Consent always has to be taken to allow you to sit in clinic. Certain specialties, such as genitourinary medicine, have more sensitive subject matter than others so it is quite likely you may be asked to leave at some point. Just go out of the room and grab a cup of coffee until the patient has left.
• Don’t act bored. You may not feel very engaged, however, do not yawn or show your boredom. Do not forget the consultation is for the patient and they are doing you a favour by letting you sit in. If you feel yourself losing interest or getting tired either excuse yourself or go grab a coffee and come back. Similarly, do not use your phone in front of patients.
• Don’t stay in the clinic if the next patient is someone you know or another student of your university. It is possible for this situation to arise, if it does just tell the consultant that you know the patient and think it would be best if you waited outside.
• Do follow the patient journey if you encounter an interesting case. You can write up a case report from GP referral, through to investigations, diagnosis, and management. Try to watch any investigations the patient will be undergoing (e.g. spirometry, bronchoscopy, and colonoscopy). Or go with them to theatre if they are due to have any surgery.
• Do get in contact with the consultant if you are interested in their specialty to ask if there any audits or projects you can get involved with. Chances are they will be impressed with your enthusiasm and initiative and lead you to an interesting project. You can even participate in outpatient clinic patient satisfaction surveys.
• Do remember which consultants you particularly enjoyed clinic with. If you find that a consultant gave very good teaching during the clinic then do ask if you can come back and sit in another time. They will appreciate your enthusiasm and enjoy teaching you. Just make sure you do not tread on your colleagues’ toes and keep things fair, as they may have plans to attend the clinic another time.
• Do read about anything you did not understand or know about. You will be exposed to a variety of conditions during clinic and it is quite possible to come across something you have not heard of before. A good idea is to read up on that when you get home, while the memory of the patient is still fresh in your mind. It will help you remember if you can associate a patient with it.
• Do attend a MDT meeting, especially if a patient you saw will be discussed. In the MDT you will get to see how different team members come together to manage difficult situations.
• Do reflect on how educationally beneficial you found your clinic experience. It will help you in future clinics if you know what works for you and what does not. Identify how you learn best then implement this the next time you sit in a clinic.
Overall, clinics can be a really good learning experience if you know how to utilize them. It may feel intimidating sitting in a room with just you and the consultant who is asking you questions; however, you will remember the facts having been questioned on it under a little pressure. Consultants like to see medical students who are interested in what is going on. If you show them you are keen they will in turn teach you and you will learn more.
Observing surgical procedures in the operating theatre can be one of the more thrilling aspects of the medical student experience. The illustration of anatomical structures, the integration of modern imaging/viewing systems and surgical instruments/prostheses, the skill of the surgeon, and the collective functioning of an effective clinical team can illustrate modern medicine at its finest. Specialities consist of the following:
| Cardio-thoracic | General (GI/vascular/ transplant/ endocrine/breast) | Neurosurgery |
| Urology | Plastics (aesthetic/burns/reconstruction) | Oral & maxillofacial |
| Trauma & orthopaedics | Otolaryngology (ENT) | Paediatrics |
| Obstetrics & gynaecology | Dentistry | Ophthalmology |
The complex nature of the theatre environment is such that you must set learning objectives for the session/day, perhaps based on the operating list/cases. Otherwise, you might find that you have passively seen lots of interesting things but have not learnt anything concrete or understood the significance of what you have seen. You may have to use your initiative and set these learning objectives yourself (refer to www.faculty.londondeanery.ac.uk/e-learning/explore-further/teaching_and_learning_in_operating_theatres.pdf).
Honours
Acute abdomen, trauma, dislocations, fractures, skin loss, extradural haemorrhage, placenta ruptio, obstructed pyelonephritis, transplant, exsanguination, draining abscesses, tropical surgery (Buruli ulcers, obstetric fistula), debridement.
Patients typically arrive at the hospital in good time prior to surgery to ensure that all necessary checks, investigations, and preparations can be undertaken to prepare patients for theatre in good time. You must therefore attend the preoperative ward round, if possible, on any theatre list you are attending. This is an excellent opportunity for learning to:
• identify the indication for surgery
• observe the process of informed consent (how the risks and benefits of any procedure are communicated to patients and relatives), final patient discussions, and surgical marking.
• observe communications skills on how difficult concepts are explained simply, and how surgeons respond to the patient’s anxiety
• identify surgical/anaesthetic challenges, so you may understand how specific issues are addressed in theatre (a difficult airway, or a comorbidity which changes the surgical approach)
• show willingness to learn and participate. If you have seen all the patients on the preoperative ward round, you will know their medical history and aspects of their care that the consultants may not be aware of. This makes you a valuable part of the team, and they will reward this by spending extra time teaching you.
1. Inspect the operating list in advance. This will allow you to know (excluding emergencies) the procedures to be undertaken and get a head start in reading around the relevant anatomy, pathology, and management relevant to the cases. You will seem informed to the surgeons, and they will reward this with more teaching.
2. Inspect the patient notes. This will allow you to understand the patient’s presentation, results of investigations, selection for surgery, and the influence of comorbidities on surgical and anaesthetic approaches to the patient.
3. Attend the preoperative ward round to ensure you know about each patient. You must be on time as it will be difficult to get the team back on side if you are late.
4. Observe the process of informed consent. It is important to know the perioperative complications (these will be listed to the patient during this process—and are easy marks for you during the interrogation that may await in theatre) and how the risk of each complication is minimized by the surgical and anaesthetic teams.
5. Accompany the surgeons to the theatre to change—they will help you find scrubs/shoes and this way, you will not get lost! Ensure you know which colour scrub top to wear for theatre (there may be more than one colour), and check the sizes by looking at the colour-coded collar. Do not wear shoes labelled with somebody else’s name—ask at the theatre reception/sister if you are struggling (you cannot wear your outdoor shoes in theatre). You must wear a hat: men generally wear tie-backs and some women prefer elastic backs. Leave valuables at home such as expensive watches/jewellery.
