Foreword vii

Preface  ix

1. Why medicine and why not? 1

2. Opportunity and reality 11

3. Requirements for entry 23

4. Choosing a medical school 33

5. Application and selection 44

6. Interviews  52

7. Medical school: the early years 58

8. Medical school: the later years 72

9. Doubts  90

10. The house officer 97

11. Choosing a specialty 104

12. Career opportunities 118

Postscript  133

Appendices  136

Index  145

vTo

Spirited students, dedicated doctors, and courageous

and forbearing patients—all of whom have helped us to

learn medicine.

With our special thanks to all those (students of three medical

schools, a patient and a BBC TV producer) who have each

contributed their piece to this book—Tom Alport, Chloe-

Maryse Baxter, Michael Brady, Esta Bovill, Sarah Cooper,

Sarah Edwards, Adam Harrison, Farhad Islam, Liz James,

Grace Robinson, Susan Spindler, Brenda Strachan—and

particularly to Larry, who most generously breathed life into

a “worthy cause”.

viviiLEARNING MEDICINE

viii

If you choose to represent the various parts in life by holes upon a

table, of different shapes—some circular, some square, some oblong—

and the persons acting these parts by bits of wood of similar shapes,

we shall generally find that the triangular person has got into the

square hole, the oblong in the triangular, and a square person has

squeezed himself into the round hole. The officer and the office, the

doer and the thing done, seldom fit so exactly that we can say they

were almost made for each other.

SYDNEY SMITH 1804

If we offend, it is with good will,

That you should think we come not to offend,

but with good will

A Midsummer Night’s Dream

SHAKESPEAREix

Preface

Have you read that doctors feel overworked and undervalued—that they

have never been more discontented? Did you know that although doctors in

training work shorter hours than ever before, their duties have never been

more arduous? Have you heard that many doctors take a break after their first

few posts and that not all return to medicine? Promotion is faster than it used

to be, but this means that consultants find themselves doing front-line work

at unsocial hours formerly done by senior trainees. General practitioners are

harassed by demanding patients and submerged in paperwork. Doctors are

retiring earlier—tired out, burnt out, or browned off.

On the other hand, everyone from time to time needs a caring and

competent doctor—someone honest, kind, and committed to putting

patients first. Most doctors enjoy doing this—most of the time. They

cannot escape the reality that roses also have thorns. Medicine is not

everyone’s cup of tea—why should it be? If you want to be realistic about

whether or not you are able to give what medicine takes, read on.

PETER RICHARDS AND SIMON STOCKILL1. Why medicine and

why not?

So you are thinking of becoming a doctor? But are you quite sure

that you know what you are letting yourself in for? You need to

look at yourself and look at the job.Working conditions and the

training itself are improving,but medicine remains a harder

taskmaster than most occupations. Doctors have also never been

under greater pressure nor been more concerned for the future

of the NHS.

Before starting medicine you really do need to think about what lies ahead.

The trouble is that it is almost impossible to understand fully what the

profession demands, particularly during the early years of postgraduate

training, without actually doing it. Becoming a doctor is a calculated risk

because it may be at least five or six years’ hard grind before you begin to

discover for sure whether or not you suit medicine and it suits you. And

you may change; you might like it now, at your present age and in your

current frame of mind, but in six years’ time other pressures and priorities

may have crowded into your life.

Medicine is both a university education and a professional training. The

first five or six years lead to a medical degree, which becomes a licence to

practise. That is followed by at least as long again in practical postgraduate

training. The medical degree course at university is too long, too expensive

(about £200 000 in university and NHS costs, quite apart from personal

costs), and too scarce an opportunity to be used merely as an education

for life.

It might seem odd not to start considering “medicine or not?” by

weighing up academic credentials and chances of admission to medical

school. Not so; of course academic and other attributes are necessary, but

there is a real danger that bright but unsuited people, encouraged by

ambitious schools, parents or their own personalities, will go for a high

profile course like medicine without having considered carefully first just

where it is leading. A few years later they find themselves on a conveyor belt

from which it becomes increasingly difficult to step. Could inappropriate

selection of students (most of whom are so gifted that they almost select

themselves) account for disillusioned doctors? Think hard about the career

first and consider the entry requirements afterwards.

1Getting into medical school and even obtaining a degree is only the

beginning of a long haul. The university course is a different ball game from

the following years of general and specialist postgraduate training.

Postgraduate training is physically, emotionally, and socially more

demanding than the life of an undergraduate medical student on the one

hand and of a settled doctor on the other. With so many uncertainties about

tomorrow it is difficult to make secure and sensible decisions today. Be

realistic, but do not falter simply for lack of courage; remember the words of

Abraham Lincoln: “legs only have to be long enough to reach the ground”.

This is your life; if you get it wrong you could become a square peg in a

round hole or join the line of disillusioned dropouts. Like a submaster key,

which opens both outer doors and a particular inner room, you need to fit

both the necessary academic shape and also the required professional

attitudes. Finally, you have to find your specific fit into one or other

particular specialty.

You must have the drive and ability to acquire a medical degree,

equipping you to continue to learn on the job after that. Also, you need to

be able to inspire trust and to accept that the interests of the patient come

before the comfort or convenience of the doctor. It also helps a lot if you

are challenged and excited by clinical practice. Personality, ability, and

interest, shaped and shaved during the undergraduate course and the early

postgraduate years, will fit you in due course, perhaps with a bit of a

squeeze, into a particular specialty “hole”. Sir James Paget, a famous

London surgeon in the 19th century concluded from his thirty years of

experience that the major determinant of students’ success as doctors was

“the personal character, the very nature, the will of each student”.

Why do people want to become doctors? Medicine is a popular career

choice for reasons perhaps both good and not so good. And who is to

say whether the reasons for going in necessarily affect the quality of what

comes out?

So, why medicine?

Glamour is not a good reason; television “soaps” and novels paint a false

picture. The routine, repetitive, and tiresome aspects do not receive the

prominence they deserve. On the other hand, the privilege (even if an

inconvenience) of being on the spot when needed, of possessing the skill to

make a correct diagnosis, and having the satisfaction of explaining,

reassuring, and giving appropriate treatment can be immensely fulfilling

even if demanding. Yet others who do not get their kicks that way might

prefer a quieter life, and there is nothing wrong with that. It is a matter of

horses for courses or, to return to the analogy, well fitting pegs and holes.

An interest in how the body works in health or in disease sometimes

leads to a career in medicine. Such interest might, however, be equally well

served by becoming an anatomist or physiologist and undertaking a lifetime

study of the structure and function of the body. As for disease itself, many

LEARNING MEDICINE

2scientists study aspects of disease processes without having medical

qualifications. Many more people are curious about how the body works

than either wish to or can become doctors. None the less, for highly able

individuals medicine does, as George Eliot wrote in Middlemarch, present

“the most perfect inter-change between science and art: offering the most

direct alliance between intellectual conquest and the social good”. Rightly

or wrongly, it is not science itself which draws most people to medicine, but

the amalgam of science and humanity.

Medical diagnosis is not like attaching a car engine to a computer.

Accurate assessment of the outcome of a complex web of interactions of

body, mind, and environment, which is the nature of much ill health, is not

achieved that way. It is a far more subjective and judgmental process.

Similarly, management of ill health is not purely mechanistic. It depends

on a relationship of trust, a unique passport to the minds and bodies of all

kinds and conditions of men, women, and children. In return the doctor

has the ethical and practical duty to work uncompromisingly for the

patient’s interest. That is not always straightforward. One person’s best

interests may conflict with another’s or with the interests of society as a

whole—for example, through competition for limited or highly expensive

treatment. On the other side of the coin, what is possible may not in fact be

WHY MEDICINE AND WHY NOT?

3in the patient’s best interest—for example, resuscitation in a hopeless

situation in which the patient is unable to choose for him or herself—leading

to ethical dilemmas for the doctor and perhaps conflict with relatives.

Dedication to the needs of others is often given as a reason for wanting to

be a doctor, but how do you either know or show you have it? Medicine has

no monopoly on dedication but perhaps it is special because patients come

first. As Sir Theodore Fox, for many years editor of the Lancet, put it:

What is not negotiable is that our profession exists to serve the patient, whose

interests come first. None but a saint could follow this principle all the time;

but so many doctors have followed it so much of the time that the profession

has been generally held in high regard. Whether its remedies worked or not,

the public have seen medicine as a vocation, admirable because of a doctor’s

dedication.

A similar reason is a wish to help people, but policemen, porters, and

plumbers do that too. If a more pastoral role is in mind why not become a

priest, a social worker, or a school teacher? On the other hand, many are

attracted by the special relationship between doctor and patient. This

relationship of trust depends on the total honesty of the doctor. It has been

said that, “Patients have a uniquely individual relationship with their

doctors not encountered in any other profession and anything which

undermines patients’ confidence in that relationship will ultimately

undermine the doctor’s ability to carry out his or her work”. A journalist

writing in the Sun wrote cynically, “In truth there is not a single reason

to suppose these days that doctors can be trusted any more than you can

trust British Gas, a double glazing salesman, or the man in the pub”. We

disagree—and you would need to disagree too if you were to become a

doctor. If it is of any comfort to the  Sun, a Mori poll in 1999 asked a

random selection of the public which professionals could be trusted to tell

the truth. The results were: doctors 91%, judges 77%, scientists 63%,

business leaders 28%, politicians 23% and journalists 15%.

Professionalism includes the expectation that doctors (and medical

students) can be relied on to look after their own health before taking

responsibility for the care of others. Doctors who are heavy drinkers or

users of prohibited drugs cannot guarantee the necessary clear and

consistent judgment, quite apart from the undermining of trust through

lawbreaking. Habits start young, and patients have a right to expect high

standards of doctors and doctors in training, higher standards than society

may demand of others. Those not prepared for such personal discipline

have an ethical duty not to choose medicine. It has been said that “Trust

is a very fragile thing: it can take years to build up; it takes seconds to

destroy”. Sir Thomas (later Lord) Bingham, when Master of the Rolls in

1994, expressed the following judgment when rejecting an Appeal by a

doctor to the Privy Council against erasure from the medical register at the

direction of the Professional Conduct Committee of the GMC. “The

reputation of the profession is more important than the fortunes of any

LEARNING MEDICINE

4individual member. Membership of a profession brings many benefits, but

that is part of the price.”

The Hippocratic oath is essentially a commitment to absolute honesty,

professional integrity, and being a good professional colleague. Many

people feel that this spirit is so integral to being a doctor and should be so

central to medical education and training that it does not need formal

recitation on qualification, especially in the paternalistic phraseology of

even modern versions of the Hippocratic oath. On the other hand is there

not a place for a formal public declaration by new doctors of their explicit

commitment to ethical behaviour? Certainly the graduating medical

students at Imperial College in 2001 thought so. They devised their own

“affirmation of a new doctor” to etch the association of their new

responsibility for the care of patients and promising to act professionally

indelibly in their minds—and hearts (see Appendix 1).

The General Medical Council (GMC) is not only responsible for

maintaining a register of all doctors licensed to practise medicine in the UK

but also for ensuring that doctors are trained to practise and do practise to

a high standard. The GMC accepts that the public want to be looked after

by doctors who are knowledgeable, skilful, honest, kind and respectful of

patients, and who do everything in their power to help them. Above all,

that patients want a doctor that they can trust. Explicit duties,

responsibilities, values and standards have been clearly set out on behalf of

the profession by the GMC in  Good Medical Practice, which medical

students now receive soon after arriving at medical school. Now that

contact with patients generally starts early in the course, so does the

responsibility of medical students to be professional.

Medicine is an attractive career to good communicators and a difficult

one for those who are not. The ability to develop empathy and

understanding with all sorts of people in all sorts of situations is an

important part of a doctor’s art. It is part of medical training, but it helps

greatly if it comes naturally in both speaking and writing. A sense of

humour and broad interests also assist communication besides helping the

doctor to survive as a person. Not all careers in medicine require face to

face encounters with patients, but most require good teamwork with other

doctors and health workers.

Arrogance, not unknown in the medical profession, hinders both good

communication and teamwork. It is not justified: few doctors do things

that others with similar training could not do as well—or better.

Confidence based on competence and the ability to understand and cope

is quite another matter; it is appreciated by patients and colleagues alike.

Respect for others and an interest in and concern for their needs is

essential. One applicant was getting near the point when she said at

interview, “I like people”, then paused and continued, “Well, I don’t like

them all, but I find them interesting”. Patients can of course sometimes

seem extremely demanding, difficult, unreasonable, and even hostile,

particularly when you are exhausted.

WHY MEDICINE AND WHY NOT?

5Many people consider medicine because they want to heal. Helping is

more common than healing because much human illness is incurable. If

curing is your main interest better perhaps become a research

pharmacologist developing new drugs. Also, bear in mind that the cost of

attempting to cure, whether by drugs or by knife, is sometimes to make

matters worse. A doctor must accept and honestly admit uncertainty and

fallibility, inescapable parts of many occupations but harder to bear in

matters of life and death.

Experience of illness near at hand, in oneself, friends, or family, may

reinforce the desire to become a doctor. Having said that, the day to day detail

of good care depends more on nurses than doctors and good career

opportunities lie there too. In any event, the emotional impact of illness

should be taken together with a broader perspective of the realities of the

training and the opportunities and obligations of the career. Dr F J Inglefinger,

editor of the New England Journal of Medicine wrote, when seriously ill himself:

In medical school, students are told about the perplexity, anxiety and

misapprehension that may affect the patient … and in the clinical years the

fortunate and sensitive student may learn much from talking to those

assigned to his supervision. But the effects of lectures and conversations are

ephemeral and are no substitute for actual experience. One might suggest, of

course, that only those who have been hospitalised during their adolescent or

adult years be admitted to medical school. Such a practice would not only

increase the number of empathic doctors; it would also permit the whole

elaborate system of medical school admissions to be jettisoned. 

He had his tongue in his cheek, of course, but he also had his heart in his

mouth.

Personal experience of the work and life of doctors, first and second

hand, preferably in more than one of the different settings of general

LEARNING MEDICINE

6practice, hospital, or public health, is in any event formative and valuable

in getting the feel of whether such work would suit. This can be difficult to

arrange while you are still at school, not least because of the confidential

nature of the doctor–patient relationship. Observation by a young person

who may or may not eventually become a medical student is intrusive and

requires great tact from the observer and good will from both doctor and

patient. Doctors’ children may have an advantage here (the only advantage

they do have in the selection process) and could well be expected to know

better than others what medical practice is all about. Most applicants have

to make do with seeing medicine from another side by helping in hospital,

nursing home, or general practitioner’s surgery, each situation giving

different insights.

And, why not?

Learning medicine involves an education and training longer and more

disruptive of personal life than in any other profession. And medicine is

moving so fast that doctors can never stop learning. To be trained, it is said,

is to have arrived; to be educated is still to be travelling.

Unsocial hours of work are almost inevitable for students and junior

doctors and are a continuing obligation in many specialties. If this really is

not how you are prepared to spend your life, better not to start than to

complain or drop out later. That does not, however, mean that the

profession and public has any excuse for failing to press for improvements

in working conditions of all doctors, especially for those in training.

Exhausted doctors are neither good nor safe, and it becomes difficult for

them to profit fully from the lessons of their experience.

What about medicine for a good salary, security, social position, and a

job which can in theory be done anywhere? Doctors in the United

Kingdom are paid poorly in comparison with other doctors in western

Europe, North America, and Australasia, unless they supplement their

income with a busy private practice, but, having said that, the pay is not

bad. Medicine in the NHS is, above all, still a relatively secure career

despite all the recent turmoil, not least because it is now clear that the

United Kingdom has for many years trained fewer doctors than it needs

and is going to take many years to catch up. Social advancement would be

a poor motive, unlikely to achieve its aim. The profession has largely been

knocked off its traditional pedestal. Much of the mystery of medicine has

been dispelled by good scientific writing and television. Public confidence

has been eroded by critical reports of error and incompetence, not to

mention a rising tide of litigation against doctors. In the words of

Sir Donald Irvine, former president of the GMC: “The public expectation

of doctors is changing. Today’s patients are better informed. They expect

their doctors to behave properly and to perform consistently well, and are

less tolerant of poor practice.” Such respect that doctors still enjoy has to

be continually earned by high standards of professionalism.

WHY MEDICINE AND WHY NOT?

7LEARNING MEDICINE

8

The freedom of doctors to practise in other countries is no longer what

it was. Most developed countries have restrictions on doctors trained

elsewhere. European Union countries are open to United Kingdom

doctors but none is short of doctors, and language barriers have to be

overcome. Need and opportunity still exist in developing countries. All in

all, there are less demanding ways than medicine of making a good living

and having the opportunity to work abroad.

Making your own decision

It would be pompous and old fashioned to insist that all medical students

should have a vocation but they do need to be prepared to put themselves

out, to earn respect, to impose self-discipline, and to take the rough with

the smooth in their training and career; they also need to be excited and

challenged intellectually and emotionally by some if not all aspects of

medicine. And, as much of the decision making in medicine is made on

incomplete evidence, they must be able to live with uncertainty. They also

need the necessary patience and determination to improve imperfect

treatment, increasingly practising “evidence-based” medicine.It is neither necessary nor normal for individuals to be entirely clear why

they want to become a doctor. Those who think they do and also know

precisely the sort of doctor they want to be usually change their minds

more than once during their training. Whatever your reasons for medicine,

the first thing to do is to test your interest as best you can against what the

career involves, its demands, its privileges, and its responsibilities. It is not

useful to try to decide now what sort of doctor you might want to be, in

fact you do not need to decide for at least seven years. But it is wise towards

the end of the undergraduate course to examine specialty career options

more carefully than most students do now, not least so that enthusiasm

about the possibility of a particular specialist career can help motivate you

through finals and especially through the somewhat harrowing clinical

responsibility of the early postgraduate years.

At the end of the day, your decisions must be your own. If you have

questions about course or career, find out who to ask and make your own

inquiries; it is your life and your responsibility to make a suitable career

choice. Do not let your parents, however willing or however wise, choose

your career for you. Beware the fate of Dr Blifil in Tom Jones who was

described as:

… a gentleman who had the misfortune of losing the advantage of great

talents by the obstinacy of his father, who would breed him for a profession

he disliked … the doctor had been obliged to study physick [medicine], or

rather to say that he had studied it …

The trust of others, regardless of wealth, poverty, or position, together

with the opportunity to understand, explain, and care, if not cure, can

bring great fulfilment. So too can the challenge of pushing back the

frontiers of medical science and of improving medical practice.

Medicine requires a lively mind, wise judgment, sharp eyes, perceptive

hearing, a stout heart, a steady hand, and the ability to learn continuously.

It is an ideal career for all rounders and the better rounded you are the

wider your career opportunity in medicine as clinician, scientist, teacher,

researcher, journalist, or even politician.

Medicine will never be an entirely comfortable or convenient career. It

also requires signing up to an ethical code stronger than the law of the land

and, even as a student, observing the law—high spirits notwithstanding.

Doctors’ convictions are never spent. Doctors breaching the law or their

ethical code may lose their registration, their licence to practise, and with

that their livelihood.

The configuration of an individual’s character, aspirations, and abilities

have to match the shape of the opportunity, like pegs in holes. Becoming

and being a doctor is not by any means everyone’s cup of tea. Yet for all its

demands, medicine offers a deeply satisfying and rewarding lifetime of

service to those prepared to give themselves to it. 

WHY MEDICINE AND WHY NOT?

9REMEMBER

• Becoming a doctor takes five or six years.

• Further postgraduate training takes about as long again.

• There is much to be said both for and against a career in medicine.

• Discover as much as possible about what being a doctor involves before

making a decision which will affect the rest of your life.

• Try spending time talking to medical students, hospital doctors, or local

GPs.

• The decision for or against applying to medical school should be your

own—do not be pressured by school, parents, or friends—it is your life.

LEARNING MEDICINE

102. Opportunity and reality

Statistically,the chances of entry to medical school are pretty

good: currently about 12 000 applicants compete for nearly

7000 places,though the current trend of applications is on the

increase. Recent moves by the Government to increase the

numbers of doctors in the NHS are leading to an increase of

available places to 7840 by 2007/08,by building new medical

schools and allowing larger numbers of students at existing

schools.

In his report,  Learning from Bristol (2001), Professor Sir Ian Kennedy

recommended that:

Access to medical schools should be widened to include people from diverse

academic and socio-economic backgrounds. Those with qualifications in

other areas of healthcare and those with educational background in subjects

other than science, who have the ability and wish to, should have greater

opportunities than is presently the case, to enter medical school.

In fact, most medical schools will consider applicants without a strong

science background, especially for some graduate entry courses.

Most applicants come from professional or clerical backgrounds. Many

others still see medicine as a closed shop in which, if you do not have such

a background, you stand little chance of either entry or success. Research

has shown that once academic ability has been discounted neither social

class, age, medical relatives, nor type of secondary school affect chances

of entry to medical school. But examination results depend partly on

educational opportunity at school, not to mention encouragement to study

at home. Some medical schools try to make some allowance for this.

The fact of the matter is that many people simply do not believe they

have a real opportunity to become a doctor. Many who might well make

excellent doctors and would broaden the perspectives and insights of the

medical profession as a whole simply do not apply. If they do not apply,

they cannot be considered.

