Monash Medicine in review – Year 5D: MED5101/5103/5105

‹ Previous: BMedSc(Hons): MED4301/4302

Placement

With the exception of the Scholarly Intensive Placement, year 5D is taught entirely from clinical sites like the preceding 2 clinical years. Like year 3B and unlike 4C, the focus returns to acute care general hospital medicine, with a focus on preparation for the duties and core rotations of medical internship.

Year 5D is divided into six 6-week rotations. At the time I completed year 5D, students were allocated on the basis of preferences submitted at the end of year 4C to one of the following: all 6 rotations at one clinical school, 5 rotations at one clinical school with one away rotation (metropolitan students rotating rurally and vice versa), or 1 semester metropolitan with 1 semester rural. At the time I completed year 5D, all domestic students were required to complete at least 1 rural rotation over the course of the medical degree, so most students completed at least 1 rural rotation.

The rotations in year 5D are:

• Core medicine
• Core surgery
• Emergency medicine
• Aged care
• Specialty
• Scholarly Intensive Placement

I completed all my rotations at the School of Clinical Sciences, except core medicine which I completed at Bairnsdale Regional Health Service, and the Scholarly Intensive Placement which I completed with my BMedSc(Hons) supervisors at the Central Clinical School.

Year 5D teaching follows the same schedule as year 4C, beginning 1 week earlier than year 3B with no mid-semester breaks.

The focus of year 5D

In previous years of the medical course, the focus is on learning content – learning about presentations, diseases and treatments – which culminates in the major exams at the end of year 4C. With those exams passed, the focus shifts away from learning content towards applying knowledge in the clinical environment, and developing the practical skills necessary for internship. In short, ‘learning to be an intern’.

On most units, this consists of shadowing the intern on the unit and assisting with junior doctors' tasks. In the morning, this may consist of writing ward round notes, and afterwards may include tasks like helping to perform clinical reviews, calling patients' relatives to obtain collateral history, making referrals to other units, performing procedures like intravenous cannulation or urinary catheterisation, or writing discharge summaries. When there is availability, placement experience may also include attending clinic sessions, or on surgical units, attending or assisting at theatre lists.

It is typical for 5D students to stay on the ward until the junior doctors leave – typically 8 am–5 pm on a medical ward or 7 am–4 pm on a surgical ward – but this varies, and students may be more likely to ask to be dismissed early towards the second half of the year, once internship applications have been completed.

The emergency medicine rotation is unique compared with other rotations, due to the nature of the emergency department. On the emergency medicine rotation, 5D students are attached to a consultant, and function essentially as an intern within the emergency department. The consultant assigns patients expected to be lower acuity or less complex, and the student interviews and examines the patient, proposes a plan for investigation and management, discusses with the consultant, and implements the plan. This may include taking blood, interpreting investigations, discussing with inpatient teams, performing procedures like suturing or plastering, or recommending discharge, as supervised by the consultant.

Scholarly Intensive Placement

The Scholarly Intensive Placement (SIP) is a mandatory 6-week rotation in year 5D, introduced since the commencement of the BMedSc/MD as Monash University's primary medical degree.¹ Students without past research experience are allocated to a supervisor and project within their clinical school, to complete a short research-related project – might include working on an audit, preparing an ethics application, or data acquisition and cleaning. Previous BMedSc(Hons) students – or to complete a short professional practice or education project. The rotation culminates in the production of a 4,000-word report and a short oral presentation.

Previous BMedSc(Hons) students like myself can instead return to their BMedSc(Hons) supervisors for 6 weeks, and most, like myself, take the opportunity to conduct additional research and/or to prepare a manuscript for publication.

Additional teaching

Formal teaching within year 5D is primarily delivered in ‘back to base’ days, with 1 day at the end of each rotation, and 1 ‘back to base’ week at the end of the year. The theme of back to base teaching, like everything in year 5D, is preparation for internship, and representative topics include management of fluids and electrolytes, safe prescribing, conflict resolution, and tips and tricks. There is also a focus on safe management of emergencies as a potential first responder, with several days of practical workshops throughout the year on topics like managing common ward calls, assessing and managing deteriorating patients, and providing basic and advanced life support. In the metropolitan programme, some deteriorating patient workshops are run out of Monash Health's new high-fidelity simulation centre, which was a great experience.

Throughout the year, there are a series of mandatory readings and associated mandatory reflective forum posts (‘ORADA’), covering topics such as professional practice and patient safety. As far as mandatory forum posts go, the tasks make for pretty good reading, and the source of one of the readings, Atul Gawande's Complications, is on my ‘to read’ list.

Internship applications

Also taking place over the course of year 5D is applications for medical internships. This is a major event of year 5D, and I reserve discussions of the details for a separate future post.