6. Attend the ‘WHO checklist’ and introduce yourself as part of the clinical team. Understand the importance of this check so that all members of the team are aware of the roles of all members of the clinical team, the needs of individual patients, and anaesthetic and surgical considerations. Note how anaesthetic technique, patient comorbidities (e.g. diabetes), and patient demographics are all taken into account in the approach to each patient, and influence the agreed order of the operating list.
7. Put your mobile phone away. Look interested and attentive.
8. Introduce yourself to the surgeons early. Let them know what preparations you have made in advance (if you have done tips 1–4); they will be more likely to provide teaching/surgical opportunities if they sense you are using your initiative, are interested, and willing.
9. Ask a member of the theatre nursing team to demonstrate how to scrub and put on gloves (including identifying your correct glove size) and gown in a sterile fashion. Remember to wash everything from your elbows down, systematically and repeatedly for at least several minutes. If assisting, remember that infection control is vital. If scrubbed, always place your hands on the patient or the sterile field, never place your hands in your lap or cross your arms (both considered dirty). If you have become desterilized, simply state so and rescrub.
10. Understand theatre etiquette. When to ask questions/when to stay quiet, where to stand (so you do not obstruct the flow of staff/patients), respect sterile surgical fields, be professional, and try to be helpful.
11. Be well fed and rested before a theatre list. It can seem like a long day if you are not used to it. There may be lots of standing, and lots of waiting. Take this handbook to read in such quiet moments. Go to the toilet before the case starts, if you think it is likely to be a lengthy case.
12. Speak clearly and loudly to the clinical team. This is essential for communication—particularly where masks make lip reading impossible and muffle sounds. If you are asked to do something, and do not hear clearly, ask for clarification.
13. There are many things you can help out with as long as you remain supervised by the scrub team. You can help transfer the patient from bed to bed, or start writing up the discharge summary, shave the surgical area with a powered-shaver, or improve the exposure of the surgical field by holding instruments to retract and wiping blood using a surgical swab or suction.
The process of informed consent factors prominently in SJTs, interviews, and examinations. It demonstrates the essence of effective patient communication (conveying the procedure, risks/benefits, postoperative care in language patients can understand), time/consultation management, and has stark medicolegal significance. The complications explained to the patient are those that the surgeon and clinical team will aim to minimize the risk of during surgery: you can ask about such strategies during surgery (e.g. how to minimize the risk of ureteric injury during hysterectomy). You should observe this process, both in clinic or on the ward, and in the preoperative ward round, to identify effective approaches to a quality process of informed consent. You must remember to respect the confidentiality of the patient: do not take patient identifiable data (such as operating lists) home with you.
Tip
Ask the surgeon, at an opportune time, what determines which risks are discussed with a patient, and why.
The WHO devised a surgical safety checklist in 2009 in order to improve surgical safety globally. There are three phases:
1. Sign in: all members of the clinical team introduce themselves by name and role before the theatre list begins. Each patient on the list is discussed in the presence of all members of the team to ensure equipment is checked, surgical equipment/prostheses are present, and anaesthetic/surgical/recovery concerns are communicated effectively.
2. Time out: occurs before ‘knife-to-skin’ to ensure all members of the clinical team confirm patient identity against a wrist band, essential details of the procedure such as nature and laterality of operation, checking consent form and surgical markings, allergies, etc. Anaesthetic, surgical, and nursing staff all confirm that they feel it is safe to proceed.
3. Sign out: before a patient leaves theatre, the team ensures that instruments are counted, the name of the procedure is recorded, specimens are labelled, and concerns for recovery are communicated.
Observe how concerns are communicated, and how this systematic approach to confirmation of clinical details at every step decreases the likelihood of an error being made. The surgical checklist may be modified to increase its relevance to certain high-turnover procedures (such as cataract surgery).
Theatre can be a somewhat confusing environment for a medical student at first: you may be unsure where to stand, what you are supposed to touch/not supposed to touch, when and how much you should speak, when you should ask questions, etc. Your understanding of theatre etiquette and its correct observation will endear you to all the clinical staff. Incomplete observation may frustrate them, or worse (such as violating sterility). Common sense, good manners, health and safety, and infection control are the main principles of good theatre etiquette. The following will help you to enjoy your time in theatre:
• Introduce yourself to all members of the clinical team if you were not present at the WHO check. This will mean all members of staff know you are there to learn, and will find things to teach you.
• Wear your name badge clearly: any member of staff is within their right to challenge you if it is not visible.
• Ask a theatre sister/nurse where the most appropriate place is to put your bag/valuables (you will not have a locker).
• Sense when the surgeons have time to talk (during scrubbing, while the patient is being positioned, or other delays where the surgeon is waiting), and when they do not (at a critical point in the surgery). Ask your questions at comfortable moments in the surgery if possible: you can ask as much as you want during wound closure.
• If you are feeling faint, tell a member of staff immediately so they can safely sit you down somewhere until you feel better. If you ignore the early symptoms, you will likely suffer vasovagal syncope, which can be dangerous near to a patient (and to yourself).
• Do not enter theatre through the anaesthetic room while a patient is being anaesthetized.
• Do not enter theatre through the main theatre doors while an operation is taking place. Entering theatre through the scrub room is the most appropriate route into theatre—although usually inconvenient.
• If you sustain a needle-stick injury, you must indicate this immediately. A member of staff will help you irrigate the wound, and discuss the next steps involving occupational health as per trust protocol.
Ask a theatre nurse to teach you how to scrub correctly, and in line with trust policy. There is usually a notice explaining the technique of washing your hands (more complex than you think) correctly (including use of brushes and nail picks), how to dry your hands, unfold/unravel the gown, and put on sterile gloves without touching the sterile outer surface. They may help you to identify your hand size. The average adult male hand size is 7.5 inches, and adult female is 6.5 inches (to get you started). Find your size: a glove that fits comfortably but does not restrict any manual manoeuvres. Scrubbing in will allow you a better view of the surgical field as you will be part of it. After scrubbing, stand with your hands, one over the other, on your chest. This will indicate to the team that you are sterile and you understand the sterile field (assumed to be the front of your gown above your waist). Remember that your mask is not sterile!