Academic achievement is the most important determinant of success in

selection. Some medical schools make their final selection on grades alone;

most also take account of attitudes, personality, and broader achievements,

qualities which being difficult to measure require judgment to assess and

therefore cannot be proved to be absolutely fair. Nevertheless, an immense

amount of effort is put into making selection as fair as possible.

11The long course of study, diminishing educational grants, mounting

student debts, and course fees also tend to deter those without financial

backing. It is extremely difficult to work one’s way through medical school.

Spare time jobs are difficult to find, and the course leaves little time for

them, especially in the later years with on call duties in hospital. The fact

that the job is secure at the end of the road and is sufficiently well paid for

debts to be repaid seems just too far away to be any consolation.

Opportunities for women

Universities across the world were slow to give women equal opportunity

to higher education, and medicine was perhaps the slowest professional

course of all. Several United Kingdom medical schools first admitted

women as students only 50 years ago (except during the world wars when

they were unable to fill all their places with men).

Women now have equal opportunity to enter medicine. In 1991, for the

first time, more women than men were admitted to medical school in the

United Kingdom, and the following year, for the first time women

predominated among both applicants and entrants. This trend continues,

and in 2001 the proportions of women and men in both applications and

entrants was about 58% women and 42% men. Such is the turn around of

LEARNING MEDICINE

12the imbalance of men and women students that some admissions tutors

are asking if the time has come to consider ways of encouraging male

applicants, although there is as yet no talk of quotas or positive action

for men!

Although it can still be argued that the medical profession as a whole is

still male dominated, there is no doubt that as the trend towards more

women students continues, this is being slowly but surely broken down by

sheer force of the numbers of women doctors. Some specialties remain

more challenging for women to succeed in than others, but some fields are

naturally finding the majority of their new recruits are women.

In the past, careers advisers, parents, and applicants were understandably

aware of the potential personal conflicts ahead between career and family at

a time when, even more than today, women were left holding the baby while

the man got on with his career. Times have changed, and society’s attitudes

to parenting are changing all the time. Also the conflict between career and

personal interests is not confined to women and to bringing up a family.

Some argue positively for medicine as being better placed than many other

careers for resolving this conflict, as Dr Susan Andrew has done:

Medicine is a most suitable career for intelligent, educated women who aspire

to married life, because it carries far more opportunities for flexible working

than other professions … My message is: remember, women have struggled

for centuries to have lives of their own and to be defined in terms of their own

achievements, not someone else’s.

Ethnic minorities

Medicine, science, and engineering are all disproportionately popular

university courses with home students from ethnic minorities, especially

those of Indian or south east Asian origin. More than a quarter of home

applicants to medical school are drawn from ethnic minorities, although

they comprise less than one tenth of the United Kingdom population.

Afro-Caribbeans are an exception, reflecting their current general

academic underachievement, a cause of national concern; medical schools

are keen to encourage them to apply.

Concern has also been expressed that applicants from ethnic minorities

with equivalent academic grades were found a few years ago to be less likely

to be shortlisted for interview; once interviewed, however, they were as likely

to receive an offer as anyone else. The difference was small, less than the

disadvantage of applying towards the end of the application period, but it still

existed in a survey in 1998. One reason may be that these applicants have had

less opportunity and encouragement to develop leadership skills, to pursue

wider interests, and to participate in community service, all important

dimensions at shortlisting in most medical schools. Prejudice may also have

OPPORTUNITY AND REALITY

13been a factor because a similar disadvantage has been found in shortlisting

for junior hospital posts. A study a few years ago showed that when identical

CVs were submitted under different names, those bearing a European name

were more likely to be shortlisted than others for senior house officer posts.

Since 1998 stringent steps have been taken in all medical schools to ensure

equal opportunities, and no recent evidence has caused concern.

A small but significant minority of Indian or Asian women students

experience family pressures which undermine their ability to cope happily

or effectively with their academic work. Parents and grandparents may

curtail freedom, command frequent presence (a demand not limited to the

women students or indeed to Asian families), and occasionally impose

arranged marriages. Deans are familiar with situations in which they have

to send down students for academic failure due to such pressures. Parents

must better understand that until the pressures that are preventing their

child from working effectively are removed—by giving them more personal

and intellectual liberty—they have no prospect of being readmitted to a

medical course.

Of course, families of any section of society can place pressures on a

student—such as a young student who has to care for younger siblings or

an elderly relative. While these pressures are understandable, and often,

inadvertent, can it ever be acceptable to undermine a young person’s

chances in life, however difficult the family circumstances?

Mature students

Age is statistically no disadvantage in application to medical school, but

that may well be because few mature students have the necessary academic

and financial credentials to apply. Most medical schools restrict

consideration to those aged under 30 or discourage those older than that,

even if not actually excluding them from open competition with equally

bright younger applicants, perhaps as committed (even if less experienced)

and with potentially an extra decade of service to offer as a doctor. Less

than 1% of entrants to medical school are over 30 when they start, only 3%

are between 25 and 30, and 6% between 21 and 24. Deans have a difficult

balancing act to perform. Some years ago as a way of challenging a mature

applicant at interview to make her case, I said, “If we offer you a place the

phone will ring and the prime minister will ask how we can possibly justify

national investment in you rather than in a younger person”, at which

moment the telephone on my desk rang. It was not the prime minister, and

the applicant won her place.

Most medical schools welcome the contribution mature students make

to the stability and responsibility of their year group and more widely

within the medical school as a result of their greater experience,

achievement, and compassion. Maturity helps in communicating and

empathising with patients, to the extent that many deans would prefer to

take all their students over the age of 21.

LEARNING MEDICINE

14Good organisation, a sufficient income, and an understanding partner

with a flexible job (if any partner at all) are the foundations of successful

medical study by mature students with family responsibilities. The early

years of the course are no more difficult for medicine than other degree

courses, except in that the intensity of lectures and practical work is greater

than in most other subjects. Efficient use of time during the day and a

regular hour or two of study most evenings (with more before examinations)

should suffice. Some students manage to support themselves for a year or

two by evening and weekend jobs. It is not easy and becomes more or less

impossible during the later years, when the working year is 48 weeks. Most

clinical assignments require one night or weekend in hospital every week or

two. Two or three “residences”—for example, in obstetrics or paediatrics—

may require living in a distant hospital for a week or two at a time, learning

as one of the medical team by day and sometimes at night. An increasing

number of schools are farming out their students to district hospitals—

often some miles from the university town—for much longer periods of

time than before. If this is likely to cause major problems with some

students it is worth checking this out before you choose where to apply.

The working day at that stage is long, starting at 8.00 am and finishing

about 5.00 pm or later, with most weekends free. The elective period of

two or three months is often spent abroad but may be spent close to home

and does not necessarily entail night or weekend duty. Finally, several

weeks as a shadow house officer involves residence in hospital at the end of

the course.

OPPORTUNITY AND REALITY

15Some mature students manage magnificently. One who started just over

the age of 30 and had two children aged between 5 and 10 and a husband

willing and able to adjust his working hours to hers had studied for A levels

when she was a busy mother. Her further education college described her

as the most academically and personally outstanding student that they

could remember; she won several prizes on her way through medical school

and qualified without difficulty. Another of similar age with four children

and separated from her husband, coped with such amazing energy and

effectiveness, despite considerable financial hardship (and the help of a

succession of competent and reliable au pairs) that she left everyone

breathless. Exceptional these two may be, but it can be done, requiring as

Susan Spindler commented in her book, Doctors To Be, “an unerring sense

of priorities in her life, tremendous stamina and the capacity to concentrate

briefly but hard”.

Mature students are at a substantial financial disadvantage if they have

already had a student loan for higher education. Even if eligible for

bursaries or additional loans, those who have already achieved financial

independence find their reduced circumstances tough.

Finance is only one of the problems facing mature students: to revert

from being an independent individual to becoming one of a bunch of

recent school leavers can be both hard and tiresome, although most mature

students in medicine seem to cope with this transition remarkably well.

Shorter courses (four years) for some graduates have now been introduced

at several universities, with students supported for the last three years by

NHS bursaries (see page 39). Better let a mature student, an Oxford

graduate in psychology, give her own impressions:

The mature student’s tale

I have always felt that the term “mature student” is vaguely uncomplimentary—

almost synonymous with “fuddy old fart” or “bearded hippy”. Personally

I have never considered myself particularly “mature” in comparison with my

year group, while others merely describe themselves as being slightly less

immature. Some of us have had previous jobs ranging from city slicker to

nurse or army officer, while others may have come straight from a previous

degree or are supporting a family. Whatever the difference in background one

common factor unites us all, we are convinced that medicine is now the career

for us. Deciding this a little later than most brings its own particular problems.

To start with, the interview tends to be rather different to that of a school

leaver. There are usually only three questions that the panel really want

answering. Firstly, why did you decide to study medicine now? Is it a realistic

decision, or just a diversion from a midlife crisis, do you know what the job

actually entails, and how can you assure them you will not change your mind

again? Secondly, “How do you think you will cope being so much older than

everybody else”, which I found rather patronising, but it is wise to have

thought of a suitable response. Thirdly—and most importantly—how will

LEARNING MEDICINE

16you finance yourself? No medical school wants to give a place to someone

who will subsequently drop out due to financial pressure.

Most mature medical students undoubtedly find that the financial burden

poses the biggest problem. While it is possible to finance yourself through

scholarships, charities, loans, and overdrafts, this takes a lot of time and

organisation. Most medical schools still want a financial guarantor in

addition. Many students get a part time job to ease the pressure but during a

heavily timetabled and examined medical course this can prove difficult.

Progression through to the clinical years brings even fewer opportunities for

work with unpredictable hours and scarce holidays. It is worth investigating

which medical schools and universities are more accepting of mature

students, and which have funds to help financially. Aside from the obvious

practical problems of having little money, coping with the financial divide

between yourself and old friends now earning can take some getting used to.

Once the financial issues have been hurdled, other worries surface. Fitting

in with school leavers may initially be viewed as a problem, but if you can

survive Freshers’ Week I can assure you it does get easier. Progressing

through the course the proportion of shared experience increases and the

initial age and experience gap no longer poses such a problem. One particular

advantage of the length of the medical course is that those in the final year

may be of a similar age to those entering as mature students, and due to the

wide range of clubs and societies offered by most universities there is ample

opportunity to meet people of all ages.

One advantage of being that little bit older is that it is much easier not to

feel you have to succumb to the peer group pressure so often prevalent in the

medical school environment. When faced with the tempting offer to stand

naked on a table and down a yard of ale, the excuse “I’ve got to get home to

the wife and kids” will usually suffice.

The attitude of some medical students to those older than themselves can

occasionally be somewhat disconcerting. A first year student was recently

heard to comment to a mature student in her year, “Isn’t it funny, you are in

our year, but when we come back for reunions, you will probably be dead.”

A variety of roles may be created by your new peer group for you to fit in to.

These can range from being initially seen as the “old freak” or “year swot” to

pseudo parent or agony aunt. These roles do tend to diminish over time, and

most mature students are viewed as an asset as they bring in a different range

of knowledge and experience. The importance of maintaining old friendships

and having an outlet away from medicine, however, cannot be overemphasised.

“Will I be able to cope with the work?” can obviously be a further worry.

A levels may seem a dim and distant memory, and the type of work or

learning most mature students have been previously doing is a far cry from

the vast amounts of memorising required by the medical course. There is no

doubt about it—studying medicine is a lot of work, with regular exams and a

full timetable. Most mature students do seem to have developed a better

notion of time management and efficient learning, however, and this, coupled

with a strong motivation to complete the course, can alleviate some of the

work pressure.

Being a clinical student learning on the wards brings its own particular

problems. The transition from having a respected job or being an instrumental

OPPORTUNITY AND REALITY

17part of a team to having no exact role perhaps presents more difficulties to a

mature student than to others. The unpleasant “teaching by humiliation”

method employed by some doctors may be particularly trying to mature

students, especially when (as has been known to happen) the person being so

patronising was in your little sister’s year at school. Being at the very bottom

of such an entrenched hierarchy can be wearing and frustrating. Overall,

however, most doctors involved in teaching are extremely supportive of

mature students, and a proportion feel all medical students should gain

outside experience before embarking on a medical career.

Progressing through the training the clinical aspects of the course become

more important and, for the majority of students, more enjoyable. Mature

students tend to find this especially true and are often in a position of

strength, being more confident and relaxed in their interactions with patients,

bringing skills and experience from previous careers. Personally I have found

this one of the greatest assets of being a mature student, finding emotional or

difficult situations easier to cope with than if I had come straight into

medicine from school.

The downside can be that fellow students and doctors can have a higher

expectation of your abilities and knowledge. While this may be true in some

aspects of communication, the learning curve for practical skills is just the

same as for others. Being a few years older does not necessarily mean you are

an instant pro at inserting a catheter.

Once you have realistically decided that medicine is the career for you,

possibly sat required A levels, got through the interview, and faced up to the

prospect of at least five years’ financial hardship, is it all worth it?

Being a mature student it is all the more important to make sure that the

decision to study medicine is not viewed idealistically. There are some

doctors who deeply regret the decision to go into the profession. One doctor,

who was a mature student, replied when asked, “It was the worst decision I

ever made. I’m permanently tired and just don’t have the time I would like

for myself or family anymore.”

Older students obviously often have different commitments and priorities

which their younger colleagues are yet to experience, such as children or a

mortgage. While life through medical school can be hard, with academic

stress and financial worry, difficulties do not end with qualification.

Becoming a doctor not only brings new opportunities but also a different way

of life. The line between work and personal life can become increasingly

blurred. Despite a more enlightened approach to junior doctors’ hours, the

time commitment is still immense. The work ethic is unlike that of any other

career. This means that inevitable sacrifices have to be made in one’s personal

life, and consideration as to how this will affect present or future partners and

children is important.

Having stated many of the difficulties, the advantages of being a mature

student are considerable. Medicine, perhaps more than any other profession,

requires a maturity of insight, both personally and in dealing with patients;

many situations are emotionally demanding and stressful; coping with added

academic pressure can be tiring and demoralising. A more mature approach

together with a greater certainty in your career choice is a definite asset.

LEARNING MEDICINE

18Maintaining friendships outside medicine means that when it all gets a bit too

much you can escape, and being offered a second chance at being a student

can mean you make far more of the opportunities offered to you than when

you first left school. Overall I have found medicine to be fascinating and

enjoyable. The career choices available once you are in the profession are

extremely varied so finding your niche should be possible. The combination

of human contact with academic interest is unlike that of any other career,

and the unique privilege of being so intimately involved in people’s lives never

fails to be exciting or interesting. It is possible and personally I feel it is worth

it … (but ask me again when I’m a junior doctor).

SE

Overseas applicants

Overseas students are in a competition of their own for reserved places,

amounting to 7·5% of the total national intake of medical students. About

1500 overseas students compete for about 330 places, giving them about

the same chance of a place as home students. The recent increases in

medical schools’ places, however, were a response to staffing problems in

the NHS, and so none of the new medical schools are able at present to

admit overseas students; this is currently under review. Students from the

European Union count as home students. Overseas students are liable for

full fees, amounting to a total of about £65 000 over five years. They will

also need about £50 000 for their living expenses. It is no longer possible

for someone from overseas to be classified as a home student by purchasing

secondary education at a British school, by nominating a “guardian” with

a United Kingdom address, or by buying a United Kingdom residence.

Nor are British expatriates working permanently abroad normally eligible

for home fee status.

Local education authorities (LEA) are responsible for finally determining

fee status; the guidelines state that students are able to pay fees at the home

rate only if they have been “ordinarily resident” in the United Kingdom or

in a member state of the European Union in the previous three years and

have not been resident during any part of that period wholly or mainly for

the purpose of receiving full time education. Exception is made for nationals

or their children who have not been ordinarily resident during that period

because of temporary employment abroad. Officially recognised refugees

and people granted asylum or exceptional leave to remain in the United

Kingdom are also treated as exceptions.

Overseas students are entitled to stay for four years and sometimes

longer after graduation to undertake their specialist postgraduate medical

education in the United Kingdom, in which capacity they make a welcome

contribution as junior doctors.

OPPORTUNITY AND REALITY

19Equal opportunities, equal difficulties?

Opportunity to enter medicine has, as far as can be judged, become equal

for those realistic about their qualifications. But everyone considering

becoming a doctor must look behind and beyond medical school to the

reality of whether a career in medicine is for them a pathway to fulfilment

or to frustration. The tension between the relative freedom of many careers

and the ties of medicine face men and women alike. But medicine is a

tougher career for many women than for most men. A few years ago we

received a letter from three students from St George’s Hospital Medical

School in London, indignant about the suggestion that the position of

women requires special consideration: “For a start, let’s bury the idea that

male and female students have different aspirations—we all wish to end up

well rounded human beings...” Sure, but it is not necessary to become a

doctor to do that, although medical education will have failed in part of its

purpose if all doctors are not “well rounded” individuals.

The difficulties particularly facing women doctors are both subtle and

unsubtle. The obvious are the dual responsibilities of family and career,

which most women do not wish to know about, consider, or even recognise

when they are medical students but which they begin to come to terms with

once the all consuming task of qualifying as a doctor has been achieved.

Opportunities for part time training and employment in many specialties

are limited. Career dice are loaded against those who patiently plod

through long years of part time training. Progress towards a training and a

career structure which would fully harness skills of (in future) at least half

the medical workforce is slow. The personal and national cost of failure to

use the skills of women doctors fully would be immense.

The potential disadvantages for women in postgraduate training can be

and often are overcome supremely well with good family support. Recent

changes in taxation allowances also mean better financial support for

working families through tax relief on childcare. Some specialties—such as

general practice, pathology, radiology, anaesthetics, and public health—can

readily be made flexible and compatible with other responsibilities.

The more subtle difficulties facing women include the feeling that more

is demanded of them as doctors because they are women. Not all women

agree but a woman doctor, Fran Reichenberg, wrote that:

Both patients and staff expect far more of female doctors. These expectations

arise from traditional female roles in society of mother, carer, soother of the

distressed …

She also believed that male doctors may get special treatment from the

team:

The perks of the male house officer who shows a clear interest in the female

staff include his ivs being drawn up and done, his results filed for him, his

blood forms filled out. Many telephone calls chasing results being done for

LEARNING MEDICINE

20him. … These differences amount to many extra hours’ work a week for the

female house officer and exacerbate her fatigue and low morale.

In our experience, special treatment can work both ways.

Women compete very effectively but sometimes against the odds. The

unsaid concern about the organisational and financial impact of maternity

leave seems to confer no overall disadvantage. Women may, however, suffer

disproportionately from the innate conservatism of consultant appointments

committees. Most members of appointments committees and most

remaining consultants in post are for historical reasons men. Having more

women on appointments committees is not necessarily the answer: on one

occasion the strongest opposition to taking gender into account in appointing

to an obstetric team serving an ethnic population with substantial preferences

for women doctors came from the only woman on the committee.

Many women still feel at a disadvantage, as Dr Anne Nicol, a consultant

pathologist, explained:

Unless we remove the glass ceiling, many top candidates for consultant posts

will fail to reach the top. Let’s face it, jobs go to the applicant wanted by the

consultants in post … [who] still see the ideal colleague as someone much like

themselves … you can almost hear them say “one has to be able to get on

with him—he has to be on your wave length” … tribalism among male

consultants is strong, pressure to be one of the herd intense; Tory voting,

middle class, privately educated, golf playing white males are the tribal group

most likely to succeed …

The common perception is that women don’t fit in, are difficult to work with

and can never be one of the tribe. A woman making a vocal stance on a topic

will find it is not long before someone comments on her hormonal balance or

time of month …

We can ensure that more women at least get their noses pressed against the

glass ceiling by creating more family friendly training packages, part time

posts and job shares.

Each aspiring entrant to medicine must come to terms with the length

and the nature of the training, the demands of the career, and the reality of

his or her own personality and ability. Add to this a strategic view of the

opportunity—open and equal on merit at the beginning, convoluted later

for several reasons, but destined to become more equal. Finally, the

professional responsibility of putting patients first is inescapable, often

uncomfortable, but fulfilling.

OPPORTUNITY AND REALITY

21REMEMBER

• Anyone with ability and aptitude stands a chance of admission to medical

school; background does not matter.

• Once academic achievement has been taken into account, social class,

age, having parents who are doctors, or the type of school you attended

will not affect your chances of admission.

• Being a woman gives a slight but statistically significant increase in your

chances.

• Mature students are welcomed by most medical schools but they often

have to overcome both financial and personal difficulties.

• Shorter courses (usually four years) are now available at an increasing

number of schools for graduates in science or health related subjects.

• Students with children will need good home support.

• About 7·5% of places at UK medical schools are reserved for overseas

students, their chance of admission is similar to home students.

LEARNING MEDICINE

223. Requirements for entry

Entry to medical school is academically the most competitive

moment in the student’s life. However,becoming a doctor

requires many more qualities than brain power,including

compassion,endurance,determination,communication skills,

enthusiasm,intellectual curiosity,balance,adaptability,integrity

and a sense of humour. All these are highly desirable attributes

but not absolute “requirements” for entry to medicine: few have

them all but a remarkable number of applicants have many.