My last day of medical school

As an illustrative example of the day-to-day of year 5D, I've sketched out what happened on my final day of regular medical school placement. This was a fairly light and generally uneventful day on the Hepato-Pancreato-Biliary (HPB) Surgery unit at Monash Medical Centre.

I got up at 6 am, had breakfast, etc., drove to Monash Medical Centre, and arrived in the HPB doctors' workroom at 6:50 am, where I was joined by the intern around 7 am. Normally at this time, I would work with the intern to prepare ward round notes for the inpatients on the ward, in anticipation of the ward round – starting a note, filling in patients' information, updating their progress, and checking and commenting on any investigations reported since yesterday.

At 7:30 am, the registrar arrived and we set off on the ward round, where the intern and I took notes, and kept tabs on which jobs would need to be actioned later in the day. By 9:30 am, we finished the ward round, and the registrar set off elsewhere to do Important Registrar Business (theatre, consults, admissions, etc.), leaving me and the intern to start the ward jobs. It eventuated that, on this particular day, there were not many ward jobs.

I called the pathology department to request a fax of a formal report for a patient's investigation results, so that I could send it to the patient's GP. This was a task left over from yesterday's outpatient clinic I'd attended, as the pathology database was down for maintenance that day. An hour later, the fax hadn't arrived, so I called back, and it appeared that faxes from the pathology department were being delayed.

At 11 am, I called the consultant anatomical pathologist to to discuss a patient's biopsy and request further staining, which was a task decided on during the morning's ward round. The pathologist was in a meeting, so their receptionist suggested calling back after lunch.

At 11:30 am, I went for lunch, at 12 pm the interns went for a coffee break and lunch, and at 12:30 pm there was regularly scheduled intern teaching via videoconference, which we all tuned in for from the doctors' workroom. After intern teaching, I called the pathologist back and discussed the patient from the ward round.

By 3 pm, the fax from the morning still hadn't arrived, so I called the pathology department, and it appeared that the pathology fax system was down for the day, so I went for a stroll to the pathology department reception to pick up a copy of the report in person, and sent it to the patient's GP.

In between all of this, I wrote some discharge summaries, read some mandatory medical school readings, and did some self-study.

At 4:30 pm, the day team was relieved by the afternoon–evening cover intern, and so I said my thank-yous and good-byes, and went home.

Assessment

Because the major summative exams of medical school are at the end of year 4C, and 5D results will not be known by the time of internship application, assessment in year 5D is effectively formative ‘assessment for learning’, although certain hurdle requirements must be met for graduation.

In the core rotations of medicine, surgery and emergency medicine, observed clinical encounters (OCEs), like those in year 3B, must be witnessed and assessed as competent by a supervising doctor. At the end of each rotation, a pre-intern appraisal (PIA) must be completed by a senior doctor and assessed as satisfactory – this serves not only as a useful opportunity for feedback, but also a convenient chance to ask for a reference for internship applications. During the emergency medicine rotation, several logbook clinical skills must be attempted and observed, including intravenous cannulation, urinary catheterisation, plastering and suturing. In 2023, the logbook requirements were revised to reduce the load, and I found them to be not too onerous.

Several year 5D assessments are styled as exams, at varying levels of formality. Introduced in 2022 due to previous COVID-19 disruption to clinical skills teaching, the safe practice assessment – physical examination (SPA-PE) is something like an informal one-station OSCE, lasting about 20 minutes and focusing on various randomly selected physical examination tasks, scheduled over the course of the year. Pleasingly, the focus is on competency with core examination skills (ascultation, palpation, etc.) rather than rattling off long lists of eponymous signs to score points.

The safe practice assessment – physical (SPA-P) is something like a 6-station OSCE, focusing on core internship skills like basic life support, writing on a drug chart, fluid prescribing and giving a handover, scheduled over the course of semester 2. Students not at the standard on the first attempt receive immediate feedback and a second attempt, so failing is not an expected outcome.

The prescribing skills assessment (PSA) is an online written exam completed during the university end-of-year exam period about prescribing decisions. Access to the Australian Medicines Handbook is permitted, so the exam is a test of applying knowledge and skills to prescribe appropriate medications, detect medication errors and make decisions about side effects and medication interactions. In 2022, it was mandatory to attempt the exam but not mandatory to pass, as the university works through its standard-setting processes.

The safe practice assessment – written (SPA-W, formerly the clinical knowledge test, CKT) is the large written exam held during the exam period. The format is similar to previous end-of-year written exams, but with a focus on core knowledge for internship and less focus on niche, rare conditions. For example, topics include selecting appropriate sutures, following a systematic A–E approach to a deteriorating patient, and important emergency department diagnoses. I found the questions fair and appropriate, and the exam educational and relevant to study for.

Footnotes