Tip
Remember to put your mask on before you scrub! (Masks with visors are available for procedures which risk ocular inoculation).
This is an active, rather than a passive skill. Most learning in theatre is through observation where there is plenty to see and understand. You should observe the requirements for both technical and non-technical skills. You should ask the surgeon where the most appropriate place to observe the surgery is; ask the consultant ‘Where would you like me to stand?’ Some procedures with viewing systems will have a monitor from which surgical anatomy can be well demonstrated. Other procedures may be viewed over a shoulder with the surgeon’s permission. In general, the closer to open surgery you are, the more detailed the view, and the richer the learning experience. If this is something you might feel is appropriate, ask for the surgeon’s permission. Observe how the team responds to changing circumstances: a procedure running longer than expected, complications, a change in the patient’s physiology, etc.
This is the fundamental surgical skill. It is the part of surgery, with time, you may be allowed to get most involved in assisting with during wound closure. It is a skill you can practise in the skills lab, and it is recommended that you practise beforehand if suturing is something you wish to assist with. Basic interrupted suture placement is important to learn, and will allow surgeons to build on this with suture tying techniques. Hand tying a suture is a valuable skill: ask one of the surgeons to demonstrate if there is a suitable opportunity. Be responsible with sharps in theatre since scrub nurses will become unhappy if you lose needles, as they will have to find them to balance the count. An excellent resource is available online ( www.animatedknots.com).
Being an assistant is easy. You may be asked to hold retractors, to assist the surgeons in viewing and manipulating the surgical field, cutting sutures to the correct length with scissors (if unsure, clarify how long the surgeon would like the suture ends), using suction to keep the surgical field clear, etc. If you feel you are getting tired, or cannot do something, tell the surgical team. If you are not sure of the instructions, always ask for clarification.
Urethral catheterization and gynaecological examination are competencies which may be performed under supervision in theatre while the patient is under GA. Do consent beforehand!
(See ‘Importance of logbooks’ p. 1016). It is important that you record (anonymously using hospital numbers) the procedure that you have witnessed and laterality. If you performed any part of the procedure (such as wound closure), this should be indicated on your record. This will allow you to demonstrate an objective record of your practical experience that may be important at appraisal or at interview in the future.
The theatre environment offers plenty to reflect on: teamwork, patient safety, personality attributes, leadership, and managing acutely ill patients.
| Suffix/prefix | Definition | Example |
| -ectomy | Cutting out | Appendicectomy |
| -otomy | Cutting open | Laparotomy |
| -oscopy | Looking into | Gastroscopy |
| -ostomy | Opening | Colostomy |
| -plasty | Reconstruction/repair | Rhinoplasty |
| Per- | Through | Percutaneous |
| Trans- | Across | Transoesophageal echocardiography |
• www.who.int/patientsafety/safesurgery/ss_checklist/en/
• www.faculty.londondeanery.ac.uk/e-learning/explore-further/teaching_and_learning_in_operating_theatres.pdf
• www.geekymedics.com/2015/04/06/theatre-etiquette/
• www.practicalplasticsurgery.org/docs/Practical_01.pdf
Mikhail Bulgakov (see Fig. 6.1) travelled by sleigh to take up a post at a remote, snowbound hospital in rural Russia in 1916, the ink barely dry on his medical degree. The only doctor, with no telephone or electric light, wrote of his metamorphosis from bookish medical student to hands-on doctor that still rings true for new doctors a century later.
Fig. 6.1 Mikhail Bulgakov. Reproduced from https://commons.wikimedia.org. Image in public domain.
In one of his stories, a woman arrives in labour with a transverse lie. He frantically thumbs through an obstetrics textbook to try and recall how to perform a ‘podalic version’ but the words are a blur. Assisting him is the hospital’s experienced midwife, Anna Nikolaevna. She cannot resist telling him how his predecessors carried out the procedure as he scrubs in. ‘Those ten minutes told me more than everything I had read on obstetrics for my qualifying exams, in which I had actually passed the obstetrics paper with distinction.’1
We see patients to focus the blurred words in our imperfect lecture notes and textbooks. Good-quality YouTube videos may be an advance on written guides to practical procedures but no second-hand source can replace the experience that you build from your own histories and examinations. ‘Medicine is learned by the bedside and not in the classroom’ wrote Sir William Osler (1849–1919). ‘Let not your conceptions of disease come from the words heard in the lecture room or read from a book. See, and then reason and compare and control. But see first.’
What is the reality? It can be uncomfortable enough introducing yourself to the busy ward sister or to get the attention of the harassed-looking registrar on-call. But to actually go and talk to and examine the thin, yellow-looking man in bed 6 (the consultant says he will be an excellent case to see jaundice, spider naevi, and palpate a liver cirrhosed by years of alcoholism) feels plain awkward—you are not going to contribute to his care, only to your own education.
But your patient, a veteran of the medical ward, sees you looking lost, knows by your hesitant gait that you are a medical student, and beckons you over. ‘The boss sent you?’ he asks with a chuckle. ‘Well come here and learn—and please tell the nurse that I’d like a cuppa!’
By seeing Mr Smith, you start the process of building your own, personal medical textbook, like the mental dermatology atlas the paediatrician is constantly adding to with each new rash she sees (so many do not match the colour plates of a textbook). You are also building your confidence as a communicator, able to broach difficult subjects with sensitivity, which will, in turn, inspire the confidence of your future patients. You might feel unprepared to cope with the patient who starts crying but you will learn that their tears are a sign of trust and that far from being awkward, your listening might have been therapeutic.
You will also learn a lot from the nurses and doctors around you, rejecting some bad examples but mostly absorbing fantastic ways to put patients at ease (like the registrar who asks the 5-year-old boy to flap his arms like a chicken and then hold his arms like a boxer to test power in his upper limbs).