Academic ability is an essential requirement for entry, and the ability to

pass examinations remains important throughout the course and the

subsequent years of postgraduate training. Less competitive than A levels,

but no less intense, were the traditional end of first and second year

examinations on the sciences underpinning medicine. New curriculums

that emphasise understanding and integration of knowledge rather than

“facts” are tested more by continuous assessment, a less destructive

process than a series of annual crises but not without a constantly recurring

academic tension. Professionally, the hardest exams are those for the higher

specialist diplomas of fellowship or membership of the medical Royal

Colleges, requiring a broad and solid grasp of the clinical skills, knowledge,

and, to an increasing extent, the attitudes appropriate to a specialist.

“Finals”—the examinations for the Bachelor of Medicine and Surgery

degree, the degree which acts as the basis for a provisional licence to

practise as a doctor, are largely a matter of hard slog, particularly in the

later years. They used to be taken as a big bang at the end of the course but

are now broken up at most universities over a period of about 18 months.

Broader requirements

Although all doctors need to be bright (not less perhaps than what it takes to

get three B grades at A level at first attempt), medicine needs a great deal

more than academic ability. With the headlong advance of science and

technology, it is no longer true to say that “the A level requirements select

people too academic for a career which needs compassion, endurance, and a

damn good memory rather than brains”, but those qualities certainly are still

needed. Compassion is easier to detect in someone who has already shown

practical concern for others, perhaps in voluntary, social, or medically related

work (such as helping with remedial teaching of younger and less able pupils

23at school or working in a local hospital or nursing home on one’s own

initiative rather than simply as a requirement for voluntary work at school).

It impresses most admissions tutors to see applicants whom, in their UCAS

form personal statements, can show a longer commitment to such work than

the odd day here or there, or perhaps a week of work experience organised

by school, as most applicants will have done this. This element of past

experience often forms popular subject matter for any interview panel, so

make sure you have something interesting to say about it and how it has

informed your decision to study medicine. The ability to communicate well,

to work in a team with a confident but not arrogant manner, and to be

prepared as need arises to lead and take responsibility is important too. A

sense of humour sprinkles oil on the wheels of communication.

Endurance, determination, and perseverance are part of the same

package. They feed on dual enthusiasm for science and for the healing art

of medicine. They are inspired by curiosity and enriched by sparks of

initiative and originality. Lord Moran (Dean of St Mary’s and Winston

Churchill’s doctor) once said, “The student who is not curious is surely no

student at all; he is already old, and his thoughts are borrowed thoughts.”

Becoming a doctor is not as formidable as it sounds, given good friends,

teachers, and opportunities to learn, but it requires solid organisation of

time and life and being self propelled. Desirable characteristics for medicine

LEARNING MEDICINE

24do not end here. Balance is needed, balance which comes from an

intellectual and personal life broader and deeper than academic success

alone. Professor David Greenfield, first Dean of the University of

Nottingham Medical School, referred to “balance of scientific and clinical

excellence, humanitarian and compassionate concern … balance of service

and learning, balance of current competence and future adaptability”. Other

interests—literary, musical, artistic, and sporting—encourage achievement,

provide recreation, and demand application, enthusiasm, and ability. They

can become great stabilisers and good points of communication with both

colleagues and patients. For a female accident and emergency consultant to

also be the medical officer for a well known football club (not that she is a

great player) is good for her and for her hospital.

Then there is the invaluable down to earth ability to organise and to cope;

a capable pair of hands and a reassuring attitude of “leave it to me and

I’ll sort it out”, taking huge weights off shoulders and loads off minds.

Sir George Pickering, onetime Regius Professor of Medicine at Oxford,

wrote, “Medicine is in some ways the most personal and responsible

profession: the patient entrusts his life and wellbeing to his doctor. Thus, the

character and personality of the doctor, his sympathy and understanding, his

sense of responsibility, his selflessness are as important as his scientific and

technical knowledge.” He also pointed out that a doctor neither needs to nor

should try to sort out every problem him or herself: “the best doctors know

to whom to turn for help”.

Many medical schools, when asked which qualities they regarded as

most important in applicants to medicine, highlighted the desirability of

a realistic understanding of what is demanded in the study of medicine

and in the subsequent career. Without this embryo insight many years of

unhappiness may lie ahead, however bright and however gifted the student.

Failure to understand the demands of the job and the limitations of the art

may explain why some doctors drop out of medicine.

Applicants from medical backgrounds have an advantage in this respect.

They have seen the effects of the career on their parents and families and have

had the opportunity to explore what their parent or parents do; they also have

relatively easy access to observing other medical specialties. All the more

regrettable if they have not taken this opportunity to find out what it’s all

about. For others, it is much more difficult. Most TV medical programmes

glamorise and trivialise and give little insight into the everyday undramatic life

of a doctor. The BBC TV series Doctors To Be and Doctors At Large, following

students through their years at St Mary’s, and now for ten years into their

careers, are an exception and offer useful insights, even if the structure of the

course itself has now changed. The rather embattled and disillusioned group

of new doctors at the end of the series has now been balanced by glimpses of

where they are now, ten years on, and reveals that they feel that it has all been

worth while. Because this is one of the most fundamental aspects of making

an informed personal decision Learning Medicine puts less emphasis on the

years in medical school and more on where they lead.

REQUIREMENTS FOR ENTRY

25Personal health requirements and disability

A doctor’s overriding responsibility is the safety and well-being of patients.

As such all applicants to medical school must have the potential to function

as a fully competent doctor and fulfil the rigorous demands of professional

fitness to practice as stated by the General Medical Council. All applicants

must therefore disclose any disabilities or medical conditions on the

application form as they may affect the ability to practise medicine. This

may be by placing patients at risk of infection, being unable to perform

necessary medical procedures, or by impairing your judgment. Similarly

applicants must also complete a declaration that they have no criminal

convictions or pending prosecutions, in line with national policies for staff

working in sensitive roles. In most circumstances a declaration does not

automatically disqualify an applicant but will allow the case to be decided

on its own merits.

The UK Department of Health has requirements for specific conditions,

which means that a student cannot be admitted with active tuberculosis or

if infectious with hepatitis B, until they can be proven to be no longer

infectious. In the case of hepatitis B, all prospective students must show

proof of adequate immunisation before commencing the course. You will

be asked for documentary proof when you arrive at medical school. Your

own GP can usually arrange for hepatitis B immunisation to be carried

out. The course and testing for a satisfactory response can take up to nine

months, so you should discuss this with your GP at the earliest

opportunity. If there is a failure to respond to the immunisation a student

will be expected to prove that they are not infectious. In these rare

circumstances, or where a student tests positive for any of the hepatitis

B antigens, they should discuss this with their GP and the admissions tutor

of their preferred school, as soon as possible.

There is no clear national policy as yet about candidates who are known

to be hepatitis C positive. However, this must be declared on the UCAS

form, and individual schools will advise in this rare instance. In any event,

failure to disclose any condition that puts patients at risk will result in

immediate dismissal from medical school.

All students are advised to be immunised against meningococcal

meningitis before starting at university.

Any disability should also be disclosed and will be dealt with by the

schools on a case by case basis. Dyslexia should also be disclosed on the

UCAS form and this will need to be supported by a formal statement from

a suitably qualified psychologist. Most medical schools will advise relevant

departments of the assistance which may be necessary for students with

dyslexia and will make some time allowances in written examinations, but

no concessions are made in clinical examinations.

Taking illegal drugs or abusing alcohol are also inconsistent with a

doctor’s professional responsibilities, both on patient safety grounds and

the need for personal integrity. Students who ignore their responsibilities to

LEARNING MEDICINE

26be utterly dependable in this regard put their place in medical school in

severe jeopardy.

Academic requirements

Although academic achievement is only the qualifying standard for

entering the real field of selection, like the Olympic qualifying standard is

to selection for the national team, it is overwhelmingly the strongest

element in selection. Unlike all the other desirable attributes of personality,

attitude, and interest examination results look deceptively objective.

Relatively objective they may be but they are still poor indicators of the

potential to become “a good doctor”—a product difficult to define, not

least because medicine is such a wide career that there may be many

different sorts of good doctors—but they all need the appropriate

knowledge, skills, and attitudes for effective medical practice and the ability

to use them competently.

Examination results at the age of 18 do not predict late developers nor

do they take account of differences in educational opportunity at school nor

of support for study at home. Results may also be upset by ill health on the

day; even minor illness or discomfort crucially timed may take the gloss off

the performance, a gloss which may make all the difference between a place

at medical school and no place at all. Having said that, however, those who

fail during the medical course are generally those with the poorest A level

results, and those who do best, especially in the early years with their

greater scientific content, are generally those with the highest. But there are

outstanding exceptions.

All medical schools set a minimum standard of at least ABB at A level

(Table 3.1). The actual achievement of entrants is very similar at all

universities whatever their target requirements, except Oxford and

Cambridge, where they are higher. Medical schools which set marginally

lower grades leave themselves the flexibility to make allowances for special

situations and to give due weight to outstanding non-academic attributes.

Most successful applicants to medical schools setting a lower minimum

substantially exceed their requirements. It is vital to realise that good

grades do not guarantee a place: far more applicants achieve the necessary

grades than can be given a place.

Chemistry or physical science is required by all universities for medicine.

They prefer this at A level, but practically all of the medical schools in the

United Kingdom are prepared to accept AS chemistry in place of A level.

Most are prepared to accept a combination of AS levels in place of another

science or maths A level. In practice AS levels are normally offered in

addition to three A levels and not in substitution for one. The detailed

requirements can be found in the UCAS Students Guide to Entry to Medicine

and should if in doubt be double checked with the medical school in

question. Many universities prefer two other science subjects at A level,

REQUIREMENTS FOR ENTRY

27taken from the group of physics (unless physical science is offered), biology,

and mathematics, but all are prepared to accept a good grade in an arts

subject in place of one, or in some medical schools, two science subjects.

Some medical schools do not accept maths and higher maths together as

two of the required three A level subjects. General studies A level is

generally not acceptable as one of the subjects.

No particular non-science subjects are favoured but knowledge based

rather than practical skills based subjects are generally preferred. It may be

difficult to compare grades in arts and science subjects, so a higher target

may be set for an arts subject for entry to medicine. Several universities

express a preference for biology over physics or maths. Chemistry and

biology are the foundations of medical science, especially if the

mathematical aspects of those subjects are included. But however useful it

is to be numerate in medicine, especially in research, students without a

LEARNING MEDICINE

28

Table 3.1—Typical grades required at first attempt for entry to medicine excluding

premedical, 1st MB, courses

Medical school Grades

Birmingham AAB

Brighton & Sussex ABB

Bristol AAB

Cambridge AAA

East Anglia AAB

Hull–York ABB

Leeds AAB

Leicester–Warwick AAB

Liverpool ABB

Imperial College, London ABB

King’s College, London (Guys, King’s, St Thomas’) ABB

Queen Mary’s, London (Bart’s & Royal London) ABB

St George’s London ABB

University College, London (Royal Free & University College) ABB

Manchester  AAB

Newcastle AAB

Nottingham AAB

Oxford AAA

Peninsula AAB

Sheffield ABB

Southampton AAB

Aberdeen ABB

Dundee ABB

Edinburgh AAB

Glasgow AAB

St Andrew’s ABB

University of Wales College of Medicine, Cardiff AAB

Queen’s University, Belfast AAB

All medical schools are prepared to accept one and sometimes more than one non-science

or maths A level.

See medical school prospectuses or websites for more details if non A level entrance

qualifications will be offered.good knowledge of biology find themselves handicapped at least in the first

year of the course by their lack of understanding of cell and organ function

and its terminology. They also generally have greater difficulty in

expressing themselves in writing, especially if their first language is not

English. Failure in the first two years of the medical course is more

common in those who did not take biology at A level. All universities

require good grades in science and mathematics at GCSE level if not

offered at A level, together with English language.

The relative popularity with applicants of mathematics over biology does

not indicate changed perception of the value of mathematics for medicine

but reflects the general usefulness of maths for entry to alternative science

courses. It may also be because good mathematicians (or average

mathematicians with good teachers) can expect higher grades in mathematics

than in the more descriptive subject of biology. A few applicants gain

excellent grades at A level in four subjects—for example, chemistry, physics,

biology, and mathematics or the less appropriate combination for medicine

of chemistry, physics or biology, mathematics, and higher mathematics. It is

a better strategy for admission to achieve three good grades than four

indifferent ones.

Scottish Highers are the usual entry qualification offered by Scottish

applicants, most of whom apply to study at Scottish medical schools. Scottish

qualifications are accepted by medical schools in England, Wales, and

Northern Ireland. Most have hitherto required a good pass in the certificate

of sixth year studies (CSYS), but with the introduction of new Scottish

Highers and Advanced Highers the CSYS has disappeared. The Scottish

academic tests are accompanied by formal testing of core study skills needed

for understanding a university course: personal effectiveness and problem

solving, communication, numeracy, and information technology.

Both the International Baccalaureate and the European Baccalaureate

are acceptable entry qualifications at United Kingdom medical schools but

only a handful of entrants come by that route. Requirements vary at

different schools and can be found in the UCAS publication. Even fewer

students enter medicine with BTEC/SCOT BTEC National Diploma

Certificate but it is a possible route of entry. The Advanced General

National Vocational Qualification (GNVQ) or General Scottish Vocational

Qualification (GSVQ) are not generally accepted, although some

universities are prepared to consider it on an individual basis. It is likely

that a distinction would be required, along with a high grade in GCE A

level, probably in chemistry. Over half the medical schools in the UK will

accept as an entry qualification the Access to Medicine Certificate from the

College of West Anglia in King’s Lynn (www.col-westanglia.ac.uk). This is

a one year full time course in physics, chemistry, and biology designed for

potential applicants to medical schools with good academic backgrounds or

professional qualifications, such as in nursing.

REQUIREMENTS FOR ENTRY

29Graduate students

Most medical schools will accept applications from graduates for the

conventional course. A first or upper second class honours degree is usually

required, most commonly in a science or health related subject. Unless

their degree includes chemistry or biochemistry, an A level in chemistry is

usually required in addition. It may be acceptable for a graduate to sit the

GAMSAT (Graduate Australian Medical School Admissions Test), a

scientific aptitude test which is usually held once a year, for example at

St George’s Hospital Medical School. A good score in this, in addition to

their degree and personal characteristics may be acceptable. Students

wishing to pursue this method of entry are best advised to contact their

preferred schools early to discuss this option. In addition a growing number

of medical schools have started—or are planning to introduce—shortened

(four year) medical courses for some graduates (see page 40). These

courses generally condense the early years and basic science component of

the course. Similarly those schools with six year courses that include an

intercalated BSc or equivalent, such as Oxford, Imperial College, and

Royal Free and University College Medical School are introducing shorter

(five year) courses if you already have a similar degree. If the degree

includes chemistry or biochemistry, it may be accepted in lieu of A level

chemistry, otherwise this is likely to be required in addition. Graduate

entrants are not normally exempted from any parts of the medical course

at most medical schools but they are in some. 

How about resits?

What about those who take longer before a first attempt or retake

examinations after further study, having failed to achieve their grade target

at first attempt? Clearly, there are perfectly understandable reasons for

poor performance at first attempt, such as illness, bereavement, and

multiple change of school, which most medical schools are prepared to take

into account, at least if they had judged the candidate worthy of an offer in

the first place. Medical schools which did not give an offer first time round

are unlikely to make an offer at second attempt. Apart from these

exceptions, most medical schools are not normally prepared to consider

applicants who failed to obtain high grades at first attempt.

Three points might be made about applicants who, for no good reason,

perform below target at first attempt. Firstly, a modest polishing of grades

confers little additional useful knowledge and gives no promise of improved

potential for further development, especially when only one or two subjects

are retaken. The less there is to do the better it should be done, and the

medical course itself requires the ability to keep several subjects on the

boil simultaneously. On the other hand, a dramatic improvement (unless

LEARNING MEDICINE

30achieved by highly professional cramming) may indicate late development

or reveal desirable and necessary qualities of determination and application.

Secondly, age should be taken into account. The usual age for taking A level

is 18, and some much younger applicants may simply have been taken

through school too fast. Thirdly, those unlikely to achieve ABB at GCE A

level (or equivalent) at first attempt are probably unwise to be thinking of

medicine, unless their non-academic credentials are very strong indeed.

Even then, it is likely to be an uphill battle. Read the prospectus carefully

between the lines to try to discover those medical schools most likely to give

weight to broader achievements.

Survival ability

So much for what we think medical schools are, or should be, looking for.

But what qualities are needed for survival? We asked Susan Spindler,

producer of Doctors To Be, what in her opinion, based on several years in

medical school and hospital making the TV series, makes a good medical

student. This is what she said:

Medical school is very hard work and great fun. There will be a vast array of

things to do in your free time coupled with a syllabus that could have you

working day and night for years. You need to be the sort of person who

can keep both opportunities and work requirements in perspective. There is

a lot of drinking and a lot of sport. In many universities the burden of the

curriculum and the emotional pressure of the course means that medics tend

to stick together and intense, but rather narrow, friendships can result. Try

to make and maintain friendships with non-medics. Many medical schools

aim to select gregarious, confident characters who have experience of facing

and overcoming challenges and leading others. It certainly helps if you fit this

mould—but there are many successful exceptions. You’ll get the most out of

medical school if you are impelled by some sort of desire to help others and

blessed with boundless curiosity. You’ll need the maturity and memory to

handle a large volume of sometimes tedious learning; the ability to get on

with people from all walks of life and a genuine interest in them; and

sufficient humility to cope cheerfully with being at the bottom of the medical

hierarchy for five years. It helps if you are good at forging strong and

sustaining friendships—you’ll need them when times get hard—and if you

have some sort of moral and ethical value system that enables you to cope

with the accelerated experience of life’s extremes (birth, death, pain, suicide,

suffering) that you will get during medical school.

REQUIREMENTS FOR ENTRY

31REMEMBER

• Academic ability is not the only quality needed to secure a place at

medical school.

• Broader attributes, such as compassion, endurance, determination,

communication skills, enthusiasm, intellectual curiosity, balance,

adaptability, integrity and a sense of humour are also needed.

• There are national guidelines regarding health and personal requirements

to which all applicants must adhere. Failure to disclose information

which may put patients at risk will result in losing a place at medical

school.

• UK universities require ABB or higher at A level at first attempt, but this

alone does not guarantee admission.

• A level chemistry (or physical science) is normally required but practically

all of the medical schools will accept AS chemistry in its place. Biology is

becoming the next preferred subject. All medical schools will accept at

least one non-science A level.

• Scottish Highers and European/International Baccalaureate examinations

are accepted at UK universities.

• Entry requirements for graduate applicants are more flexible, and options

exist for some graduates to apply for shortened courses in some schools.

• Applicants who are resitting A levels will usually only be considered in

special circumstances and should expect to be given higher entry

requirements.

LEARNING MEDICINE

324. Choosing a medical

school

The attitude that “beggars can’t be choosers” is not only

pessimistic but wrong. If,after serious consideration,you have

decided that medicine is the right career for you and you are the

right person for medicine,then the next step is to find a place at

which to study where you can be happy and successful. This

chapter is designed to help guide you into choosing the right

schools to consider flirting with,rather than necessarily ending

up (metaphorically speaking,of course) in bed with.

Walk into any medical school in the country and ask a bunch of the

students which is the best medical school in the country and you will

receive an almost universal shout of “This one, of course!” The general

public’s typical image of medical students is one of a group of young people

who live life to the full, work hard, and play harder; hotheaded youngsters

who can be excused their puerile pranks and mischievous misdemeanors,

because, “Well, they must have a release from all that pressure, mustn’t

33they”. While this image should be treated with the same caution that is

required with any stereotype, it none the less contains grains of truth.

When you further consider the outstanding abilities of many medical

students in their chosen extracurricular interests, it will come as no surprise

to find that medical schools are full of students letting their hair down,

getting involved in the things they enjoy, having a good time, and still doing

enough work to pass those dreaded exams and assessments—or at least

most of the time anyway. The only dilemma you have is to find which of

these centres of social excitement and intellectual challenge best suits your

particular interests and nature. Like all the best decisions in life the only

way to find out is to do a bit of groundwork and research, plan out the lay

of the land, then follow your instincts and go for it.

Medical schools vary greatly in the size of their yearly intake (Table 4.1).

It is difficult to offer more precise advice about discovering the “spirit” or

“identity” of an institution. However hard it may be to define, all the

LEARNING MEDICINE

34

Table 4.1—Predicted size of entry to first year of medicine in UK medical schools

for 2003

Over 350

Birmingham

Leicester–Warwick

King’s (Guy’s, King’s and St Thomas’)*

Over 300

Liverpool

Imperial

Queen Mary’s (Bart’s and Royal London)

UCL (Royal Free and University College)

Manchester*

Newcastle*

Nottingham

Over 200

Bristol*

Cambridge

Leeds

St George’s

Sheffield*

Edinburgh*

Glasgow

UWCM, Cardiff*

150–200

Oxford

Peninsula

Southampton

Aberdeen

Dundee*

Queen’s, Belfast*

Less than 150

Brighton–Sussex

Hull–York

East Anglia

St Andrew’s

*Indicates that a premedical (1st MB) course is available.medical schools possess a uniqueness of which they are rightly proud. Of

course some schools wear their hearts more on their sleeves than others or

have a more easily identifiable image, but often the traditional identities are

past memories, especially in London, where medical schools’ identities

have changed considerably in the past decade, particularly with recent

amalgamations between medical schools and their mergers with larger

multidisciplinary university colleges.