Come your clinical exams, if you have not clerked and examined patients, it will show. Some patients will not want to see you but most will (in one study, 85.6% of women attending a gynaecology clinic were happy to have a medical student present and 63.9% said they would allow a medical student to examine them, although there was a preference for female students).2
And do not worry about all the things you ‘missed’ when the registrar or consultant goes over the history with the patient. It can often take several goes before the relevant bit of history comes out to clinch the diagnosis. Do not forget that the only difference between you and the doctor is experience and practice which cannot be rushed or bought—only earned.
Before seeing patients, you will have had teaching regarding consent (see pp. 141–142 and p. 861). But on a busy post-take ward round, this can sometimes be forgotten. The classic is sitting in clinic and the busy doctor forgets to explain your presence to the next patient. If you think the doctor has forgotten, you must learn how to interrupt politely and succinctly to explain who you are and if it is okay with the patient for you to be there—the consultant will thank you later for avoiding a complaint (some clinics usefully advise patients before they see the doctor that a medical student is sitting in—you could turn this into a quality improvement project).
You must gain consent for both history taking and examination. Explain to the patient not only who you are, giving your surname (‘I’m Jo Bloggs, a 4th-year medical student …’) but also add that it is fine for the patient not to see you (‘It won’t affect your care in any way’) or to stop the interview/examination if they are feeling tired. Giving the patient an out is far more likely to win them round.
Explain that what the patient tells you is confidential to the medical team looking after them. You will hear and be told some very private things—do not chat about their case outside the ward (what would you feel like if something you discussed with your doctor was overheard in the hospital lift or on the bus home?). Also, do not be buttonholed by friends or family to discuss the patient’s case—say they must talk to the patient and the team looking after them. Ensure there are no patient identifiers if you need to write up or present cases outside the ward as part of your teaching. Be very careful about how you keep and dispose of patient lists—better not to have one. Likewise, keep your clinical life out of social media.
Get advice from the senior nursing staff or doctors on the ward when approaching patients who you think may lack capacity or when examining children (do not examine them when their parents are not there). Always consider the need for a chaperone—it is easier if you are working in pairs as then you will not have to pull a nurse or doctor away from what they are doing. However, you should be supervised for any intimate examinations (breast, genitalia, rectum, etc.) and you should have prior, written consent from the patient before any intimate examination under anaesthesia.
It is said that 80% of the diagnosis lies within the patient’s history and the rest is confirmed by investigations. Spend the first few minutes of your consultation listening carefully and allow the patient time to speak about their symptoms (i.e. changes in the body) and start thinking of possible signs (i.e. clinical findings) to support your differentials. That is the mark of a good doctor!
Learning to take a history continues long after medical school. How to draw out vital symptoms from a shy patient—or how to negotiate the rapids of a patient who wants to tell you about their granddaughter’s cold, her holiday in York, and the problems with her bus service—is a challenge. You will also have to learn tact, such as asking a partner to leave when taking a sexual history. The challenge is then making a coherent whole of all that you have been told so that you can communicate it succinctly to the healthcare team—not just presenting the history but giving a differential diagnosis and a management plan.
This is what brought the patient into your GP surgery/outpatient clinic. Keep the PC in the patient’s own words—the differential for ‘feeling tired’ is wide.
This is where you go over the complaint in more detail. At first, use open questions: ‘What’s brought you in today? How long have you had these symptoms?’ The let the patient talk and simply listen. One study looking at history taking by optometrists showed that the median time it took for adult patients to state the reason for their attendance in their ‘uninterrupted initial talking time’ was 28.87 sec.3 All your most useful information will be here and you will have gained valuable time in establishing rapport—because you listened. Once the patient has told you what the problem is, you can then start asking more closed questions: when the symptoms started, risk factors (e.g. smoking, alcohol intake, travel history), about pain and what alleviates or exacerbates this. The SOCRATES mnemonic is invaluable:
S: site
O: onset
C: character
R: radiation
A: associations
T: timing
E: exacerbating or relieving factors
S: severity, e.g. pain score.
The patient can score their pain: ‘If 1 is no pain and 10 is the worst pain ever, how would you score your pain?’ Also, you can use Wong–Baker FACES® pain rating scale for children.
Each system will also have its own set of questions (e.g. asking about breathlessness on exertion for someone with chest pain or times of the day when joint stiffness is worst).
Ask about any established medical conditions, admissions to hospital, medical conditions or previous surgery (if the patient has undergone surgery, ask about anaesthetic problems). In particular, ask about hypertension, diabetes, heart disease, stroke asthma or epilepsy. You might find important illnesses revealed from the drug history.
Important to ask about any drug allergies. If a patient has a drug allergy, ask how it affects them (e.g. anaphylaxis or a simple rash with penicillin?). Then go through all the patient’s medications—you can pick up problems that a patient or parent omitted to tell you (‘Oh yes, he’s on folic acid and penicillin V for his sickle cell’) and also alert yourself to potential problems. For instance, it is vital to know if the patient who presents with rectal bleeding is on warfarin, or to know that the normal heart rate which does not fit with the ill-looking patient in front of you because she is on a beta blocker.
Remember drugs, drug interactions (and attendant polypharmacy) can cause problems—learn to recognize drugs that will be toxic to the liver, kidneys, and hearing (e.g. the antibiotic gentamicin which can cause renal and ototoxicity).
Steroid use can have wide-ranging side effects. Remember CUSHINGOID:
C: cataracts
U: ulcers
S: skin—striae, thinning
H: hypertension, hirsutism, hyperglycaemia
I: infections
N: avascular necrosis of the femoral head
G: glycosuria
O: osteoporosis, obesity
I: immunosuppression
D: diabetes mellitus.
Ask about contraception, pregnancy, and breastfeeding—prescribing drugs such as certain antibiotics can reduce the combined oral contraceptive pill’s efficacy while some drugs are toxic to the fetus or are present in breast milk. Start looking up medications in the BNF to learn how to identify common side effects, their toxicity to the liver and kidneys, especially Appendix 1, and the list of drug interactions. Ask about over-the-counter medications and alternative therapies—some of these, such as the herbal remedy St John’s wort (taken for depression), interact with several medications.