In days gone by a choice had to be made between a hospital based medical

school, such as several in London, or an initially firmly multifaculty university

environment, with a much broader student community with greater diversity

of personalities, outlooks, and opportunities. This distinction has largely now

disappeared; soon only the course at St George’s in London will be hospital

and medical school based throughout.

Accommodation may play an important part in choice, as some colleges

house all the medics in one hall of residence while others spread them out,

so you may end up living on a corridor with a lawyer, a historian, a musician,

a dentist, a physicist, and someone who seems to sleep all day and smoke

funny smelling tobacco who is allegedly doing “Media Studies and Ancient

Icelandic”.

Many find this kind of variety gives them exactly what they came to

university for and would find spending all their work and play time with

people on the same course socially stifling. While it is essentially a matter

of personal preference, it is also worth noting that both have pros and

cons—for example, when the workload is heavy it may be easier to knuckle

down if everyone around you is doing likewise. Conversely when a bunch

of medics get together they inevitably talk medicine, and, although

recounting tales and anecdotes can amuse many a dinner party it may well

breed narrow individuals with a social circle limited only to other medics.

Choosing a campus site or a city site where you live side by side with the

community your hospital serves may also have a different appeal.

Increasing diversity is being introduced to the design of the curriculum

and how it is delivered. The traditional method of spending two or three

years studying the basic sciences in the isolation of the medical school and

never seeing a patient until you embarked on the clinical part of the course

has all but disappeared. The teaching of subjects is generally much more

integrated both between the different departments and between clinical

and preclinical aspects. Even so, some curriculums are predominantly

“systems based” and others “clinical problem based”. Much more

emphasis is being placed in all courses on clinical relevance, self directed

learning and problem solving rather than memorising facts given in didactic

lectures. There is substantial variation in the extent to which these changes

have evolved and in many respects there is greater choice between courses

than ever before. Diversity of approach is a strength of the United

Kingdom system: “You pay your money and take your choice”.

The courses at Oxford, Cambridge, and St Andrews remain more

traditional in structure if not in subject matter and teaching methods.

CHOOSING A MEDICAL SCHOOL

35These courses maintain a distinct separation between the more scientific

and the more clinical, although they have moved away to some extent from

separate subjects towards systems based teaching of the sciences and have

introduced reference to clinical relevance; their philosophy is that it is

still valid to study in depth the sciences related to medicine (anatomy,

physiology, biochemistry, pharmacology, and pathology) as disciplines

important in their own right, primarily as tools of intellectual development

and scientific education rather than of vocational equipment. Cambridge

and Oxford, however, have also introduced a four year course for graduate

students, which combines the intellectual rigour of the traditional course

with community-based clinical insights from the outset.

At Oxford all the basic sciences required for the professional

qualifications are covered in the intensive first five terms’ work and are then

examined in the first BM. All students then take in their remaining four

terms the honours school in physiology, a course much wider than its name

suggests with options to choose from all the basic medical sciences,

including pathology and psychology.

Cambridge adopts a more flexible approach. All the essential

components of the medical sciences course are covered in two years. The

third year is spent studying in depth one of a number of subjects, the choice

being determined partly by whether or not the student is going on to

continue a conventional clinical course at another university, usually, but

not exclusively, London or Oxford, or continue on to the shorter

Cambridge clinical course. For students remaining in Cambridge for

clinical studies, the third year choices are limited to subjects approved by

the GMC as “a year of medical study”; apart from the normal basic

sciences these include subjects such as anthropology, history of medicine,

social and political sciences, and zoology. Those moving on to a

conventional clinical course have the attractive opportunity to spend their

third year reading for a part II in any subject—law, music, or whatever

takes their fancy—provided they have a suitable educational background

and their local education authority is sufficiently inspired to support them.

The three years lead to an honours BA.

At St Andrews the students spend three years studying for an ordinary

degree or four years for an honours degree in medical sciences. Although

strongly science based, clinical relevance is emphasised and some clinical

insights are given, mainly in a community setting. Most St Andrews

graduates go on to clinical studies at Manchester University, but a few go

to other universities.

With the recent expansion in medical school places, the government has

approved four completely new undergraduate medical schools. The first

two of these—Peninsula Medical School (Universities of Exeter and

Plymouth) and the University of East Anglia—started their first students

on a standard five year course in Autumn 2002. Two further schools,

Hull–York Medical School and Brighton and Sussex Medical School, will

have their first students in Autumn 2003.

LEARNING MEDICINE

36This then brings us back to those important but less tangible attractions

of each medical school—the spirit and identity of the place. Unless you are

an aficionado of architecture and simply could not concentrate unless in a

neoclassical style lecture theatre or an art deco dissecting room, then what

gives a place its unique character are the people who inhabit it; the

biomedical science teachers, the hospital consultants who involve

themselves in student life, the mad old dear who runs the canteen, the

porter who knows everyone’s name and most people’s business, the all

important dean and admissions tutor, and not least by any means the

students themselves. It is the ever changing student body that above all else

shapes the identity of a school and certainly gives it spirit and expresses its

ever changing nature in a dynamic spirit. Just listen to any final year

student bemoaning how the old place has changed and how the new first

year just aren’t the same as the rest of us and how what used to be like a

rugby academy is more like a ballet school these days. What these oldies

don’t realise is that exactly the same was said five years ago when they were

the freshers and five years before that and so on and so on.

The most obvious expression of this spirit is the plethora of clubs and

societies that grow up in every medical school. Whatever your fancy it is

worth investigating what facilities could be on offer. There is little point in

being determined to gain entry to a medical school to pursue your hobby

in climbing mountains if there is no tradition of such activities at that

college, especially when another equally good college in other respects has

a climbing wall on campus, a mountaineering hut in the Lake District, and

an alpine club which goes on annual trips to Switzerland.

CHOOSING A MEDICAL SCHOOL

37Location

Most individuals will have some idea of what sort of medical school they

are looking for. The first criterion is usually a suitable geographical

location. Some prefer to stay nearer home, some cannot move away fast

enough. Some want to be up north or down south, out in the sticks or right

in the smoke. Almost all medical schools are in large cities within the

academic centres of research and teaching and where patients of endless

variety are concentrated. Most medical schools, however, are making

increasing use of associated district hospitals and primary care centres,

such as general practice surgeries, in surrounding suburban and rural areas.

This allows for a broader and more balanced experience and exposure to

different medical conditions and practices.

If you wish to stay near home it is worth remembering that medical school

accommodation may be limited, and consequently you may be given low

priority and find yourself having to live at home. The downside is that those

not living in halls of residence with their new friends and having to commute

to and from home find it more difficult to immerse themselves in student life

and may end up feeling isolated and unfulfilled by university life.

Finances

An increasingly important issue related to accommodation and other living

costs which has to be considered is student debt. Surveys over the past

10 years have shown a consistent and alarming rise in the levels of debt for

all students, in both the government student loans scheme and in overdrafts

and loans from banks. The situation is worse for medical students because

of the length of the course, the shorter vacations in the later years, and the

intensive nature of the training and exams limiting opportunities for part

time casual work. Other factors such as expensive books and equipment and

the need to dress appropriately also add to the cost; turning up to the

professor’s clinic attired in smelly old trainers, ragged jeans, and an “I love

Britney” T-shirt is hardly portraying a professional image.

The one advantage that medical students do have over many other

students is that when they qualify they are pretty certain of falling into

secure and reasonably well paid jobs. Still, seeing a large chunk of your

hard earned first pay cheque disappear into the repayments of your several

thousand pound debt is not a pleasant feeling, especially when the shackles

of debt can last for several years after you leave medical school. The size of

individuals’ debts at the end of their time at medical school can vary

enormously, depending on personal circumstances, but it is now not

uncommon for students to owe at least £10 000, and in many cases

considerably more. For overseas students who do not qualify for student

loans and who have to pay full tuition fees, most schools expect proof of

the ability not only to pay the fees but also of resources to live on during

their time at medical school.

LEARNING MEDICINE

38For mature students, particularly graduates, who may not qualify for the

usual support from their local council, the Departments of Health for

England and Wales now have a bursary scheme to support the last three

years of training. The amounts which will be paid vary according to the

student’s individual case, for instance if they have children to support or

other income sources. More information can be obtained by reading

Financial Help for Healthcare Students (5th edition) (which is available

online at www.doh.gov.uk/hcsmain.htm) or by contacting NHS Careers

(tel 0845 6060655).

It would be sensible then to consider that in choosing your medical school

some areas are obviously more expensive to live in than others. It should

not, however, completely put you off these areas because many students in

London or Edinburgh, for instance, believe that the advantages they have of

being in such a place are well worth the extra expense. It is therefore worth

finding out about the cost and availability of accommodation and general

living expenses at any school that you are keen on.

Range of entrance requirements

Choice of medical school must be guided by a realistic expectation of the

chances of achieving its basic entrance requirements. This does not just

mean will you reach the right grades, all of which are between ABB and

AAA for A levels but, more importantly, have you done acceptable

subjects, and acceptable exams (see pp. 27–29).

Overseas students from outside the European Union should check

with medical authorities in their own country which medical schools will

provide them with a qualification that will be recognised at home, as not all

CHOOSING A MEDICAL SCHOOL

39LEARNING MEDICINE

40

United Kingdom medical degrees may be acceptable. Overseas students

should check the quota allowed for each school and whether any particular

criteria are used in selecting applicants—for example, if priority is given

to students from the developing world or countries with historic links to

one school or another or to students without a medical school in their

own country.

A gap year?

Most schools now encourage students to take a gap year if they want to,

although it is not a requirement. It is important however to follow some

basic ground rules. Firstly, if you are planning a gap year, ensure you mark

your UCAS form for deferred entry. Although you can apply for this

retrospectively, it is much more likely that schools will agree to your request

if they know about it as early as possible. Secondly, have some firm plans

of what you want to do in your year out and why. It is something you

should write—albeit briefly—in your personal statement and is a common

topic for questioning in an interview. Your year out does not need to be

spent doing anything medical, but you may want it to be, nor does it always

have to involve travelling to the four corners of the earth. Finally, it is worth

remembering that five or six years at medical school for most people means

a considerable financial debt. So if you can spend some time earning some

money, it will certainly come in useful; whatever you do, do not start your

course already burdened with a large overdraft and credit card bills. Most

of all, enjoy your gap year; it will give you lots of experiences you will never

forget and be a great preparation for life as a student.

Mature and graduate students

A considerable number of graduates and other mature students decide

medicine is for them. UCAS uses a definition of being 21 years of age or over

as being “mature” for the basis of medical school applications. Trying to find

a medical school presents them with many of the same challenges and

choices that face school leavers, but with added problems on top. Family or

personal commitments may limit the choice of geographical location of a

school. Financial commitments such as mortgages and reduced income will

also affect mature students’ choices. These factors, however, must be set

against the government’s commitment to attracting medical students from

more diverse educational and socioeconomic backgrounds, and the recent

rapid expansion in available places for this purpose. In addition an increasing

number of medical schools are introducing shortened courses for students

with science or healthcare related degrees. In the next few years, many

medical schools are planning such moves although the numbers of availableplaces and the precise nature of graduates they are designed for will vary from

school to school.

Practically all schools are happy to consider applications from mature

students, but it is fair to say that successful applicants over 30 are unusual—

though there are some notable exceptions—and medical students over 40

are very rare. Schools tend not to have specific quotas but will judge each

case on merit, although in the past mature students have counted for about

10 per cent on conventional courses. Some schools have better records

of admitting mature students than others, and some actually encourage

such applications in their prospectus (for example Leeds, Manchester,

Southampton, St George’s, and Guy’s, King’s & St Thomas’).

The schools which currently offer shortened course for graduates (usually,

but not exclusively, in life science or related subjects) include Birmingham,

Dundee, Leicester–Warwick, Newcastle, St George’s, Oxford, and Cambridge.

Bart’s and the Royal London and Cardiff currently have shortened courses for

dental graduates who wish to pursue maxillo-facial surgery.

Several other schools are planning similar courses for entry in Autumn

2003 or 2004 including Aberdeen, Liverpool, Nottingham, Imperial

College, Royal Free and University College, Southampton, and University

of Wales (joint venture between Cardiff and Swansea). It is worth checking

up-to-date details with these schools nearer the time for application as they

are changing all the time and some are still awaiting formal approval of their

courses and funding arrangements. Also the numbers of available places

vary from school to school and year to year, as do their selection criteria and

the precise design of their curriculum. For example, at Cambridge, arts

graduates are particularly encouraged in the expectation that they may bring

a different perspective and that through the college system they will receive

the necessary academic and pastoral support. Three Cambridge colleges are

sharing the responsibility for these students: Hughes Hall, Lucy Cavendish

(women only), and Wolfson. Arts graduates are expected to have acquired

basic science knowledge, whether through A levels or an approved

foundation course. St George’s requires satisfactory performance in a

professionally designed written entrance exam testing basic knowledge,

reasoning skills, and communication. 

This variety is increasing choices for prospective medical students, and

means you will need to shop around to find what suits you best.

Interview or no interview

If you have a fear of interviews or an objection to being selected on the

basis of an interview then there are schools which still do not interview

(Table 4.2), despite the trend towards more schools adopting the interview

as a useful adjunct to the confidential reference, the academic record, and

the student’s own comments on the UCAS form.

CHOOSING A MEDICAL SCHOOL

41Visits and open days

In summary, there are numerous factors which prospective students should

take into consideration when deciding which medical schools to apply to,

some relevant to all students and some specific to special cases. The most

important advice is to visit as many schools as possible, take in the general

feel of the place, look at the accommodation and facilities, explore the local

area, and especially take time to talk to the current students, most of whom

will, of course, be biased in favour of their school but who will at least be

able to enthuse about the good points and answer your questions. Open

days and sixth form conferences provide a more formal opportunity to do

this. Later, a visit for interview may reinforce first impressions. A little

careful groundwork can not only improve your chances of obtaining a place

at a medical school but also help you to ensure that that place is at the right

school in which to spend some of the best years of your life.

LEARNING MEDICINE

42

Table 4.2—Interviewing policies of United Kingdom medical schools according to

whether or not they normally interview shortlisted applicants

Medical school Interviews

Birmingham Yes

Brighton and Sussex Yes

Bristol Yes

Cambridge Yes

East Anglia Yes

Hull–York Yes

Leeds Yes

Leicester–Warwick Yes

Liverpool Yes

Imperial College, London Yes

King’s College, London (Guy’s, King’s and

St Thomas’) Yes

Queen Mary and Westfield College, London

(Bart’s and Royal London) Yes

St George’s, London Yes

University College, London (Royal Free and

University College) Yes

Manchester  Yes

Newcastle Yes

Nottingham Yes

Oxford Yes

Peninsula Yes

Sheffield Yes

Southampton No, only interview non-school leavers

Aberdeen Yes, but not in all cases

Dundee Yes

Edinburgh No, only interview non-school leavers

Glasgow Yes

St Andrew’s No

University of Wales, Cardiff Yes

Queen’s University, Belfast NoREMEMBER

• Medical schools vary greatly in size, location and style.

• Most, but not all, medical schools are in large cities, but often use

hospitals and health centres in nearby towns and villages for teaching

attachments.

• Cost of living can vary considerably between different parts of the

country.

• Availability and quality of accommodation and leisure facilities should be

considered.

• Living at home costs less, but most students prefer to move away from

home and widen their experience.

• Courses are all giving increasing emphasis to clinical relevance and

experience in the early years, but some have more than others.

• Only one school—St George’s—is entirely hospital campus based

throughout.

• Check up on the medical school’s attitude to overseas students and

mature applicants if relevant to you.

• Many opportunities now exist for graduates to apply for shortened

courses.

• Most importantly do your homework—read the prospectuses (most

universities publish an official one and an “alternative prospectus”

written by students), read the online prospectus or course outline and

selection criteria on the school’s website, attend open days, careers fairs

or ring medical schools to arrange to look round—most will be happy to

oblige—you can get a feel for the place, check out the facilities, and you

will be able to ask questions of students already there.

CHOOSING A MEDICAL SCHOOL

4344

5. Application and selection

The whole emphasis of this book is to aid and encourage

potential medical students to examine properly the career they

are considering. This chapter deals in more detail with some of

the practical “nuts and bolts” of the process of applying to and

being selected by a medical school. All too often careers advice

concentrates too much on these practicalities,implying the only

criteria for choosing future doctors are whether they can fill out

an impressive application form and get themselves selected.This

detracts from the more important process of your addressing

medicine’s suitability as a career for you,and your suitability to

be a doctor. Only after giving this serious consideration should

you consider the details of application and selection set out in

this chapter.

Unfortunately, the qualities which count for most in medicine are not

precisely measurable. The measurable—examination performance at

school—neither necessarily relates to these qualities nor guarantees

intellectual or practical potential. Stewart Wolfe, an American physician,

was right to ask:

Are the clearly specified and hence readily defensible criteria those most likely

to yield a wise and cultivated doctor—a person capable of dealing with

uncertainty, of compassionate understanding and wise judgment? Can an

ideal physician be expected from an intellectual forme fuste who has spent his

college years only learning the “right answers”?

Furthermore, there is no acceptable objective measure of the quality of

the doctor against which to test the validity of selection decisions. In this

sea of uncertainty it is not surprising that selection processes are open to

criticism. None the less, few patients would choose a doctor without

meeting him or her first and a strong argument can be made for discovering

the people behind their UCAS forms, if only briefly. Also, many applicants

think that they should have a opportunity to put their own case for

becoming a doctor.

Selection for interview (and at some schools for offer without interview)

is made on the strength of an application submitted through UCAS. An

application completed partly by the applicant and partly by a referee,usually the head or a member of the school staff, who submits a

confidential reference.

Altogether, about 12 000 home and European Union applicants compete

for over 6000 (soon to be 7000) places to read medicine at United

Kingdom universities, together with about 1500 overseas students who

compete for about 330 places. Women comprise over half of all applicants

and entrants. Some of the new places are on new accelerated courses for

graduates (see p. 40).

It is worth completing the UCAS form accurately and legibly. Deans and

admission tutors who have to scan a thousand or two application forms

(which they receive reduced in size from the original application) simply do

not have time to spend deciphering illegible handwriting. A legible, even

stylish, presentation creates a good impression from the start.

Personal details

The first section of the UCAS form presents the personal details of the

applicant, including age on 30 September of the coming academic year.

Many applicants give instead their current age and at a glance seem to fall

below the minimum age for entry at some medical schools or to be so

young that older applicants might reasonably be given priority over them.

True, the date of birth is also requested, but the quickly scanning eye may

not pick up the discrepancy.

The list of schools attended by an applicant is often a useful guide to the

educational opportunity received. More ability and determination are needed

to emerge as a serious candidate for medicine from an unselective school with

APPLICATION AND SELECTION

452000 pupils, of whom only 10–15 normally enter university each year, than

from a selective school for which university entry is the norm.

Choices

Applicants are not expected to give all their course choices to medicine. Six

university courses can be nominated on UCAS forms, and the medical

schools have requested that applicants should limit the number of

applications for medicine to four. The remaining choices can be used for

an alternative course without prejudice to the applications for medicine.

You should remember, however, that if a backup offer for a non-medical

course is accepted and the candidate fails to get the grades for medical

school but does sufficiently well for the backup then that offer has to be

accepted, and it is not possible to enter clearing for medicine. The only

alternative is to withdraw from university entry in that year and to apply

again the following year.

Other information

Examination results should be clearly listed by year. It is sensible to list first

those subjects immediately relevant to the science requirements for

medicine and those subjects needed for university matriculation, usually

English language and mathematics. All attempts at examinations should be

entered and clearly separated. The date and number of A level or degree

examinations yet to be taken complete the picture.

While it probably never pays to try to amuse on an application form it is

worth being interesting. Your personal statement presents an opportunity

to catch the eye of a tired admissions dean because medicine demands so

much more than academic ability, so include mention of your outside

interests and experiences. John Todd, a consultant physician, observed

from his own experience that:

The value of the physician is derived far more from what may be called his

general qualities than from his special knowledge … such qualities as good

judgment, the ability to see a patient as a whole, the ability to see all aspects

of a problem in the right perspective and the ability to weigh up evidence are

far more important than the detailed knowledge of some rare syndrome.

Small details, such as the information that an applicant spends his free

moments delivering newspapers, assisting in the village shop, and acting as

“pall-bearer and coffin-carrier to the local undertaker” converts a cipher

into a person. None of those particular activities may be immediately

relevant to future medical practice but at least they show initiative. Other

activities, such as hobbies, music, drama, and sport, indicate a willingness

and ability to acquire intellectual and practical skills and to participate,

characteristics useful in life in general but also to a medical school which

needs its own cultural life to divert tired minds and to develop full

personalities during a long course of training.