The information gathered here can have big implications for managing our patients but we all too often skip over this part of the history, perhaps embarrassed to ask such personal questions. Watch in clinic or at the bedside how an experienced doctor will normalize and signpost while taking such a history. For instance, if you suspect cocaine or amphetamine use by the young patient in front of you with a tachyarrhythmia, you could say ‘We need to know about any recreational drug use so we know how best to treat you’; or the child presenting with unusual bruising: ‘Mrs Smith, it’s a question we ask everyone who comes to the department—does Jonny have a social worker?’
Knowing who is at home is especially important for a paediatric or elderly patient, to gauge what kind of support they have. It will also be your duty as a doctor to establish any safeguarding issues to best protect your patients from any potential threat. Is the patient unemployed or receiving the benefits they need? Health follows a social gradient, whether in Angola or America.4 Some specialties will go into much greater depth on social issues (e.g. psychiatry).
Likely to be underestimated by the patient. Ask the patient how much they drink and when they drink (e.g. binge drinking at weekends). The recommended maximum weekly alcohol intake in the UK is up to 14 units. The CAGE questionnaire remains a useful screening tool for alcoholism (‘yes’ to two or more suggests a problem):
C: have you felt the need to cut down on your alcohol intake?
A: have you felt annoyed by people asking about your drinking?
G: have you ever felt guilty about your drinking?
E: have you ever drunk an eye-opener in the morning?
A major, preventable risk factor for cardiovascular disease, respiratory illness, and cancer. Smoking is measured in pack-years (i.e. 1 pack-year = smoking 20 cigarettes/day for 1 year).
Do not forget passive smoking—paediatricians see many children with their asthma and viral-induced wheeze worsened by smokers in the household. ‘But I smoke outside, doc!’ does not, unfortunately, lessen the harm.5
This last part of the history aims to reveal important symptoms not picked up in the HPC.
• General (constitutional symptoms): fever, night sweats, weight loss, fatigue (thyroid problem?), lumps/bumps, trauma, appetite.
• Cardiorespiratory: shortness of breath on exertion (‘I run out of puff after 5 stairs’), chest pain, palpitations (thyroid problem?), orthopnoea (breathlessness when lying flat—ask how many pillows the patient sleeps on, >3 suggestive of heart failure), haemoptysis (coughing blood), wheeze.
• Gut: mouth ulcers, difficulty swallowing (dysphagia), acid brash, pain (SOCRATES), vomiting (haematemesis = vomiting blood, bilious = dark green), stool (blood—on surface of stool, bright red, on toilet paper; malaena = dark, tarry stool, a sign of upper GI bleeding), feeling of being unable to completely empty bowels (tenesmus, possible sign of rectal mass), testicular pain (torsion—an emergency).
• Genitourinary: dysuria (pain on passing urine), haematuria (blood in urine), frequency, incontinence, polyuria (passing large amounts of urine often—with polydipsia, drinking large amounts, points to a diagnosis of diabetes mellitus. Consider taking a sexual history but ensure confidentiality (rash, discharge, partners, travel, injected drug use, previous sexually transmitted diseases). Testicular pain—torsion is a surgical emergency.
• Neurological: headaches, dizziness, changes in vision, weakness, pins and needles (paraesthesia), speech problems, memory problems.
• Rheumatological: pain/stiffness/swelling of joints, when worst (diurnal variation between rheumatoid arthritis (RA) and osteoarthritis (OA)), how function affected.
Like the different array of normal values for a child’s heart rate, so with how you approach the history. Along with usual schema, you will want to ask about birth history (especially in neonates—babies <28 days old) and development (a 3-year-old falling off the sofa after bouncing around and breaking their wrist is likely to be an accident, but you would be highly suspicious of the same story from a parent presenting with a 3-month-old).
Vaccination status is important not only in terms of disease prevention but a lack of immunizations can point to social problems and change your management of an 8-month-old with fever (they will not be protected against several nasty bacteria). Always take a feeding history—if a baby is not feeding, they are unwell (ask the parents how much milk she usually takes and how often and compare to how she is feeding now. Time spent on the breast is a helpful measure if the parents are not bottle-feeding the baby).
The social history will be important (living alone/in a care home/with relatives?). Elderly patients may have non-specific presentations—a pneumonia with no cough or sputum production or a ‘silent’ myocardial infarction (MI; i.e. no chest pain). Elderly patients can be on several different medications—has the new antihypertensive inadvertently caused the patient to fall and fracture their hip? Ensure a thorough dug history. You will also learn how to take a collateral history from a carer or GP. Common presentations are problems with mobility and falls; dementia and confusion; infection; stroke; and incontinence (see Chapter 11).
Be careful with confidentiality. For a gynaecological history, cover menstrual, contraceptive, and sexual history. For obstetrics, remember gravidity = the total number of pregnancies while parity is the number of pregnancies carried beyond 24 weeks (NB abortion = fetal death <24 weeks and stillbirth = fetal death >24 weeks). A patient who with two children and one spontaneous abortion would be described as 2+1 (i.e. gravid 3) but less confusing simply to write ‘2 live children, 1 spontaneous abortion’ (see Chapter 23).
A language barrier will greatly limit the patient’s access to healthcare. In an emergency, using a family member as an interpreter might be the only option but this is the only time friends or family should be used due to issues of confidentiality etc. In the UK, you can dial Language Line, a 24/7 telephone interpreting service.
Take an AMPLE history covering the very basics for the patient arriving in the resuscitation area (see p. 262):
A: allergies
M: medications
P: past medical history
L: last time eaten
E: environment, events leading to presentation.
This takes practice and different clinicians will have their preferences (e.g. a paediatrician will always want to hear the age of the child right at the beginning as this immediately helps narrow down the differential diagnosis, an intensivist will want a systems approach). Speak up, and go through your history and examination findings in a systematic order (which means you are less likely to miss things). Keep the PC in the patient’s own words—give your differential diagnosis at the end. Again, knowing what to leave out takes practice. Do not worry about interjections—it means the team is listening to you! Also, always give a differential diagnosis and have a go at making a management plan, both signs of a thinking doctor rather than a clerking machine. Present succinctly with positive findings before negative.
References
1. Bulgakov M (2010). A Country Doctor’s Notebook (Tr. Michael Glenny). London: Vintage Classics.
2. Yang J, Black K (2014). Medical students in gynaecology clinics. Clin Teach 11(4):254–8.
3. Pointer JS (2014). The primary eye care examination: opening the case history and the patient’s uninterrupted initial talking time. J Optom 7(2):79–85.
4. Marmot M (2015). The Health Gap: The Challenge of an Unequal World. London: Bloomsbury.
5. Tabuchi T, Fujiwara T, Nakayama T, et al. (2015). Maternal and paternal indoor or outdoor smoking and the risk of asthma in their children: a nationwide prospective birth cohort study. Drug Alcohol Depend 147:103–8.
The key to being comfortable with radiological investigations and interpreting plain films is gaining as much exposure to imaging as possible while you are a medical student and junior doctor. There are several easy avenues to gaining exposure to imaging:
• Radiologists are all too willing to teach keen students/junior doctors and most of us enjoy it, this can be arranged by discussing with your local radiology department.
• Further exposure can be obtained by attending radiology MDTs. These occur most days within a radiology department. This will give you exposure to imaging techniques, common pathologies, and their radiological findings.
• There are also various free websites that cover imaging including www.radiopedia.org, www.radiologyassistant.nl, and www.learningradiology.com.
This section gives you the basics of how to interpret plain films but also start learning early how to orientate yourself around common CT and MRI investigations. If you have been asked by your team to request imaging, make sure there is a clear question that needs to be answered. If you or your team is unsure of the correct investigation to request, to answer your clinical question, you should discuss this with the radiology department. Most departments have a duty radiologist who will help facilitate this. Some important logistical issues to consider when requesting investigations include the following:
• Many cross-sectional techniques require the patient to remain still. If this is not possible, then the procedure may have to be performed under GA. This is more of an issue in the acutely unwell, intoxicated, and young patients.
• Many modalities require the use of contrast agents, the use of which has risks attached. CT often requires the use of IV iodinated agents which are contraindicated in those with allergies to iodine and which are nephrotoxic, and these should be used in caution in patients with renal failure. Most hospitals have guidelines relating to this.
• MRI often requires the use of gadolinium-based agents which also have relative contraindications in renal failure due to the risk of nephrogenic systemic fibrosis.
• For IV contrast to be successful, good IV access is required and the type of cannula required should be discussed with the radiology department.
• With MRI there is a relative contraindication to patients who contain metal foreign bodies (pacemakers, metal surgical clips, etc.). MRI request forms usually contain an extensive safety questionnaire relating to these issues.
• Some techniques require the use of oral contrast agents, the patient must be able to swallow these safely for the techniques to be performed.
• Identify the patient, their date of birth, and hospital number.
• Some pathologies are more common in certain age groups (e.g. malignancy or cardiac failure in older patients).
• Know the anatomy demonstrated on a CXR (see Fig. 6.2 and Fig. 6.3).
• Appearance of structures on the CXR are determined by their density (reflects the amount of photons that reach the X-ray plate/detector).
Bones which are dense appear white, while lungs, which essentially contain air, and bronchovascular structures are dark.
Fig. 6.2 Anatomy of anteroposterior (AP) plain chest radiograph demonstrating the mediastinal structures. Reproduced from Wikimedia Commons. Illustration by Mikael Häggström, licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.
Fig. 6.3 Anatomy of the lateral chest radiograph. Reproduced from Wikimedia Commons. Illustration by Mikael Häggström, released to the public domain.
If not stated on the film, the standard projection is PA (posterior to anterior) radiograph. The heart size and mediastinal width can only be accurately assessed in a PA projection. This is because they are anterior mediastinal structures and lie closer to the X-ray plate in a PA projection.
In a well-penetrated film, the thoracic vertebra should be visible (although now that radiographs are acquired digitally, this is less important as the image can be manipulated, or ‘windowed’ to see structures more clearly).
The distances between the clavicular heads (the sternal ends) and spinous process of the thoracic vertebra should be equal. If the patient is rotated, it can make assessment of the structures difficult as they no longer lie in their correct anatomical plane.
To accurately assess the lungs, the radiograph should be assessed in inspiration. In a good inspiratory film there should be 8–10 posterior ribs above the diaphragm (or 6–8 anterior ribs, the ones that curve downwards and intersect the diaphragm in the mid-clavicular line). Poorly inspired films can make normal lungs look pathological by exaggerating anatomical structures.
Are the heart and gastric bubble on the left side (if not, the radiograph should clearly state which side is left)? Remember, there are patients who have dextrocardia (heart on the right side) or situs inversus (organs lie on the opposite side to normal).
When interpreting the radiographic findings on any plain film, be systematic. This results in nothing being missed, especially in stressful situations. There are many ways to interpret a CXR but a simple method to adopt is:
A = airways
B = breathing (lungs)
C = circulation and central structures (heart, hilum, and aorta)
D = diaphragm and review areas (apices, behind heart)
E = extras (bones and soft tissues).
These include ETTs, central lines, and enteric tubes. Ensure they are correctly located. An ETT should lie above the carina, the amount depends on the position of the neck. In a neutral position, it should lie approximately 5 cm above the carina in an adult. In a non-rotated patient, a nasogastric (NG) tube should bisect the carina and descend down the midline. The tip should lie below the level of the left hemidiaphragm.
Beware the NG tube that has entered one of the main bronchi and the associated lung (missing one of these is a ‘never event’ according to the National Patient Safety Agency). There are various online tools to help demonstrate the correct position. Central lines should terminate within the SVC or at the SVC/right atrial junction.
Is the trachea central? If not, is it deviated away or towards pathology? This reflects a change in lung volumes. Is the carina angle correct? This should be <90°; if 
this suggests left atrial enlargement as the left atrium lies directly underneath the carina. Are the major airways patent or is there an obvious obstructing mass/foreign body within them?
Initially look at each lung individually, then compare the two. Use a systematic approach looking through all zones. This is where you are looking for pathology such as consolidation, masses, pneumothoraces, or effusions.