LEARNING MEDICINE

46Some applicants offer a remarkably wide variety of accomplishments,

such as the boy who declared in his UCAS form: “I play various types of

music, including jazz, Irish traditional, orchestral and military band, on

trombone, fiddle, tin whistle, mandolin, and bodhran. … ” If Irish music

be the food of medicine, play on. But that was not all, for he continued:

“I also enjoy boxing and I have a brown belt (judo). My more social

pastimes include ballroom dancing, photography, driving and motor

cycling.” Would this young man have time for medicine?

It is not sensible to enter every peripheral interest and pastime lest it

appears, as indeed may be so, that many of these activities are superficial.

It is also unwise for an applicant to enter any interest that he or she would

be unable to discuss intelligently at interview.

The applicant’s own account of interests and the confidential report (for

which a whole page is available) sometimes bring to life the different sides

of an applicant’s character. For example, one young man professed “a great

interest in music” and confessed that he was “lead vocalist in a rowdy pop

group” while his headmaster reported that he was “fairly quiet in lessons …

science and medicine afford him good motivation … his choice of career

suits him well. There is no doubt that he has the ability and temperament

successfully to follow his calling”. All in all this interplay of information is

useful, for medicine is a suitable profession for multifaceted characters.

The confidential report is always important and is sometimes crucial.

Most teachers take great care to give a balanced, realistic assessment of

progress and potential in these confidential reports. Readers of UCAS

forms quickly discover the few schools pupilled entirely by angels.

Cautionary nuances are more commonly conveyed by what is omitted than

by what is said, but a few heads are sufficiently outspoken to write from the

hip in appropriate circumstances. Euphemisms may or may not be

translated such as: “Economy of effort and calm optimism have been the

hall mark of his academic process. Put another way, his teachers used to

complain of idleness and lack of interest.” Others indicate that they are

attempting to get the candidate to come to terms with reality. For example:

“We have explained to him that you are not in the business to supply fairy

tale endings to touching UCAS references and that you will judge him on

his merits.”

It sounded as if that candidate was likely to come to the same fate as the

would be officer cadet rejected from Sandhurst with the explanation that

“he sets himself extremely low standards—unfortunately he totally fails to

live up to them”. Not that every head gets it right, like the one whose pen

slipped in writing, “Ian also has the distinction of being something of an

expert in breeding erotic forms of rabbits”.

Fair but frank confidential references are an essential part of an

acceptable selection process. The confidential report usually includes a

prediction of performance at A level, useful because it is set in the context

of the report as a whole; but predictions can be misleading. A recent survey

of the accuracy of A level predictions indicated that only about one third

APPLICATION AND SELECTION

47turned out to be correct, a half were too high (and half of these by two or

more grades) and a tenth were too low. Occasionally a candidate is

seriously underestimated, with the result that an interview is not offered

and the applicant is at the mercy of the clearing procedure after the results

are declared or has to apply again next year. Application to medical school

after the results are known would be fairer but the practical difficulties in

changing the system have so far proved insuperable.

Getting an interview

What in the mass of information counts most in the decision to shortlist a

candidate for interview or even, at some medical schools, an offer without

interview? Grades achieved in GCSE and A level if already taken or

predicted grades if not yet taken are universally important. Medical schools

also take notice of, but may give different weighting to, outstanding

achievement in any field because excellence is not lightly achieved. They

look for evidence of determination, perseverance, and consideration for

others; for an ability to communicate, for breadth and depth of other

interests, especially to signs of originality, for the contribution likely to be

made to the life of the medical school, for a solid confidential report, and

for assessment of potential for further development by taking all the

evidence together. Highly though achievement is valued, potential, both

personal and intellectual, is even more important. Perceptive shortlisters

look for applicants who are just beginning to get into their stride in

preference to those who have already been forced to their peak, aptly

described by Dorothy L Sayers in  Gaudy Night  as possessed of “small

summery brains that flower early and run to seed”. Although the

shortlisting process deliberately sets out to view applicants widely, analysis

of the outcome has shown that academic achievement still carries the

weight in selecting candidates from their UCAS forms. The great majority

of applicants called for interview are academically strong, and it is then that

their personal characteristics decide the outcome (see next chapter).

What weight is put on medically related work experience in

shortlisting—and what indeed is “medically related”? If you look through

the stated views of individual medical schools in the UCAS Guide to Entry

to Medicine on the “qualities” they are seeking in applicants, you will find

three constantly recurring themes: communication skills, evidence of

concern for the welfare of others, and a realistic perception of what

medicine entails. It follows that any work experience that entails dealing

with the public, actively helping or caring for others, or which shows

doctors at work and health care in action may enable you to be convincing

in establishing your ability to communicate, your understanding of what

you would be letting yourself in for, and your discovery of the skills and

attributes you already possess which make you suitable in principle for the

responsibilities of a doctor. It is not so much precisely what you do but why

you have done it and what you have both given to it and gained from it.

LEARNING MEDICINE

48Applicants could legitimately ask whether any factors, apart from the

strength of the UCAS application form, enter into the selection for

interview. It used to be customary at many medical schools (a tradition by

no means confined to them) for the children of graduates of the school or

of staff to be offered an interview, but that has now been abandoned out of

conviction that the selection process must be and be seen to be open and,

as far as can be, scrupulously fair.

Unsolicited letters of recommendation are a sensitive matter. Factual

information additional to the UCAS confidential report is occasionally

important and is welcome from any source. For example, one applicant

had left another medical school in his first term against the advice of his

dean to work to support his mother and younger brother. Three years later,

when the family was on its feet and he wanted to reapply to medical school,

he was under a cloud for having given up his place. The UCAS form did

not tell the full story; and a note from the family doctor was most helpful

in giving the full background to a courageous and self sacrificing young

man. Some other unsolicited letters add only the information that an

applicant is either well connected or has good friends, and it is difficult to

see why such applicants should be given an advantage over those whose

friends do not feel it proper to canvass.

APPLICATION AND SELECTION

49It is not only unsolicited testimonials that recommend in glowing terms.

How could any dean resist the angel described thus by her headmaster:

The charm of her personal character defies analysis. She is possessed by all

the graces and her noble qualities impress everybody. She has proved the soul

of courtesy and overlying all her virtues is sound common sense. She has

always been mindful of her obligations and has fulfilled her responsibilities

and duties as a prefect admirably well. Amiable and industrious, she appears

to have a spirit incapable of boredom and her constructive loyalty to the

school, along with her unfailing good nature, has won her the high esteem

and admiration of staff and contemporaries alike. We recommend her warmly

as a top drawer student.

A “top drawer” student indeed—and a top drawer headmaster.

When to apply

All UCAS forms for applicants to medicine must be received by 15 October

at the latest, so get on with it as early as possible. Late applications are rarely

even considered and almost never successful.

In principle a year’s break between school and university is a good thing.

The year is particularly valuable if used to experience the discipline and,

often, the drudgery of earning a living from relatively unskilled work. It can

provide insights for students (most of whom come from relatively well off

families) into the everyday life and thinking of the community which will

provide most of their patients in due course and may be very different from

their own background. There is no need for such work to be in the setting

of health care; in fact much is to be said for escaping from the environment

of doctors and hospitals.

If the earnings of these months are then used to discover something of

different cultures abroad that is a bonus. Alternatively, you may work

abroad through Project Trust, Gap Projects, Operation Raleigh, or other

similar organisations. But just being a year older, more experienced, and

more mature is, in itself, helpful to the discipline and motivation of study

and especially useful when you are faced with patients. In practice, short

term employment may, unfortunately, be difficult to find but there are few

places where work of some description cannot be obtained if a student is

prepared to do anything legal, however menial. Settling down to academic

work again after a year off can be a problem, but it is not insuperable if the

motivation and self discipline are there. If commitment has evaporated

after a year’s break, better to have discovered early than late; better to drop

out before starting rather than to waste a place that another could use and

to waste your own time, which could better be channelled elsewhere.

A practical dilemma arises for those planning a year off over whether to

apply for deferred entry before taking A levels or to apply with completed

A levels early the year afterwards. Universities may be reluctant to commit

themselves a year ahead to average applicants because the standard seems

LEARNING MEDICINE

50to be rising all the time. Outstanding applicants, however, should have

no difficulty in arranging deferred entry before taking A levels, but it is

worth checking the policy of schools in which you are interested before

application. If you are not offered a deferred place apply early the next year

and send a covering letter to the deans of your chosen medical schools

asking for as early an interview as possible if you are planning to go abroad.

REMEMBER

• Each year about 12 000 home and EU students apply for 6000 (soon to

be 7000) places to read medicine in the UK.

• Some of the additional places will be shorter courses for graduates,

mostly, but not entirely, science graduates.

• About 1500 overseas students compete for 330 reserved places.

• Women comprise just over half of applicants and entrants.

• Academic achievement is the strongest determinant in selection, but

broader interests and achievements also count.

• It generally pays to apply as early as possible.

• Applications should be legible, honest, and, as far as possible, interesting.

• Use four choices for medicine; it is entirely reasonable to give a fifth and

sixth to a non-medical option, but this is not compulsory.

• If you are planning a gap year, apply for a deferred entry rather than delay

your application, and be prepared to discuss your plans for the year at

interview.

APPLICATION AND SELECTION

5152

6. Interviews

Academics and careers advisers may argue about the usefulness

and fairness of an interview in the process for selecting future

medical students and doctors. Those on the receiving end—the

candidates—are unanimous in the belief that the interview is

somewhere between daunting and dreadful. Some of the dread

is fear of the unknown,as well as fear of being judged on what is

little more than first impressions. Read on,and you may have

some of those fears dispelled and be able to give yourself a better

chance at creating a positive impression.

On a dull overcast day due for an imminent downpour, you step off the early

morning train in your best new outfit, shoes polished, hair neatly brushed,

clutching a copy of a newspaper in which you have just been reading an

article about trendy new treatments for anxiety. As you approach the gates of

the medical school and see the sign directing “Interview Candidates ThisWay” you wish you could remember any of the useful tips from that

newspaper article; as it is you are so nervous you are no longer sure you can

even remember your own name. It is not your first interview for a place at

medical school, you had one last week. Although most of the details are lost

in a haze of pounding heartbeats and sweaty palms, you are unable to rid

yourself of the image of that professor’s face when you dug yourself into a

hole discussing the nutritional requirements of the Twa pygmies, a subject in

which the sum of your knowledge was gleaned from the last five minutes of a

late night documentary on BBC2. In what seemed like only half a minute,

you are back at the railway station, on your way home, while the fearsome trio

of interviewers dissect your inner being and decide your worth for that

precious place at their medical school; your passport to their worthy

profession. It feels like your life is in their hands.

SS

Most medical schools interview those students who seem the strongest

on paper (through past achievements, predicted exam success, the

confidential reference, and the student’s own statements on the application

form) and use the 15 to 20 minute interview as a way of choosing between

them. The remaining schools interview smaller numbers such as mature

students, in an attempt to assess motivation and circumstances more fully

(see Table 4.2, p. 42).

The purpose

In general the interview is an opportunity to test the students’ awareness of

what they are letting themselves in for, both at medical school and as a

doctor, ranging from the impact of medicine on personal life to how

medicine relates to the society it serves. It also allows the interviewers to

explore whether applicants can communicate effectively, can think a

problem through with logic and reason, and are speaking for themselves

and not regurgitating well rehearsed answers which teachers and parents

have thought up for them; it also reveals some of the qualities above and

beyond academic ability which are desirable in a caring profession, such as

compassion and a sense of humour. Occasionally a student who seems

outstanding on paper can seem so lacking in motivation, insight, or

humanity that he or she loses an offer which would otherwise have seemed

a certainty. Likewise the interview can allow students who seem equal on

their UCAS forms to make their own case either through special

circumstances or by a shining performance.

The panel

The interview panels differ in style and substance between schools but

typically consist of three or four members of staff and often a student. The

INTERVIEWS

53panel is a mixture of basic scientists, hospital consultants, and general

practitioners, one of whom, often the dean or admissions tutor, will take

the chair. Members of panels attend in an individual capacity and not as

representatives of particular specialties. They know that medicine offers a

wide range of career opportunities, that most doctors will end up looking

after patients but not all do, that more will work outside hospitals than in,

and that both the training and the job itself are demanding physically and

emotionally. They also know that whatever their final occupation doctors

need to make decisions, deal with uncertainty, and communicate effectively

and compassionately with patients and colleagues alike as well as maintaining

moderately exacting academic standards. The aim is not to pick men and

women for specific tasks but to train wise, bright, humane, rounded

individuals who will find their niche somewhere in medicine. The format

may be formal, with the interview conducted in traditional fashion across a

large table, or more informal, sitting in comfortable chairs around a coffee

table by the fireside. The tenor of the interview, however, depends much

more on the style of questioning; no matter how soft the armchairs are, they

can still feel decidedly uncomfortable if you are made to feel like you are

being grilled and about to be eaten for breakfast.

Dress and demeanour

Although the interview is a chance to be yourself and sell yourself, there

are certain codes of conduct that even the most individual or eccentric

candidate should be encouraged to heed. Rightly or wrongly first

impressions count, and so what you wear matters. Dress smartly and

comfortably and make an effort to look as presentable as you would expect

from a mature professional. If your usual style of clothing is rather off beat,

then perhaps for once it may be wise to let your tongue make any statements

about your individuality rather than your all in one leather number and

preference for nose piercing.

Nothing is more of a turn off to interviewers than someone who is full of

himself (or herself!) and seems to be finding it hard to accept that his offer is

not a formality. On the other hand an obviously talented and caring student

whose modesty and nerves get the better of him and who fails to give the

panel any reasons at all to give him an offer is almost as frustrating. The key

is balance. When asked to blow your own trumpet make it sound like a

melodious fugue not a ship’s fog horn. The best way to learn how to achieve

this delicate balance is by practice. Many schools will be able to organise

mock interviews, which can be useful, but often the more specific points

relating to entering medical school can be best thought through by enlisting

the help of your local family doctor or a family friend who is a doctor or by

talking to anyone experienced in interviewing or being interviewed in any

context or by asking the advice of people who have themselves recently been

through it when you visit the medical schools on open days or tours.

LEARNING MEDICINE

54The conversation

Almost anything can be asked. It would be advisable to have thought about

such things as why medicine? why here? why now? You should be able to

show you have a realistic insight into the life of a doctor, and this is often

best achieved by relating personal experience of spending some time with

a doctor in hospital or general practice or, for example, by voluntary work

in an old people’s home or with children with special needs. Some panels

put great store by your showing them how much you can achieve when you

put your mind to it and will want to discuss your expedition to Nepal, your

work on the school magazine, your musical or sporting successes.

Remember to keep a copy of your UCAS form personal statement to read

before you go into your interview. It is very often used as a source for

questions and it can be embarrassing if you appear not to remember what

you wrote. Even more importantly, do not invent interests or experience,

as you may get caught out. One candidate at interview recently struggled

through his interview after he was asked about the voluntary work at a local

nursing home which he put on his form and replied: “I haven’t actually got

round to doing it yet, but I’d like to.” He was not offered a place.

It is often sensible to have kept in touch with current affairs and

developments in research. This is particularly relevant if the medical school

has a strong interest in a research topic which has a high media profile. By

reading a good quality daily newspaper you will greatly assist your ability to

provide informed comment on issues of the moment. One candidate at

interview cited the strong research background as a reason for applying to

that school, and when asked to discuss which research at the school

impressed him he replied: “Fleming’s discovery of penicillin”. He knew he

had not done himself any favours when the dean replied: “Could you not

perhaps think of anything a little more recent than 1928?”

With contentious issues such as ethics or politics, candidates will be

neither criticised nor penalised for holding particular views but will be

expected to be capable of explaining their case. Specific questions on

subjects such as abortion, religion, or party politics are discouraged, but if

they are likely to cause personal professional dilemmas it is reasonable

and sensible to have thought about them and to be able to discuss how

you would approach resolving such issues. Candidates with special

circumstances, especially mature students, should be fully prepared for the

interview panel to concentrate on particularly relevant factors such as

whether they can afford to support themselves during the course, rigorous

testing of their motivation, and questioning of the reasons behind their

decision to enter the medical profession.

It is usual for the panel to offer an opportunity for the candidate to ask

questions. A current student at the school sitting in on the interview can

often be useful in answering the candidate’s questions. Make sure if you do

ask a question that you do not spoil an otherwise successful interview by

asking a question which simply indicates that you have failed to read the

INTERVIEWS

55prospectus thoroughly or which has no direct bearing on your entry to or

time at medical school.

Offers

An offer made to a candidate who has already achieved the minimum

academic requirement is unconditional. All candidates who have already

attained the minimum grades at first attempt cannot automatically receive

a place because far more applicants will achieve this than the school can

take. Offers are made on all round merit as can best be assessed on all the

evidence.

If the A level examinations have yet to be taken an offer is conditional on

the candidate achieving the required grades at first attempt. Occasionally a

student who seems in need of an incentive may be given a higher target but

would normally be accepted with the minimum. Sometimes a lower than

normal offer is made to reduce the pressure on a candidate working under

exceptional circumstances. If A levels are being retaken, most medical

schools will expect higher than normal targets to be reached.

Finally, applicants must remember that achievement of minimum grades

does no more than qualify them to enter the real competition. No level

of examination success gives entitlement to a place without necessary

consideration of the other factors important to being a doctor, an assessment

of which is the whole basis for calling applicants to interview. Many more

candidates can achieve the required grades than can possibly be taken

under the fixed quota system which exists for the training of doctors. All

medical schools try very hard to be fair but a number of able applicants will

inevitably be disappointed.

LEARNING MEDICINE

56REMEMBER

• Most medical schools interview all applicants to whom they make an

offer.

• Usually a panel of three to five people—doctors, lecturers and often a

student observer—will be present.

• The interview will usually last 10–20 minutes, giving you time to settle

into it—the interviewers know that you will be nervous, but try to relax

and show yourself at your best.

• The major purpose of an interview is to test your awareness about the

course and the career, and to discover whether you can think and reason

for yourself.

• To prepare for the day read the prospectus thoroughly, read up on

current relevant issues in the health section of a daily newspaper, arrange

some practice interviews and be prepared to elaborate on what you wrote

on your application form.

• On the day dress smartly and comfortably, arrive in plenty of time, speak

up clearly and do not ask questions that have no direct bearing on entry

to, or time at, medical school.

• Offers will be unconditional if the academic requirements have already

been met, or for most applicants will be conditional on achieving target

grades at the first attempt.

• All medical schools try hard to be fair but some able applicants will

inevitably be disappointed.

INTERVIEWS

5758

7. Medical school:

the early years

The first few weeks at medical school are bewildering. On top of

all the upheaval of finding your feet in a new place,finding new

friends,finding the supermarket,and finding that your bed does

not miraculously make itself,you will find yourself at the

beginning of a course that will mould the rest of your life. Ahead

there are new subjects to study,a whole new language to learn,

a new approach to seeing problems,new experiences and

challenges,thrills and spills,ups and downs,laughter and tears.

You are now at university,you are a medical student and you are

on your way to being a doctor.

Until recently the undergraduate medical course had remained largely

unaltered for decades, having slowly and steadily evolved over centuries of

medical learning. All that has had to change in the past decade as the

structure of the traditional course came face to face with the strains of

modern medicine. The explosion of scientific knowledge, the unstoppable

advances in technology, the ever developing complexity of clinical practice,

and changing health care provision have all added to the tremendous

demands on tomorrow’s doctors.

At the same time there has been a reaction against the soaring

dominance of modern science over old-fashioned art in medicine, technical

capability over wise restraint, and process over humanity. A growing

concern (not necessarily justified) that preoccupation with the diagnostic

and therapeutic potential of molecular biology will obscure the patient as a

whole person, a person who so often simply does not feel well for relatively

trivial and unscientific reasons, and probably only needs to be listened to

and encouraged to take responsibility for his or her own health. A fear

that healthcare teams under pressure from every direction may give the

impression that they have forgotten how to care in the fullest sense—and,

worse still, may indeed lose sight of the humanity of medicine.

The Prince of Wales put his finger on the issue in a “Personal View” in

the British Medical Journal, writing “Many patients feel rushed and confused

at seeing a different doctor each time … and many healthcare professionals

feel frustrated and dissatisfied at being unable to deliver the quality of care

they would like in today’s overstretched service.”There has also been a reaction against the traditionally closed mind of

the medical profession towards complementary and alternative medicine,

partly because of dissatisfaction with the fragmentation of conventional

medicine and partly because of the effects of relentless pressure on doctors.

As some patients derive benefit from unorthodox medicine (often when

traditional medicine has failed)—however obscure the mechanism of the

benefit may be—doctors need to be informed about such therapies and the

evidence, such as it is, for their effectiveness. As the Prince of Wales

observed in his “Personal View”: “It would be a tragic loss if traditional

human caring had to move to complementary medicine, leaving orthodox

medicine with just the technical management of disease”. At the end of the

day, it may well be that the greatest benefit of complementary therapies

derives from the therapist being able to give more time to listening to the

patient. Be that as it may, it is clearly in the patient’s interest to “create a

more inclusive system that incorporates the best and most effective of both

complementary and orthodox medicine … choice where appropriate, and

the best of both worlds whenever it is possible.”

Recommendations published by the GMC in 1993 (revised 2002)

provided a new impetus to the introduction of a new medical curriculum.

Less emphasis was put on absorbing facts like a sponge and more on

thinking: on listening, analysing, questioning, problem solving, explaining,

and involving the patient in his or her own care; more emphasis on the

patient as a whole in his or her human setting. The biological and

behavioural basis of medicine in most medical schools now focuses on

“need to know and understand”. Oxford and Cambridge remain perfectly

MEDICAL SCHOOL: THE EARLY YEARS

59reasonable exceptions, having retained a strongly and intrinsically medical

science centred curriculum in the first three years. The GMC encourages

diversity within the curriculum and students should carefully consider which

sort of curriculum would best inspire their mind, heart, and enthusiasm.

You can usually get a flavour of how the course is delivered at each

school by reading the curriculum and students’ views section on the

medical schools’ websites or in their prospectuses.

Nevertheless, at most universities the traditionally separate scientific and

clinical aspects of the course have become very substantially integrated to

prevent excited and enthusiastic students becoming disillusioned in the

first two years with what understandably seemed to be divorced from real

patients and real lives, from clinical relevance and clinical understanding.

The subjects, systems, and topics

Most first year students begin with a foundation course covering the

fundamental principles of the basic medical sciences. These include

anatomy—the structure of the human body, including cell and tissue

biology and embryology, the process of development; physiology—the

normal functions of the body; biochemistry—the chemistry of body

processes, with increasing amounts of molecular biology and genetics;

pharmacology—the properties and metabolism of drugs within the body;

psychology and sociology—the basis of human behaviour and the placing

of health and illness in a wider context; and basic pathology—the general

principles underlying the process of disease.

As the general understanding of the basics increases, the focus of the

teaching often then moves from parallel courses in each individual subject

to integrated interdepartmental teaching based on body systems—such

as the respiratory system, the cardiovascular system, or the locomotor

system—and into topics such as development and aging, infection and

immunity, and public health and epidemiology.

In the systems approach the anatomy, physiology, and biochemistry of a

system can be looked at simultaneously, building up knowledge of the body

in a steady logical way. As time and knowledge progress the pathology and

pharmacology of the system can be studied, and the psychological and

sociological aspects of related illnesses are considered.

Often the normal structure and function can best be understood by

illustrating how it can go wrong in disease, and so clinicians are

increasingly involved at an early stage; this has an added advantage of

placing the science into a patient focused context, making the subject more

relevant and stimulating for would be doctors. It also allows for early

contact with patients to take place in the form of clinical demonstrations

or, for example, in a project looking at chronic disease in a general practice

population or on a hospital ward.

In some medical schools, such as Manchester and Liverpool, practically

all the learning in the early years is built around clinical problems that focus

LEARNING MEDICINE

60all the different dimensions of knowledge needed to understand the illness,

the patient, and the management.

The teaching and the teachers

The teaching of these subjects usually takes the form of lectures, laboratory

practicals, demonstrations, films, tutorials and projects, and, increasingly,

computer assisted interactive learning programmes; even virtual reality is

beginning to find its uses in teaching medical students.

The teaching of anatomy in particular has undergone great change.

Dissection of dead bodies (cadavers) has been replaced in most schools by

increased use of closed circuit television and demonstrations of prosected

specimens and an ever improving range of synthetic models. Preserved

cadavers make for difficult dissection, especially in inexperienced if

enthusiastic hands, and, although many regarded the dissecting room as an

important initiation for the young medical student, fortunately much of the

detail needed for surgical practice is revised and extended later by observing

and assisting at operations and during postgraduate training. Much more

useful to general clinical practice is the increased teaching of living and

radiological anatomy. In living anatomy, which is vital before trying to learn

how to examine a patient, the surface markings of internal structures are

learnt by using each other as models. This makes for a fun change from a

stuffy lecture theatre as willing volunteers (and there are always one or two

in every year) strip off to their smalls while some blushing colleague draws

out the position of their liver and spleen with a felt tip marker pen.

MEDICAL SCHOOL: THE EARLY YEARS

61Similarly, with the technological advances in imaging parts of the body

with  x  rays, ultrasound, computed tomography, magnetic resonance

imaging, radionucleotide scans, and the like, and their subsequent use in

both diagnosis and treatment, the need to have a basic understanding of

anatomy through radiology has never been greater.

Practical sessions in other subjects, especially physiology and

pharmacology, often involve students performing simple tests on each other

under supervision. Memorable afternoons are recalled in the lab being

tipped upside down on a special revolving table while someone checked my

blood pressure or peddling on an exercise bike at 20 km/h for half an hour

with a long air pipe in my mouth and a clip on my nose while my vital signs

were recorded by highly entertained friends or recording the effect on the

colour of my urine of eating three whole beetroots, feeling relieved not to be

the one who had to test the effects of 20 fish oil capsules. As well as the

performing of the experiments, the collation and analysis of the data and the

researching and writing up of conclusions is seen as central to the exercise,

and so students may find themselves being introduced to teaching in

information technology, effective use of a library, statistics, critical reading

of academic papers, and data handling and presentation skills.

The teaching of much of the early parts of the course is carried out by

basic medical scientists, most of whom are not medically qualified but who

are specialist researchers in their subject. Few have formal training in

teaching but despite this the quality of the teaching is generally good and the

widespread introduction of student evaluation of their teachers is pushing

up standards even further. Small group tutorials play an important part in

supplementing the more formal lectures, particularly when learning is

centred around a problem solving approach, with students working through

clinical based problems to aid the understanding of the system or topic

being studied at that time. The tutorial system is also an important anchor

point for students who find the self discipline of much of the learning harder

than the spoon feeding they may have become used to at school.

Students may also have an academic tutor or director of studies or a

personal tutor, or both, a member of staff who can act as a friend and

adviser. The success or failure of such a system depends on the individuals

concerned, and many students prefer to obtain personal advice from

sympathetic staff members they encounter in their day to day course rather

than seeking out a contrived adviser with whom they have little or no

natural contact. In some schools, most notably in Oxbridge, the college

based tutor system is much more established and generally plays a more

important personal and academic part.

Links are sometimes also set up between new students and those in older

years; these “link friends”, “mentors”, or “parents” can often be extremely

useful sources of information on a whole range of issues from which

textbooks to buy to which local general practitioner to register with and

useful tips on how to study for exams, and of course numerous suggestions

on how to spend what little spare time you can scrape together.

LEARNING MEDICINE

62In every school there will be a senior member of staff, a sub-dean or

director of medical education, who oversees the whole academic

programme and can follow the progress of individuals and offer a guiding

hand where needed.

As students progress other topics are added into the course. Most

schools provide first aid training for their students, and a choice of special

study modules (SSMs) are offered each year to encourage students to

spend some time studying in breadth or depth an area which interests them

and in which they can develop more knowledge and understanding. Early

patient contact is encouraged; sometimes through schemes which link a

junior student with a ward where small group teaching takes place or

through projects or simply by gaining experience of the work of other staff,

such as nurses, health visitors, physiotherapists, and occupational

therapists; or time can be spent just talking to patients and relatives. Some

schools begin a module in the first year which introduces aspects of clinical

training, ideally in the setting of general practice, with the same doctor

every week or two for one or two years. The supervised learning includes

skills such as history taking and clinical examination or the interpretation

of results of clinical investigations.

In the early part of some courses students may be introduced to a local

family with whom they will remain in contact for the duration of their time

as a student. Such attachment schemes, which are often organised by general

practice departments, are designed to give students a realistic experience of

the effects on people of events such as child birth, bereavement, financial

hardship, or ill health from a perspective which few would otherwise

encounter.

It is difficult to get the true feel of being in the early years of medical

training from the rather dry description of the course, so let a student at

that stage herself describe a typical week in her life on a new style problem

based course.

A week on a problem-based learning course

Thursday

Yes, Thursday is the start of the week as far as we’re concerned in

Manchester. At least that’s when we start each new case.

The idea behind problem-based learning (PBL) is that we use real clinical

problems (or cases) as the main stimulus for our learning. Each week we have

a new case to study; understanding the background to the problem itself and

exploring aspects related to it. Nobody tells us what we “need” to know, we

must decide for ourselves which information is important to learn and

understand. At first, like everybody, I found it difficult to adjust to this new

way of learning—I was used to the spoon fed process at school which helped

me pass my A levels. I found it quite daunting and challenging to make up

my own learning objectives and search out the information for myself. Once

MEDICAL SCHOOL: THE EARLY YEARS

63I got used to it, however, it became a really enjoyable way to study medicine.

I found myself actually wanting to spend time in the library or in hospital to

find the answers to my questions. I quickly found out that there is no need to

rote learn all the muscle attachments of the bones in the hand or every single

anatomical feature of the femur. I learnt to discriminate between useless

information and useful information—for example, how antidepressants work

or the functions of the stomach.

In the past, medics on traditional courses spent their first two years trying

to cram textbooks of information into their heads and usually hating every

minute of it, desperately waiting for the clinical years. If you ask them how

much information they retained after their preclinical exams were over they’ll

find it difficult to admit that they forgot nearly everything straightaway! By

using the PBL method to learn medicine the information we learn now is

more likely to be retained in the future, long after our exams when we’re

doctors on the wards. I discovered that it’s a very satisfying way to learn

medicine as I am constantly solving cases and applying my knowledge to real

life situations. My motivation to learn is increased and because I actually

want and like to learn I find it easier to understand and remember what I read

about. It’s one thing being able to learn facts and principles, it’s quite another

to apply them in real life. Problem based learning helps us to learn the skills

necessary to do this—skills that we must learn to be good doctors.

In Manchester, the first two years are divided into four semesters. Each

semester has a title—for example, Nutrition and Metabolism, Cardiorespiratory

Fitness. This semester I am studying “Abilities and Disabilities”, and it involves

learning mainly about the brain, nervous system, muscles, and bones.

At 10 am I have a theatre event. This usually means going into the lecture

theatre (hence the name!) to listen to a lecture, but sometimes we’ll watch a

video or take part in a clinical demonstration. The lectures are usually

interactive too, and we’re encouraged to ask questions or participate in

discussion. The theatre event this morning introduced us to aspects of that

week’s case by giving us an overview of how the eye works. The patient in the

case this week is followed from childhood (when she has a squint) through to

old age (when her eyesight deteriorates, partly due to disease).

Afterwards I decided to go to the library for a couple of hours to read up

before my first discussion group. Each week we study the case with our tutor

group (consisting of about 12–15 students). We have 3 one hour meetings in

the week to work through the case. This week, Mary is assigned the role of

chairperson and Mike is scribe. The chairperson tries to keep the discussion

on track (and keep us under control!) whereas the scribe has the job of

writing the important points down during the session and typing them up. We

rotate the two jobs each week so everyone has a chance. Each group has two

tutors who are always present but usually do not take part in the discussion

unless we ask them a specific question. One tutor is a basic medical scientist

and the other is a clinician. The tutors are there to facilitate our discussion

and will interrupt us only if we go off on a tangent. The clinician is also there

as our main link to hospital and will invite us in to have small group teaching

on the wards or will make it possible for us to come in pairs to shadow other

doctors on shifts. In my first year I chose to spend a Saturday night in

accident and emergency. Unfortunately (or fortunately!), it was not the

LEARNING MEDICINE

64Casualty/ER scenario I expected, and two drunks and a regular were the only

ones to come in during the entire 12 hour shift.

We usually read through the case in the first session, defining things we

don’t understand, using clues in the case to decide what we need to learn

about, and dividing up the tasks between us. We form learning objectives

based on the case itself, which means that we cover anatomy, physiology,

biochemistry, pharmacology, psychology, etc, altogether instead of each

subject being learned separately. I’ve found that this method of learning

medicine, the “systems based” method, gives me a more complete picture

and I’m able to connect up the anatomy, physiology, etc, of an organ better

and remember how they are related to each other. It also means that we

understand disease processes more thoroughly and that we’re encouraged to

look at the patient as a whole person within society not just as an illness.

Friday

I didn’t have to be in for dissection until 11 am. We have two hours of

dissection every week when we get hands on experience of the body and

primarily discuss anatomy with a tutor in our tutor groups. Today we

dissected the eye and the orbit of the brain of our cadaver. The first time I

saw the cadaver was a moment I’ll remember for ever, and I think dissection

is one of the most interesting times of the week, the only thing I don’t like is

the smell! We also use this time to do living anatomy and look at  x ray

pictures and body scans.

Just had time to grab a sandwich from the coffee bar before the theatre

event at 1 pm. This time it was a demonstration and video about how the

eye detects colour, especially in the dark. It was really good fun, and we

experimented with optical illusions.

Finished again at 3 pm and went to the library for an hour to learn more

about colour vision but found it difficult to focus on the textbook at first since

my eyes were still suffering from the optical illusions.

Weekend

I spent most of the weekend in the library, working on the case. Except for

Saturday morning when I played in a mixed hockey match against Edinburgh

medics. Medicine takes up a large part of my life but I always manage to find

time to do other things.

Monday

Early start for computers at 9 am. We have two hours of computing class

every week. We also learn about statistics during that time and how to carry

out statistical procedures using the computer. I didn’t do statistics at school

but it’s not a disadvantage since we are taken through things step by step. It’s

the same with computing so that even if you’ve never even switched one on

before, it soon becomes possible to produce spreadsheets and data analyses.

At 11 am I have histology class. We also have two hours of histology a

week. We work through the lesson in pairs with the help of tutors. Depending

on the case, I sometimes find myself spending longer in the lab to make sure

MEDICAL SCHOOL: THE EARLY YEARS

65I’ve seen everything that I’m supposed to see down the microscope. Although

it can be fascinating this is not my favourite medical pastime.

That was it for the day and I was able to take my time over lunch. In the

afternoon Lucy and I headed across to the Manchester Royal Infirmary. We

eventually found the ophthalmology department and introduced ourselves to

the nurses and met the consultant as arranged. We were able to see five

patients during the three hours we were there, and it really opened my eyes

to the treatments possible.

Tuesday

From 9–11 am we had lab work. This is the time when we learn how to carry

out certain examinations or procedures, everything from blood pressure

measurement to drug dilutions. This week we learnt how to examine the eye

with an ophthalmoscope and carry out an eye test like you have done at the

opticians. It was more complicated than it seemed, and it took me and my

partner Toby the entire two hours to get through everything.

At noon we had our second discussion group. Lucy and I gave an account

about what we’d seen on the ward, and Farid gave a presentation on how

laser treatments work to improve eyesight. We discussed the case but realised

there were still some aspects to it we didn’t understand. Some people were

assigned specific things to find out for tomorrow’s session. We also agreed to

go out for a group meal tomorrow night! We do this about twice each

semester so we have some time to socialise together as a group.

At 3 pm we had another theatre event, this one was about eye surgery and

the techniques they use—it was quite gruesome. At the end of the lecture we

had a feedback session. Each semester we’re asked to give our opinions on

how the course is going and any improvements that we think should be made.

We fill in lots of questionnaires about everything, from the books we use in

the library to what we think of our tutors. The staff are really good and

although PBL is now well established in its third year, they are still willing to

make changes and genuinely listen to our problems. Students are actively

involved in all faculty committees too.

We finished at 4 pm but I went to the computer lab to use one of the

computer assisted learning (CAL) programmes. I like using them because

they’re more interactive than textbooks; they usually have quizzes so I can

test myself at the end.

Wednesday

At 10 am we had our final discussion session about the case. It was quite a

good session since we managed to tie up nearly all our loose ends and still had

time to talk about the social issues that the case raised. Our clinical tutor gave

us a clinical perspective on the case and told us a few of his experiences too.

The good thing about working in groups is that it helps us to develop our

communication skills. We are always having to explain our theories and listen

to each other, which means we get very good at talking about medicine. It is

good preparation for us as future doctors as we’ll have to do this constantly

with patients. I’ve become very good at working in a team too—an invaluable

skill to have as a doctor.

LEARNING MEDICINE

66That evening we had a group night out and went for a curry. One of the

best things about PBL is that you really get to know the people in your group

very well because you work together as a team. You go through a lot together,

and the groups are small enough to allow you to work closely with everyone

during the semester.

I really enjoy studying medicine PBL style. It teaches you important and

essential skills for being a doctor as well as being brilliant fun.

C-MB

Communication skills

The teaching of communication skills to medical students has improved

greatly across the board in recent years, largely in response to public

demand. Patients want to know more about their condition and to have

more involvement in the decisions, for instance about treatment options,

which affect their lives. The skills needed to communicate well with

patients are often not fully appreciated, and many, including well

established doctors think it is something you either have or do not have.

While it is true that some doctors do have a natural flair for the right

bedside manner and know instinctively when to hold a hand or when a

moment of quiet reflection is appropriate, many of the skills can in fact be

learnt quite easily. Such skills are not just about explaining procedures and

MEDICAL SCHOOL: THE EARLY YEARS

67breaking bad news but also about how and when to keep quiet and listen,

to ask the right questions in the right way, drawing out the patient’s story,

which allows you to make an accurate diagnosis and formulate a suitable

management plan, as well as earning trust and showing empathy. Much of

this teaching is done in small groups and uses actors role playing patients

with fellow students watching on television monitors. This type of training

is also a compulsory part of postgraduate training in general practice, so the

practice early on is time doubly well spent. Let a former student, now a

medical senior house officer, describe her experiences of communication

skills training.

Communication skills

You will be spending the rest of your prospective career talking to patients so

it’s nice to be able to do it well—indeed it’s one of the major ways in which

your medical skills are judged. To this end, the communication skills teaching

is designed to give you a few pointers as to how to handle various patient

scenarios so that you and the patient go away happy (and less liable to sue!).

There is a small group of students, a doctor, psychologist, and a TV/video

at each session. You are in the room next door with an actor and a video

camera to keep you company. Before it starts, all you can think of are your

friends watching you on TV next door in this totally artificial situation and

how stupid it all seems! But then the actor arrives playing your patient and

you’re away. They might be trying to tell you about their piles or of “trouble

down below, Doctor”. They may be a shy, retiring nun or the Marquis de

Sade—anything is fair game. There are various scenarios and patients that

the actors can play, and they are invariably superb. You forget it’s all a sham

and that your friends are next door watching you on TV.

A particular favourite that you are asked to do is explain to a patient (actor)

a special test he or she needs to have done and what it will be like for him or

her. The old chestnut is endoscopy. This usually leads to some wonderful

descriptions of TV cameras being forced down the unfortunate patient’s

throat which, judging by their aghast expressions, seems to conjure up images

of the cameraman, floor manager, and producer going down to have a look,

too! The most difficult to explain are tests involving the injection of a

harmless radioactive isotope. On at least one occasion the patient left the

room convinced his hair would fall out and his skin peel and blister in a most

Chernobyl-esque manner!

After the consultation you go back next door and receive comments from

those watching. Emphasis is put on your good points as well as your goofs,

so it boosts your confidence (that’s half the trick in good communication) for

dealing with real patients, as well as raising your awareness of the possible

pitfalls. Invaluable skills are learnt, which past students—now doctors—say

they are still using on the wards now.

LJ

LEARNING MEDICINE

68Intercalated honours degrees

An increasing number of students are choosing to spend an extra year

studying for an honours degree during the medical course. This is usually

a Bachelor of Science (BSc) or Bachelor of Medical Science (BMedSci)

and can usually be taken from the end of the second year to the beginning

of the final year, depending on the design of the course and the exact nature

of the subject being studied. These degrees can either have a more basic

science emphasis—for example, extending study from a SSM in

neurosciences or neonatal physiology—or if it is taken later in the course

some schools offer clinical science related degrees. This extra year of study

is often the only opportunity an undergraduate has to experience front line

scientific research; besides the subject knowledge gained, it is a unique

chance to develop skills in research and laboratory techniques, and writing

scientific papers. Occasionally there are opportunities for a much broader

range of study encompassing humanities such as history of medicine or

modern languages. There are numerous grants and scholarships available

from schools and research funds to assist with the expense of this additional

year to cover living expenses if not tuition fees. Despite the extra expense

the number of students seeing the advantages of making the sacrifices

needed to take up this valuable opportunity is continuing to grow.

There are several notable exceptions to the general design of the

intercalated degrees being outlined here. At St Andrew’s University the

student takes a three year (or four if an honours degree) preclinical course

leading to a BSc in Medical Sciences and then usually transfers to clinical

studies at Manchester University. At both Imperial College School of

Medicine and the Royal Free and University College London School of

Medicine a six year course includes a modular BSc (Hons) as well as the

MB BS. At Nottingham University, all students on the five year course are

awarded a BMedSci if they successfully complete the first three years,

which includes research based project work.

The other main exceptions are the courses at Oxford and Cambridge,

whose first three years lead to a Bachelor of Arts degree, in Medical

Sciences at Cambridge and Physiological Sciences at Oxford.

Occasionally a student who has a particular research interest continues

the BSc break in their medical course to complete a further three years of

advanced research leading to the award of Doctor of Philosophy (PhD).