Is the heart enlarged? This can only be accurately assessed on the PA projection. Heart size is assessed using the cardiothoracic ratio which is the ratio of maximal horizontal cardiac width to maximal horizontal thoracic width on a PA radiograph. The heart size should be <50%. Is the mediastinum widened (you should normally see the aortic knuckle clearly)? If the mediastinum is widened, there could be an underlying vascular (dissection) or malignant (tumour or nodes) cause.
Are the diaphragms at a similar level, with the right diaphragm normally slightly higher than the left (due to the underlying liver)? The diaphragms should be clearly defined. If they are obscured, it suggests that there is something abutting the diaphragm—consolidation/mass—which obscures the air/diaphragm interface. Is there free air underneath the diaphragm? This is suggestive of an abdominal hollow viscous perforation. An erect CXR is the most sensitive plain radiograph for detecting free air (more so than an abdominal radiograph) (see Fig. 6.4). Review areas include the apices and behind the heart where pathology is not clearly visualized due to overlying structures (clavicles and heart).
Fig. 6.4 Pneumoperitoneum on (a) supine abdominal and (b) upright chest radiographs. There is central lucency beneath the hemidiaphragm (arrow in a), representing the cupola sign. The upright chest radiograph shows free intraperitoneal air beneath the hemidiaphragms (arrows in b). Reproduced with permission from Levy, Angela, et al, Gastrointestinal Imaging, 2015, Oxford University Press.
It is not only the lungs and heart that are included on the chest radiograph. Often the bones and soft tissues are overlooked when looking at radiographs. Beware of pneumothoraces, fractures (ribs, clavicles), and destructive bony lesions. If significant you can also see axillary/neck adenopathy and surgical emphysema.
Tip
Since many patients will be in and out of hospital due to regular chest pathology (e.g. congenital, smokers, immunodeficient patients), make sure you go through any previous imaging to compare severity or resolution. Any prior radiological studies can usually be found in the patients electronic imaging folder with the current study. When reviewing an image, be careful to check the date of the study.
There are numerous different pathologies that can be seen on a CXR. It is easiest to break these down into lung and cardiac pathologies.
Consolidation is merely fluid/tissue within the alveoli. While the term is often used in relation to infection, consolidation can be caused by pus, haemorrhage, fluid, or cells (tumour). On a CXR, consolidation appears radiopaque (white) compared to the adjacent normally aerated lung (black). When looking at consolidation you need to decide its location and distribution. Lobar pneumonia will present as a consolidated lobe. Pulmonary haemorrhage may present as diffuse, patchy consolidation throughout the affected lungs. Similarly, acute respiratory distress syndrome (ARDS) can look like diffuse patchy consolidation throughout both lungs.
Top tip
It can take up to 6 weeks before radiological resolution of consolidation can be seen. This can be ordered and followed up by the patient’s GP.
Lobar collapse has various different radiological signs depending on the lobe affected. Equally, a whole lung can collapse. Collapse causes a loss of volume within the affected hemithorax with resultant movement of structures towards the collapse (e.g. elevation of hemidiaphragm/movement of fissures and mediastinal shift towards collapse). Certain collapses have key radiological signs (see Figs 6.5–6.8).
Fig. 6.5 PA CXR showing mediastinal shift to the left, depression of the left hilum, and density behind the heart (‘sail sign’) due to left lower lobe collapse. Reproduced with permission from Darby, M. J., et al, Oxford Handbook of Medical Imaging, 2011, Oxford University Press.
Fig. 6.6 PA CXR of left upper lobe collapse, showing ‘veil like’ opacification of the left chest, obliteration of the heart border, elevation of the hilum, and preservation of the arch and descending thoracic aorta. Reproduced with permission from Darby, M. J., et al, Oxford Handbook of Medical Imaging, 2011, Oxford University Press.
Fig. 6.7 PA CXR of patient with persistent cough, showing right upper lobe collapse. The opacity in the right upper chest has a clearly defined, curved inferior border, consisting of the elevated horizontal fissure and the inferior border of a right hilar mass (the ‘golden S’ sign). Note also the mediastinal shift to the right and volume loss in the right chest. Reproduced with permission from Darby, M. J., et al, Oxford Handbook of Medical Imaging, 2011, Oxford University Press.
Similar to consolidation, an opacity refers to an area of density within the normally aerated lung. Opacities can be single or multiple and the term is often used to describe malignant masses whereas consolidation is often used to describe infection. A single opacity is likely to reflect a primary lung malignancy. Multiple opacities are likely to reflect pulmonary metastases.
Some opacities can cavitate where an air fluid level is seen within the opacity. While some malignancies can cavitate (particularly squamous cell carcinoma), cavitatory lesions are often caused by a lung abscess which can be single or multiple (Staphylococcus septic emboli). Some vasculitides can also cause cavitatory lesions (e.g. granulomatosis with polyangiitis (previously known as Wegener’s granulomatosis)).
A pleural effusion is fluid within the pleural space, most commonly caused by congestive cardiac failure, infection, or malignancy. Small pleural effusions cause blunting of the costophrenic angle. As they in size you get density within the affected hemithorax with an associated meniscus sign. If the effusion enlarges it can cause a ‘white out’ of the affected hemithorax and often causes collapse of the underlying lung which compensates for this (see Fig. 6.8). Effusions can be bilateral or unilateral. If bilateral, this usually suggests a systemic cause. Remember, if a CXR is taken with the patient lying down, then smaller effusions can be difficult to visualize as they often only cause minor density within the affected hemithorax.
Fig. 6.8 PA CXR showing a large pleural effusion filling much of the right chest. Note the shift of the mediastinum away from the opacity and the meniscus extending up over the apex of the lung. Reproduced with permission from Darby, M. J., et al, Oxford Handbook of Medical Imaging, 2011, Oxford University Press.
A pneumothorax is air within the pleural space and can be spontaneous or iatrogenic. When looking for a pneumothorax, assess the lung markings and see if they extend to the thoracic wall. If they do not and there is a lung edge visualized, a pneumothorax is present. It is often easier to see pneumothoraces by inverting the image (so structures that are normally dark are white and vice versa).