Some medical schools such as Cambridge and University College, London,

offer selected students a combined MB/PhD which is shorter than taking

the two degrees separately.

Assessment

The variety and complexity of the courses offered by different medical

schools are reflected in the numerous types of assessment used to check the

progress of each student’s learning. Attendance is not usually checked, but a

MEDICAL SCHOOL: THE EARLY YEARS

69student who is thought to be missing large amounts of the course should

expect to be questioned by tutors and the senior tutor to discover whether

there are any major problems with which the school may be able to help. Like

most university courses the obligation to attend is the responsibility of the

student, and it is salutary to note that poor course attendance, for whatever

reason, corresponds highly with failing the early phases of the course.

Most schools use a mixture of continuous assessment of course work and

major examinations at the end of terms or years, though the balance varies

greatly. There are pros and cons of both systems, with students at schools

where exams play a larger part wishing that more credit were given to good

work throughout the year rather than everything resting on their

performance on one particular day. Students who undergo more continuous

assessment, however, complain about the stresses and strains of frequent

tests and projects, so it seems to be a case of “swings and roundabouts”.

Around 5% of students fail to complete the course, most of these leaving

at the end of the first year. This is most commonly due to a waning of

motivation, the realisation of a wrong career choice, or, unfortunately,

because of misjudgments of the amount of work necessary and a failure to

organise their time effectively or because of the diversions of personal

entanglements. A few fail their second or third year assessments, but

students surviving this far have generally worked out what is required of

them to qualify.

There is often a chance to resit examinations or resubmit unsatisfactory

course work, but this is not to be recommended as it leads to extra work

often at times when friends are away on vacations, sunning themselves on

faraway beaches or earning much needed cash in holiday jobs. In exceptional

circumstances, such as illness or bereavement, students may be allowed to

resit a whole year, but this often has financial implications which may preclude

some people. In any event, students who are experiencing difficulties are

encouraged to discuss the problems with their tutor or another member of

staff sooner rather than later.

Working hard, playing hard

On my first day at medical school the then president of the Royal College

of Radiologists, Dr Oscar Craig, told the assembled mass of eager freshers,

“this is the greatest day of your life”. He continued, “Does it take great

brains to become a doctor? I hate to disappoint you, but I don’t think it

does, you know. Does it take hard work and determination? … Like

nothing else!”

Students who have gained a place at medical school have not only proved

themselves bright enough to cope with the academic rigours of the course

but have also usually shown exceptional interest or achievement in some

other area or activity, often an activity requiring teamwork. It is usual then

for medical schools to be hives of activity on the social scene, where clubs

and societies abound providing sports fixtures, training sessions, plays and

LEARNING MEDICINE

70concerts, balls and discos, talks on this and that, and trips to here and

there, all of which can lead to a wonderfully full life.

While the object of going to medical school is ultimately to train as a

doctor, most students take full advantage of the chance to pursue their

hobbies or try new ones, meet new friends, do new things, and generally do

all the “growing up and finding yourself” things that students are supposed

to do. The secret in all this is the fine balancing act between work and play.

Each year a few potentially good doctors forget the real reason for their

being at medical school, fail their exams, and have to leave their friends and

all that social life behind, not to mention having to find a new career. It is

an unpleasant feeling seeing a good friend and colleague being asked to

leave, so a great effort is made to encourage students to find the right

balance so that medical schools train doctors who are both skilled at their

job and also interesting and talented in other things; something they will

cherish in later life.

REMEMBER

• Being a medical student, like any university student, is a complete change

from being at school—you will have endless opportunities available to

you but you will need to realise them for yourself.

• There is generally much less “spoon feeding” and more self-directed

learning, requiring self-motivation, determination and discipline, which

some students find difficult at first.

• All medical courses now provide early clinical insights and problem

solving in addition to teaching the scientific and ethical basis of medicine.

• Courses range from the recognisably traditional at Oxford, Cambridge,

and St Andrew’s to substantially more integrated, problem-based

approaches such as at Liverpool and Manchester.

• Several universities have introduced shorter (four year) courses for

graduate students.

• A few universities award a science degree as an integral part of the

medical course; most universities award a BSc or BMedSci degree for an

optional, additional (intercalated) year.

• Assessment in the early years is by a variable mixture of continuous

assessments and end of year exams.

• Achieving the right balance between work and play can be a challenge for

some new medical students, but most succeed.

• About 5% of students overall fail to complete the course, most in the first

two years and they normally find fulfilling careers outside medicine.

MEDICAL SCHOOL: THE EARLY YEARS

7172

8. Medical school:

the later years

As the medical student progresses through into their third year

and beyond,increasing amounts of time are spent in the various

clinical teaching settings and less in the classroom. The white

coat is donned,and the shiny new stethoscope is placed

ostentatiously in the pocket,usually alongside numerous

pocket-sized textbooks,pens,notepads,and sweet wrappers.

Most students by now have some experience of listening and

talking to patients and of the hospital wards. The sight of the ill

patient in a bed does not come as the awful surprise it did to

generations of medical students who spent their first two years

cocooned in the medical school.

The style of teaching changes emphasis, becoming more of an apprenticeship

but retaining the academic backup of lectures, seminars, and particularly

tutorials. More of the course is taught by clinical staff: consultants, general

practitioners, and junior doctors, often in small groups at the bedside, on

dedicated teaching rounds or in tutorials, in the operating theatre, in the

outpatient clinic, or general practice surgery. Teaching also takes place at

clinical meetings or Grand Rounds and the firm’s regular radiology meeting

(when the week’s x ray pictures and scans are reviewed and discussed with a

radiologist) and histopathology meeting (when the results of tissue biopsies

and postmortem examinations are discussed). Some students find the change

in the style of teaching frustrating as much time seems to be wasted hanging

around waiting for teaching that never seems to happen. The registrar or

consultant who is due to be teaching is often delayed in theatre with a

difficult case or still has a queue of patients waiting in the outpatient clinic.

Many of these doctors are fitting in their teaching commitments around an

already punishing clinical workload, and so often a combination of better

organisation by the schools and some initiative in self directed learning from

the students is all that is needed to extract the value from such a valuable

educational source.

It may well be that with so much to learn, insufficient attention is given

to the formation of attitudes. It is said that medical students have more

appropriate attitudes to both patients and to others with whom they share

care when they enter medical school than when they qualify as doctors.

There may be more than a grain of truth in this. In the Bristol report,Professor Sir Ian Kennedy expressed the view that “the education and

training of all healthcare professionals should be imbued with the idea of

partnership … (with) … the patient … whereby the patient and the

professional meet as equals”. As far as mutual respect in teamwork is

concerned, opportunities for learning together (multdisciplinary learning),

both in the undergraduate and postgraduate years, are not fully exploited.

Much can be learned from reasonable complaints. A patient who had

complained about the attitude of his surgeon was interviewed by another

surgeon as part of a formal investigation into the complaint. The patient was

pleased to find that the investigating surgeon was a complete contrast—

“conversational, sympathetic, and informative; wide ranging and encouraged

questions (with) a very human approach which inspired trust.” As the

complainant explained, the matter need never have reached the stage of

formal complaint: all he had been seeking was “a small acceptance (from the

first surgeon) that some of the procedures are inadequate and will be revised”.

Arrogance is something that students need to lose early in their training, if

they have the misfortune to be afflicted by it; patients can do without it.

First patients

Stepping tentatively on to the ward for the first time, resplendent in my new

white coat, I felt that the long awaited moment had arrived. “Clerking”

involves taking a history from and examining the patient. We had been told

that this process, which has been handed down from doctor to medical

student for countless generations, enables the doctor to make 95% of the

MEDICAL SCHOOL: THE LATER YEARS

73diagnosis (75% from the history and a further 20% from the examination—

the last 5% comes from further investigations). This is why clerking has and

will continue to be such a powerful tool in the hands of the clinician, though

not necessarily in the hands of a junior clinical student.

On the first day of the junior course we learn how to take a thorough

history. This involves an overall framework of “presenting complaint”,

“history of presenting complaint”, “past medical history”, “family history”,

“drug history”, “social history”, and “any other information”. With practice

it becomes possible to tailor the history taking to the individual.

Next comes the examination, something which opens up a veritable

minefield for the inexperienced. When you perform a general examination

every body system has to be inspected, palpated (lightly and deeply),

percussed (examined by tapping with the fingers and listening to the pitch of

the sound produced), and auscultated (listened to with a stethoscope). This

is the theory but inevitably, either through incompetence or sheer bad luck,

it is almost impossible to perform a perfect examination on every patient—

either some of the pulses are not felt or the enlarged liver does not seem that

enlarged; whatever the sign of disease that causes such frustration by escaping

the student, you can guarantee that the senior house officer will come along

and find it within seconds!

The introduction to basic surgical techniques was one of the better

activities organised for us during the junior clinical course. Armed with

scalpels, sutures, forceps, and pigs trotters the surgeons demonstrated the

basic principles of stitching wounds and then let us loose on our own practice

limbs. This was an excellent afternoon for the students, not least because it

gave us the opportunity to do something incredibly practical that most of us

had never done before. Having mastered (?) the mattress stitch, we moved on

to the more cosmetically friendly subcuticular stitch, and I am sure we greatly

impressed our surgical superiors with our manual dexterity!

The afternoon concluded with teaching us how to draw up and mix drugs

with a syringe and how to inject them subcutaneously and intramuscularly

(the intramuscular route was cleverly improvised with an orange).

My first firm was a series of firsts. First clerking of a patient—nerve racking

as the whole scenario is new. I felt ill equipped and slightly obtrusive as I

clumsily searched, questioned, and of course palpated and percussed my

patient. The sense of relief as I parted the curtains and left the cubicle, history

complete, was overwhelming.

First ward round—how I regretted not learning my anatomy better as in

the words of our senior registrar I displayed “chasms of ignorance”, only

managing to redeem myself by the narrowest of margins.

First surgical operation—it was a real privilege to clerk a patient, then later

watch and even assist in the operation and later still revisit the patient on the

ward. Theatre also provided a superb way to learn by watching but also by

the excellent active teaching of the surgeons.

First freedom—for the first time since entering medical school I was

expected to decide for myself what to go to, what to learn, what to read, and

to think more laterally and broadly than ever before.

First encounter with real patients with lives we are able to be part of for

some small time—call us naive and overenthusiastic and we would agree. We

LEARNING MEDICINE

74are sure that some of the novelty will wear off after nights on take and

unpleasant patients. Call us idealistic and we would agree and pray that it

may be a comment levelled at us not just now as we experience our “firsts”

but on until we experience our very “lasts”. When idealism dies it is not

replaced by realism but by cynicism and long may we be idealistic realists.

AH, SC

Meanwhile, at another medical school, another student was seeing a

similar experience through somewhat different eyes.

First clinical “firm”

The first day as a clinical student is a little like the first time you have sex. There

is a lot of anxiety and excitement for what often ends up as a disappointing and

humiliating experience. At last an escape from lecture halls and seminar rooms;

an end to being force fed mind numbing facts such as the course of the left

recurrent laryngeal nerve or the intricacies of gluconeogenesis. I had a crisp

white coat and smart matching shirt and tie. The finishing touch being a

stethoscope slung casually around my neck. I had arrived, I looked fantastic,

and I was IT.

I was attached to a firm run by a consultant whose fearsome reputation was

unrivalled in the region. She had a moustache that Stalin would have been

proud of and a personality to match. My fellow students were a real mixed

bag; two rugby lads, two sloanes, a girly swot, a computer geek, and a goth!

Most medical students wear a common uniform; boys in light blue shirts,

stripy ties (preferably rugby ties), chinos (regulation length one inch too

short), and either shiny, pointy shoes or those brown deck shoe things. Girls

tend to opt for simple blouses with pretty necklines and floaty, flowery,

shapeless skirts … invariably sensible and never fashionable.

Every aspect of being a clinical student combines in an attempt both to

educate you and to expose you to the realities of being a junior doctor. The time

is split between seeing patients on the wards, teaching sessions, sitting in clinics,

and assisting in operating theatres. The day usually begins with a ward round.

Medicine is like a huge machine; everyone has an allocated role; everyone is an

essential moving part. The system works well if we all know our place and act

according to our roles. The ward round reflects this system and demonstrates

the hierarchy and tradition that exists in medicine. The consultant is the boss.

His (or less commonly her) role is twofold. Firstly, to impart knowledge to the

more junior members of the team (that is, everyone) in the form of witty and

wise anecdotes and, secondly, to use derision, disapproval or old-fashioned

humiliation on his or her juniors lest they forget their places.

Next in line are the registrars who are occasionally allowed to adopt the

role of the consultant if he or she is otherwise engaged at the golf course/race

course/Harley Street. Very rarely registrars are allowed to know something

the consultant doesn’t. There are strict limitations on what this information

can be, but it generally involves very obscure areas of research that will never

MEDICAL SCHOOL: THE LATER YEARS

75make it into the textbooks anyway! The senior house officers and house

officers ensure the smooth running of the firm; taking notes, making lists,

organising tests, and collecting results. They are also objects for ritual

humiliation (that is, teaching) when the students are not around. Your role as

a student is not difficult; laugh at the consultant’s jokes, help out when

needed, learn lots, and make great tea.

I was strangely reassured to find that ward rounds conformed to my

preconceived idea of an all powerful consultant sweeping down the ward with

an entourage of doctors and students following in order of decreasing

seniority. Each student is allocated their own patients. On this particular day,

my luck is in; the procession stops at the bedside of a young asthmatic man

with a chest infection. He is not my patient. The student concerned steps

forward, a little flushed and sweaty, but none the less does a good job of

presenting her case and answers well under interrogation from the

consultant. Her triumph, however, is short lived. It is revealed that she has

not looked in the patient’s sputum pot for three days. This is just short of a

hanging offence on a respiratory firm!

There are a number of skills that make life as a medical student more

tolerable. Most of these involve creating the impression that you know more

than you actually do. This means avoiding answering questions about which

you know nothing (which at the beginning is most things). Consider the ritual

of bedside teaching. I made it my mission to avoid speaking to or touching

the patients at all costs. Avoiding eye contact is a guaranteed way to be asked

a question! All patients are examined from the right hand side, therefore

initially it is advisable to stand on the left hand side of the patient. One needs

to judge the time accurately, however, when the clinician will try to be

cunning and ask the student standing the furthest away from the patient. The

skilled student will anticipate this moment and, at the appropriate time,

enthusiastically stands on the right of the patient, hence double bluffing the

clinician. When successful this manoeuvre is poetry in motion.

After clinic I went to the casualty department as it was my turn to shadow

the house officer on call. This turns out to be highly enjoyable; seeing

real patients with real diseases and being involved in the process of sorting

them out without the responsibility of having to  know  things or make

decisions. In the space of a few hours we see two old ladies with chest

infections, a man with heart failure, two paracetamol overdoses, and a heart

attack. A moment’s peace some four or five hours later is shattered by a series

of piercing bleeps and a crackling disjointed voice proclaims from the house

officer’s pocket that there has been a cardiac arrest on one of the wards. The

dreaded crash bleep: we get up, and we run. We arrive on the ward, and very

quickly there is a small crowd of doctors and nurses around the bed of the

old man we had admitted earlier with a heart attack. I stand back feeling

more than a little useless. Intrigued and a little appalled, I watch as the

registrar gives instructions to insert lines and tubes and to administer drugs

and electric shocks. After about 20 minutes everything stops; a stillness

replaces the activity and the old gentleman is left to rest in peace. I feel upset

and shocked, but to everyone else it’s just part of the job.

The clinical years are the first real opportunity to manage your own time.

It is important to do so sensibly. The system is open to abuse and many a

LEARNING MEDICINE

76cunning student manages to do the minimum amount of work in the shortest

period of time. There will be things you love about being a student and things

you’ll hate. I personally would avoid operating theatres like the plague. There

is nothing pleasant about standing around in green pyjamas, a paper shower

cap, and fetid, communal shoes in which most decent people would not even

grow mushrooms, never mind put their feet. The student in theatre is meant

to  retract. This involves pulling very hard on metal implements (which are

usually inserted in a stranger’s abdomen) in directions that your body was not

designed to go. This causes pain, stiffness, and eventually loss of sensation in

the hands, the likes of which have never been felt before outside a Siberian

salt mine.

It is important to learn the things you need to get through the exams, but

there are a lot of other valuable lessons to learn. One day you will be a house

officer and your social life and sanity will be seriously compromised … so

don’t waste the time you have now. Medicine  is  great, with something to

appeal to everyone. It’s a little like a pomegranate: you will hopefully find it

satisfying and worth while in the end, but it can be challenging and

infuriating going through the process!

MB

Self directed learning plays an ever increasing part as time goes on

through the course and as you will be repeatedly reminded “every patient

is a learning opportunity”. There are always patients to be clerked and

examined. This may be in the holistic mould of learning about the person,

their condition, and the whole experience of their illness or learning the

clinical features and management of the diseases relating to the specialty

you are currently studying. Students nearing their clinical finals adopt a

rather more focused approach: racing around the wards examining “the

massive liver in bed 4”, “the wheezy chest in bed 9”, and the “rather

embarrassing rash in the sideward”, grabbing a quick coffee while firing

questions at each other about the causes of finger clubbing and the side

effects of amiodarone, then fitting in a couple of children and a mad person

before lunch.

Keen students who spend more time on the wards seeing patients and

learning about conditions for themselves often benefit from impromptu,

informal teaching from junior doctors who can teach during the course of

completing their ward work. Following a junior doctor on call is very

valuable experience and is often the best way to see a general mix of cases.

Students need to be around when things happen if they are not only to

learn but to experience the excitement and satisfaction of clinical medicine.

A group of students once reported on their experience in these words:

Our teaching was really, really good from house officers right through to

consultants. So much time and effort was put in for us at all hours of the night

and day, so much so that some of us learnt some important skills like how to

read ECGs in the early hours of the morning on take in the hospital.

MEDICAL SCHOOL: THE LATER YEARS

77Spending an evening with the registrar in the accident and emergency

department on the front line, seeing patients brought in by ambulance or

referred by local general practitioners, is far more interesting for most

students than standing at the back of an operating theatre, craning your

neck, and still not being able to see what the surgeon is doing and getting

flustered when you are shouted at for getting in the way or because you have

momentarily forgotten the anatomical borders of Hasselback’s triangle.

A night in casualty

I remember my first night in casualty as a medical student as one of the most

exciting times of my whole medical training. My placement in what is properly

called accident and emergency medicine was relatively early in my time at

medical school so, although I felt that my knowledge was minimal, my

enthusiasm levels had never been higher; how many other students would be

excited at the prospect of spending all of Friday night doing college work? The

department resembled Piccadilly Circus, in all senses, especially noise and

smell. There was a constant flow of people milling here and rushing there,

lying on trolleys, sitting on floors, banging on the wall, singing in the toilet,

crying in the corner, or sleeping in the waiting room; men, women, children,

patients, relatives, doctors, nurses, porters, receptionists, radiographers, a

couple of burly policemen and a rather conspicuous and obvious plain clothed

detective, and to cap it all two nuns looking for a missing mother superior.

As well as the large number of walking wounded, an increasing proportion of

whom as the night wore on and the pubs closed became staggering wounded,

there were a couple of cases which I think I will never forget as they showed me

medicine in all its glory. A lovely lady in her 80s was brought in by ambulance,

LEARNING MEDICINE

78acutely short of breath and looking extremely distressed and scared. She had

heart failure and her lungs were filling up with fluid as her heart could no longer

pump effectively. Within minutes the junior doctor I was following around had

put in a drip and was giving her some drugs which I had learnt about only a few

weeks before in a tutorial. As I stood by her bed filling in the blood forms trying

to help out a bit, she started to get her breath back and soon was able to talk to

me. Within an hour she had managed to tell me her whole life story, including

her several boyfriends during the war, the relevance of which to her medical

history I still find hard to grasp, but she insisted it was important. About 2 am

a young man of my age was rushed in from a road traffic accident, having been

knocked off his motorcycle at high speed. He was unconscious and had several

broken bones. Seemingly out of nowhere an enormous group of doctors and

nurses appeared in the resuscitation room and pounced on the man, but with

awe inspiring calm and organisation; it really was like watching an episode of

Casualty, except that on TV you get a better view than you do when you are

right at the back of a group of frantically busy people and you are trying not to

get in the way. By 3.30 am everything had quietened down somewhat, though

the waiting area was still half full. The motorcyclist was in theatre having one

of his fractures screwed together, and the sweet old lady with an interesting

history was apparently soundly asleep on a ward, one of the lucky few not

having to stay on a trolley in casualty. I wandered off to bed exhausted and

exhilarated; the doctors and nurses carried on seeing patients. How, I

wondered, will I ever know what to do and be able to treat people as well as

they did, and, more worrying, how will I be able to stay awake that long?

GR

MEDICAL SCHOOL: THE LATER YEARS

79One of the most valuable experiences towards the end of training, which

most schools encourage, is a period of several weeks shadowing a junior

doctor. This usually occurs in medicine, surgery, or obstetrics and may take

place in a general hospital away from the medical school. This allows only

one or two students to be placed in each location, maximising their

exposure to patients and teaching, and giving the opportunity for close

supervision as clinical skills such as bladder catheterisation or intravenous

cannulation are practised.