If there is underlying collapse of the lung in conjunction with the pneumothorax there is often minimal mediastinal shift. If air cannot escape, the pneumothorax is at risk of tensioning (one-way valve, see Fig. 6.9). This means the pneumothorax gets progressively bigger causing mediastinal shift away from the pneumothorax. If severe, there can be cardiac compromise and a tension pneumothorax is a medical emergency. A radiograph should never be used to determine a tension pneumothorax and you should be ready to act upon this finding. A tip is to invert the CXR to make it easier to spot the pneumothorax.
Fig. 6.9 CXR of a tension pneumothorax on the right. The collapsed lung is opacified, the mediastinum is shifted away from the affected side, and the ipsilateral diaphragm is depressed. This needs urgent decompression. Reproduced with permission from Darby, M. J., et al, Oxford Handbook of Medical Imaging, 2011, Oxford University Press.
The presence of extraluminal gas within the mediastinum. This can arise from the airways, lungs, or oesophagus and results from injury to any of these organs. There are many radiological signs but a rim of air is often seen around the mediastinal structures. If it tracks underneath the heart you get the continuous diaphragm sign. Often there is associated surgical emphysema as mediastinal air tracks into the soft tissue planes of the neck. If associated with an oesophageal perforation there will often be an associated pleural effusion which is usually left sided.
Cardiac failure can manifest in various different forms on a radiograph from an essentially normal film to having overt findings of cardiac failure. Generally speaking, the heart will be enlarged, with a cardiothoracic ratio >50%. Other radiological findings include pleural effusions, Kerley B lines (small 1–2cm horizontal lines in the periphery of the lung representing fluid within interlobular septa, typically seen at the lung bases), upper lobe pulmonary venous diversion, interstitial changes and patchy consolidation (secondary to pulmonary oedema).
There are few indications for an abdominal radiograph (AXR). These include acute abdomen (including exacerbation of IBD), bowel obstruction, renal or ureteric calculi, foreign bodies, and to assess lines/tubes. Constipation is rarely an acceptable indication, especially in children. Pregnancy is a relative contraindication.
An AXR is relatively more straightforward than a CXR as there is less anatomy and less pathology that can be visualized. A good AXR should include the whole abdomen (including lung bases) and pelvis. The spine should be visible. There is no set way to look at an AXR but a good approach will include looking at ‘BACK the FOCK UP!’:
Bones
Air (bowel gas patterns)/Aorta lining
Calcifications
Kidneys and bladder
the
Foreign bodies
Organs
Contrast
K(C)alculi
Ureters
Psoas shadow—obliteration may signify retroperitoneal pathology such as haematoma.
It is normal to see gas within bowel loops and you want to be able to see bowel gas down to the rectum. Small bowel is allowed to be dilated up to 3 cm, large bowel up to 6 cm, caecum up to 9 cm. Small bowel is generally central and contains valvulae conniventes which are thin circular folds that extend across the full width of the lumen. Large bowel contains haustra which are thickened folds that do not extend across the lumen. Large bowel also contains faeces. If bowel is dilated it is important to assess which parts are dilated as this will help suggest the level of possible obstruction (see Fig. 6.10–6.12)
Fig. 6.10 Normal large bowel gas pattern. Reproduced from Oxford Handbook of Clinical Medicine 8th edition (2010), p741, courtesy of Norwich Radiology Department.
Fig. 6.11 The pattern seen in small bowel obstruction. Reproduced from Oxford Handbook of Clinical Medicine 8th edition (2010), p741, courtesy of Norwich Radiology Department.
Fig. 6.12 Multiple dilated air filled loops of large and small bowel. This pattern is seen in ileus. Reproduced from Oxford Handbook of Clinical Medicine 8th edition (2010), p741, courtesy of Norwich Radiology Department.
When looking at the bowel it is also possible to assess for bowel wall thickening particularly within the colon. This may reflect colitis (infective, ischaemic, or inflammatory). In colonic wall thickening, you can get thumb printing and mucosal islands. Assess the bowel wall for evidence of intramural gas (pneumatosis intestinalis). This is concerning for ischaemic bowel (although it can be seen in benign conditions such as chronic obstructive pulmonary disease (COPD)). If there is pneumatosis intestinalis, the liver should be assessed for evidence of portal venous gas. While assessing the bowel also look for signs of perforation. The main sign in the abdomen is Rigler’s sign which is when air is seen either side of the bowel wall. Free air can also be seen underneath the hemidiaphragm and along the falciform ligament. Remember, an erect CXR is far more sensitive for looking for bowel perforation (pneumoperitoneum).
Look at the outline of the upper abdominal organs, are they enlarged? While looking at the kidneys is there evidence of renal calculi (90% of renal calculi contain enough calcium to be seen on a plain film radiograph)? While looking at the liver, is there any evidence of gallstones (only 10–15% contain enough calcium to be seen on a radiograph, hence ultrasound (US) is the normal first-line investigation for gallstones)? Look for calcification within adrenal glands (past haemorrhage) and pancreas (chronic pancreatitis).
These include bones, lung bases, hernial orifices, and abnormal areas of calcification:
• Bones: look at the spine, imaged pelvis, and thoracic rib cage. Look for destructive lesions and do not miss fractures (especially vertebral compression fractures and hips fractures if included).
• Lung bases: basal consolidation and effusions can often mimic abdominal pain and needs to be excluded.
• Hernial orifices: if there is bowel obstruction beware a hernia, ensure that there is no bowel gas seen below the hernial orifices.
Look for other areas of calcification—vascular calcification is common in the elderly, beware the calcified aortic aneurysm. If there is concern about ureteric calculi, trace the outline of the ureters which run parallel to the transverse process of the lumbar vertebra. They then take an arc as they descend into the pelvis where they enter the bladder. Do not forget to assess the pelvis for bladder calculi. Appendicoliths are calcifications seen in the right iliac fossa that lie within the appendix. If a patient presents with right iliac fossa pain and an appendicolith is visualized, there is a 90% certainty the patient has acute appendicitis.