First delivery

I was woken up by the sound of my bleep. It was barely 4 am, and I had been

asleep for less than two hours. By the time I had wearily put on my shoes and

rushed to her cubicle, she had already begun to push. Jane, the midwife,

decided that there was not time for me to put on a gown, so I just put on the

gloves. The mother to be began to scream as the contractions became

stronger and with each push the baby descended further. I placed my left

hand on the head as the crown appeared to stop it rushing out too quickly,

while supporting the mother with my right. I could almost feel my heart

thumping against my chest. Any remaining signs of tiredness had now

completely disappeared in all the excitement. Here I was minutes away from

helping to bring a new life into the world.

It all went so quickly after that. First the baby’s head appeared, and I pulled

it down gently to release the anterior shoulder. The rest appeared to come out

all by itself. It was 4.36 am precisely, and a big baby boy was born. The

mother cried with joy as I placed him on her tummy. It’s an amazing feeling.

The family wouldn’t let me go until they had taken a photograph of me

holding him in my arms. By the time I had helped the midwife clear the mess

and made sure all was well, it was way past 5 am. Time to get some sleep.

FI

The clinical subjects

The major subjects to be learnt are general medicine and general surgery,

and these are often studied in several blocks throughout the later years.

Increasingly, the emphasis is on core clinical skills rather than an

encyclopaedic knowledge of different disciplines. The boundaries between

“subjects” are blurred and they are learned in a more integrated way and

examined in integrated clinical exams. If they are not integrated, and as

medicine and surgery become ever more specialised, the best general

experience is often achieved by rotating through several firms covering a

range of subjects as well as being around when the firm is “on take” (the

team responsible for general admissions on that day). An eight week

medical attachment may involve a fortnight each of chest medicine,

infectious diseases, endocrinology, and cardiology. A similar rotation in

LEARNING MEDICINE

80surgery could include gastrointestinal surgery, vascular surgery, urology,

and orthopaedics.

Generally, students are split into small groups and allocated to a

particular firm in the relevant specialty. The firm is the working unit of

hospital medicine and usually comprises a consultant or professor, one or

two specialist registrars (who qualified several years before and are in

training for that specialty), a senior house officer (who is usually a couple

of years out of medical school and may be wanting to follow that specialty

or may be in training for general practice or may just be drifting waiting for

inspiration), and a house officer (who is newly qualified and will try and

whisper the answers to the boss’s questions to you, which is generally why

you will get them wrong).

The patients in hospital (inpatients) under the care of that team also

provide the teaching subjects for the students and are shared out between

the students, who are expected to talk to their patients and examine them

before being taught on ward rounds or teaching sessions by the senior

members of the team. In the past much of this teaching was in the form of

humiliation; ritualistic grillings of students in front of patient and

colleagues alike, in the style of Richard Gordon’s character Sir Lancelot

Spratt and his blustering, “You boy! What’s the bleeding time. Speak up.

Speak up”. While the occasional medical dinosaur can still be found eating

a brace of medical students for lunch, it is no longer acceptable today and

is much less likely to occur. The student who has taken the effort to prepare

for such teaching can gain enormous benefit from seeing a condition he or

she has previously only read about being illustrated in flesh and blood,

making far easier the committing to memory of facts and figures as they

suddenly take on real meaning and significance.

The use of community-based services as resources for learning is growing

in all schools, some at a faster rate than others. For example, Bristol now

has a series of clinical academies across the West Country in Bath, Swindon,

and Taunton for instance, where students spend several months at a time

MEDICAL SCHOOL: THE LATER YEARS

81on attachment to various teaching firms. As more care passes from hospital

to community, such as in mental illness or child health, and as hospital

stays tend to be much shorter, such as after having a baby or having day

surgery, students are having to go to where the patients are.

General practitioners are playing an increasing part in undergraduate

teaching of clinical skills, such as examination of body systems, in addition

to their traditional role of teaching consultation skills and health

promotion. Insight can also be gained into a broader spectrum of disease

and social problems than is apparent in hospitals, learning to deal

appropriately with minor everyday illnesses or major personal upheavals

that affect people’s lives.

A day in general practice

My practice starts the day with a team meeting. A coffee fix gives everyone

time to label the important events of the next few days. The builders are in,

so all hearts will have a continuous murmur today; a new software package

will be demonstrated to allow current problems to be highlighted while listing

previous diagnoses, but will it really help? Instantly I am involved, my

opinion sought in a warm welcome to the group. I ask what book I should

read to learn about general practice and am told Middlemarch  by George

Eliot. Six months later, having read the book, I am still thinking about what

was meant by that answer. In return, they ask me what skills a doctor should

have in general practice. Everyone joins in, and the discussion leads us into

seeing the patients.

Today I see the patients on my own first. I receive more trust and

responsibility from these doctors in a week than in a year at the hospital.

Presenting the complaint and my thoughts to the GP is excellent practice

at developing a “problem-oriented approach”. I am daunted by the

impossibility of knowing the person and their history in 10 minutes, and

hospital clerkings are little preparation. The long relationship between GP

and patient is such a privilege and opportunity for appropriate intervention

relevant to the patient’s needs and wishes.

I think through the messages I learnt from watching myself on video being

“consulted” by actors back at the St Mary’s department of general practice.

The skills are those of good listening, while considering the possible

background to the presenting problem—the family problems, alcoholism—

and the needs, articulated or unspoken, for caring, a further specialist

opinion, or a prescription. I remember the advice that a holistic viewpoint

and the availability of complementary therapies can obviate the need for

drugs as psychological props for either doctor or patient.

Mr A has low back pain and was given short shrift by the orthopaedic

consultant for not having sciatica that would be worth operating on, entirely

ignoring his pain. We talk about his weight, posture, and stress at work and

re-emphasise his need for exercises and a good chair, which seems more

appropriate. Ms B comes in with severe abdominal pain and iliac fossa pain

LEARNING MEDICINE

82and rebound tenderness. My excitement at a possible hospital referral dies

down as the doctor reassures both of us that this is constipation. The case

mix is so different in a teaching hospital; a sense of proportion is vital and can

come only with experience. Mr C was found to be hypertensive

opportunistically at a previous visit, and the nurse has confirmed this

subsequently. We discuss what this implies for his future health and

treatment, and the doctor and I talk afterwards about current concepts in the

management of blood pressure from both personal care and population

health perspectives. Every person is different and requires integrating an

understanding of the possible pathologies with what is realistic in their life.

Without time or fast investigations nearly every diagnosis may be provisional;

“come back tomorrow” is not a cop-out but good management.

In the corridor we have a “kerbside” case conference about what to do with

Ms X. She has many problems, and all the partners have been to visit her at

one time or other. The latest news is not good, and, although she has heart

failure, it is her mobility and risk of hip fracture that we worry about. We visit

her before lunch, assess her cardiovascular and neurological status, and find

out how well the carers are coping. It may be that improving the lighting will

counter her drowsiness and prevent a disastrous fall.

Over lunch we discuss strategies and priorities in looking after someone

with diabetes and the implications for general practitioners of the new NHS

changes. The balance has swung away from clinical freedom; doctors have

lost much control over their time and decisions but to quite an extent are

being forced to do what they would have liked to do anyway, namely more

work on prevention and health promotion. Computerisation has been

unavoidable but as yet wastes far more time than it saves. There is great

potential for clear presentation of patient information and for networking

outcomes between patients and practices for audit and research. I sit in

quietly as another partner runs a yoga class in her lunchbreak and feel greatly

refreshed for the afternoon.

Later on, I join the local community psychiatric nurse. One of the people

we visit has panic attacks when she goes outside. The nurse has given her

mental exercises to do at home and a routine to use when she feels the panic

attack developing. We take her out for a walk calmly and get along without

her anxiety becoming panic, which encourages her greatly. Another woman

has gradually become more depressed since her husband died, and the nurse

is delighted that she has a chance to intervene with counselling and cognitive

therapy before a doctor (not from my practice!) has filled her full of tricyclic

antidepressants. A third has Alzheimer’s disease, and the issue is whether

she will leave the frying pan on and burn the house down while her son is out

at work.

Back at the practice I get on my bike to go home, overwhelmed by the

breadth of insight needed in this work. The loneliness in the consulting room

is more than compensated by the warmth of genuine teamwork and equal

exchange of views and approaches. Humanity and pathophysiology do mix

after all.

TA

MEDICAL SCHOOL: THE LATER YEARS

83The major clinical subjects in addition to medicine and surgery are

also taught in a similar fashion: obstetrics (the care of pregnant women)

and gynaecology (the specialty devoted to diseases confined to women);

paediatrics (child health); and psychiatry (the care of patients with mental

illness).

Other specialties occupy a smaller part of the students’ time, and only a

general understanding is required as detailed knowledge is beyond the scope

of basic general medical training. These include neurology (disorders of the

motor and sensory function of the brain, spinal cord, and peripheral nerves);

rheumatology (medical disorders of joints such as arthritis); genitourinary

medicine (sexually transmitted diseases which may involve the study and

care of HIV and AIDS); dermatology (skin diseases); ophthalmology (eye

diseases); ear, nose, and throat surgery; and anaesthetics, which also covers

pain management.

An attachment in the accident and emergency department is one of the

most popular parts of the course for most students. The glamorous image

portrayed by TV series is never all it is cracked up to be, but the excitement

level is generally high, especially when there is the chance to be a useful pair

of hands, suturing a laceration, helping the nurse put a plaster cast on the

broken arm of a wriggling 5 year old, or providing chest compressions

during a resuscitation.

At some stage in the later years a more detailed approach to pathology is

required, and this may take the form of a block of lectures, tutorials, and

practicals or may be covered throughout the later years alongside the

LEARNING MEDICINE

84relevant clinical attachments. The subjects studied under the heading of

pathology are chemical pathology (the biochemical basis of diseases);

histopathology (the macro and microscopic structure of diseased tissues);

haematology (the diseases affecting blood and bone marrow); microbiology

(combining the study of bacteria, viruses, and other infectious organisms);

and immunology (the role of the immune system in disease). Without a

knowledge of these disease processes it is difficult to understand clinical

signs and symptoms and to interpret the results of laboratory tests which

play a crucial part in diagnosis and management of patients.

Other topics are fitted in as the course progresses including clinical

pharmacology and therapeutics (the prescribing of drugs to treat illness),

palliative medicine (the care of the dying), medical law and ethics, more

advanced communication skills such as breaking bad news and bereavement

counselling, and sometimes personal care (how to look after yourself with all

the physical and emotional stresses and strains of being a doctor) and basic

management skills. An increasing number of medical schools also give

students a general introduction to complementary and alternative medicine,

so that as doctors they may have at least some insight into their patients’

choices and also consider whether some aspects, such as acupuncture,

might become a useful adjunct to their own practice. The aim of the later

years is to build on the basic knowledge and skills learnt in the early years

MEDICAL SCHOOL: THE LATER YEARS

85and to add to that the necessary attitudes and skills in decision making,

coping with uncertainty, and dealing effectively with patients, relatives, and

colleagues that patients should expect of a good doctor.

The elective

As well as the special study modules which allow each student choices in

the precise content of their course, and the opportunity to learn how to

study in greater depth, all schools set time aside in the later years of the

course for what is known as the elective period. This is usually between

6 and 12 weeks long and is an opportunity for a student to undertake any

medically related study at home or abroad. Most students take the chance

to travel and see medicine being practised in a very different setting

whether in a trauma unit in down town Washington DC, the Australian

Flying Doctor Service, or a children’s immunisation clinic in a canoe in

Sarawak. Some students carry out research while on elective or gain

experience of a subject to which they have only limited exposure in their

undergraduate course such as learning difficulties or tropical diseases. The

British Medical Journal  offers a different sort of opportunity through the

Clegg scholarship for electives working in medical journalism.

A day on elective

Breakfast is pawpaw and aromatic coffee with sacred ibis calling as they fly

along the Indian ocean shore. The day starts with the ward round. Eighty

kids are packed two or three to a bed. They variously smile or cry, run

around fighting or lie listlessly, bellies bulging with kwashiorkor or skin,

eyes, and hope flaccid with dehydration. I stride into the measles side ward,

a tiny room with three cots now packed with 10 mothers and babies in

various stages of spottiness.

Admitting a child with measles is easy. The repertoire of a 1 year old is

limited to vomiting, diarrhoea, fever, cough, and breathlessness, and with

measles all are present in abundance. Red eyes, throat, and eardrums

complete the picture examined carefully on the mother’s knee (not my own

after it was drenched on day one), and the vague but, with experience,

characteristic graininess that will pass for a rash on black skin the next day is

hardly needed. The mothers know it to be measles anyway. This is not my

benign childhood discomfort of measles. Many of them will die of

bronchopneumonia (ampicillin is probably just to keep the doctors happy,

but we watch carefully for signs of staphylococci) or of dehydration, which

has become my personal crusade. My five minute lecture in broken Swahili

attempts to persuade the mother to take on the responsibility of forcing in

rehydration fluid tirelessly. So my round of the measles ward is basically to

take the temperature and respiratory rate and get a general feeling for each

child’s health. The sick ones get a closer look that always comes down to not

LEARNING MEDICINE

86enough water, and so, to the general amusement of all, I’m back on my hobby

horse for a bit more negotiating about why the child won’t drink or is not

getting enough.

Talking about fluids and measles has been fascinating. Discussions in small

groups, wandering round the rickety shacks both in town and out in the

surrounding forest, stumble on in Swahili or are translated from Giriama by

the wonderful local fieldworker who introduces me. Drunken men lolling in

front of their huts accost us and gesticulate aggressively; a group of young

women waiting to fill their buckets with water are shy but add their opinions

once the most assured has spoken. Water and blood are symbolically related,

and when water is drunk they believe it goes into the lungs (hence people

with not enough blood, with anaemia, are breathless) and from there round

the body in the veins (everyone knows doctors shortcut this by pouring water

into the veins direct). Measles, in turn, is within the essence of all people, and

must “come out” at some time, inevitably. Vaccines are accepted with

equanimity and wry suspension of disbelief in their action. Most dangerous

is when the measles goes “back in”—I would explain it as severe dehydration

that stops a child’s tears, vomit, and diarrhoea—but we agree anyway that

death may be imminent.

The ward round continues, from the successes—the child with nephrotic

syndrome receiving steroids, whose smile widens daily as his swelling

subsides, and the bored happy ones with broken legs hanging from pulleys—

to the failures—a paralysed speechless girl brought in after fitting with

meningitis for hours, whose family can no longer manage, her living skeleton

malnourished and fading away despite all our efforts.

By the end of the ward round the first five or so of the day’s 10 or

20 admissions are gathered. Some, at their last gasp for water or air, are given

water or blood respectively. The Kenyan medical students amaze me yet

again with their skill at slipping needles into the most fragile of dried out baby

scalp veins; I amaze myself with a perfect lumbar puncture on a screaming

urchin, and take the happily crystal-clear drops off to the laboratory. There I

check the results from the day’s malaria slides and write the prescriptions

accordingly. After a lunch break, I wander into one of the town’s cafes, the

loose ends on the ward are tied up, and it is time for projects. Rob’s is with

the high tech transcranial Doppler ultrasound measuring blood flow in the

middle cerebral artery—will this tell us important things about disease

processes in very sick children? The whoosh-whoosh-whoosh pulses out at us

as we walk past the little research ward.

My project is to count every drop of fluid going into and out of a child with

cerebral malaria over 24 hours. Endlessly there are extra sources of error, not

noticed by me as I try to add up volumes and nappy weights in the middle of

the night. This year, for better and worse, the rains haven’t come properly, so

there is little severe malaria, and instead today I can amble back to the

guesthouse, luxurious by local standards, for a swim in the balmy buoyant

water. There I can dream of my next trip up the coast to the ancient Islamic

island city of Lamu, an African Venice of narrow streets, donkeys, cool wind,

relaxed gossip, and self indulgence by the waterside.

TA

MEDICAL SCHOOL: THE LATER YEARS

87Assessments and exams

Schools adopt different systems of assessing students’ clinical progress.

Most combine end of attachment assessments with a final MB exam at the

end of the course, which were traditionally taken in one grand slam but are

increasingly now divided up into different parts over a year or longer. The

final MB consists of different sections in pathology, medicine, surgery,

clinical pharmacology and therapeutics, and obstetrics and gynaecology.

The “minor” specialty attachments are included in the major subjects. The

amount of emphasis placed on each varies, and within each the emphasis

is on the ability to reason and use knowledge rather than to function as a

mixture between a sponge and a parrot. Some schools prefer almost total

continuous assessment with each exam contributing to the final MB.

Others continue to put major emphasis on finals with the regular

assessments being used to monitor progress and certify satisfactory

attendance and completion of an attachment.

An increasing number of schools split finals into two, with the written

papers taken a year earlier than clinicals, to encourage concentration on

clinical skills and decision making before becoming a house officer.

The final MB comprises multiple choice questions, extended answers to

structured questions, or essays, and practicals. In medicine (which includes

paediatrics and psychiatry), surgery, and obstetrics and gynaecology

considerable emphasis is placed on the clinical bedside examination, which

tests skills in talking to patients, eliciting the relevant clinical signs, and

making a diagnosis. Oral examinations are also held in most subjects.

Clinical skills are increasingly being tested in a more systematic way

through Objective Structured Clinical Exams (OSCEs). A few minutes are

spent by all candidates at a series of “stations” at which they have to

perform a particular task, or address a problem.

LEARNING MEDICINE

88However the exams are structured, there is no avoiding the fact that they

require considerable amounts of work over a prolonged period. They are as

much a test of emotional stability and physical endurance as they are of

knowledge and skills. Most students do pass at their first attempt; up to

10% have to resit all or part of their finals six months later. Very few fail

more than once.

REMEMBER

• The later years are more like being an apprentice than a conventional

student.

• The course is largely concerned with core clinical skills, strategies of

investigation and treatment, and professional attitudes.

• Much of the learning is from patients, including acute emergencies, and

at times it is necessary for students to live in the hospital overnight or

occasionally for longer periods.

• Students may travel to nearby hospitals, community health centres and

GP surgeries for a broader exposure to medical practice.

• The main clinical components are the principles and practice of general

medicine and surgery and their related sub-specialties: obstetrics and

gynaecology, child health, psychiatry, clinical pharmacology and

therapeutics, and the underlying pathology sciences. Communication

skills and ethics continue as important themes.

• Choice and opportunities for study in depth are provided through special

study modules which may be expanded to lead to an intercalated science

degree.

• The elective period, which most students spend abroad, is a great

opportunity to travel and learn how medicine is practised in other

countries and cultures.

• Assessment in the later years is by a mixture of in-course and end-of-

course assessments and final examinations, testing clinical skills, attitudes

and ability to use the knowledge gained. The pattern of assessment used

varies substantially between schools.

• Up to 10% of students may fail one or more parts of their finals on one

occasion but most are successful at a second attempt.

MEDICAL SCHOOL: THE LATER YEARS

8990

9. Doubts

Doubts are a very normal part of most people’s lives. No

university course,and no professional training,is more likely to

raise doubts than medicine: academic doubts,vocational doubts,

and personal doubts.

As Richard Smith, editor of the BMJ, once wrote:

Once they arrive, medical students are put through a gruelling course and

exposed younger than most of their non-medical friends to death, pain,

sickness, and what the great doctor William Osler called the perplexity of the

soul. And all this within an environment where “real doctors” get on with the

job and only the weak weep or feel distressed. After qualification, doctors

work absurdly hard, are encouraged to tackle horrible problems with

inadequate support, and then face a lifetime of pretending that they have

more powers than they actually do. And all this within an environment where

narcotics and the means to kill yourself are readily available. No wonder some

doctors develop serious problems.

Few intending medical students never have reservations whether

medicine is right for them and they for medicine. All too often these doubts

have concentrated too much on the process of getting into medical school

and too little on what being a doctor is all about, the consequence of which

being to add to the cynicism and disillusionment which is rife among junior

doctors. After working for several years on the BBC TV series Doctors To Be,

the producer Susan Spindler recognised this problem and offered some

good advice:

It’s hard to take a career decision at the age of 17; at that age many people

haven’t quite decided who they are and many of us change almost beyond

recognition between the ages of 17 and 25. If you are in any doubt about your

suitability for the medical life, postpone the decision: do another degree first

and wait until you are certain before entering medicine. Even if you’ve been

set on becoming a doctor since you were a young child, do your homework

first: spend time with as many doctors as you can—in hospitals and surgeries,

doing different kinds of jobs. Get a clear idea of the range of possibilities that

medicine can offer.

Once at medical school not many students survive five years without

wondering if they are on the right track. Doctors in the early years after

qualification are almost universally nagged with doubts about finding jobs,

obtaining higher qualifications, and whether their aspirations are realistic in

terms of skills and opportunities.Alongside these academic and vocational doubts the world of doctors in

training also creaks and groans with all the normal difficulties of men and

women finding their feet in an adult world. If newly away from home they

must find accommodation and adjust to the responsibilities that brings.

Mature students must acclimatise to a world that is often very different,

more hierarchical, and more juvenile than that in which their feet have

been so firmly planted for some years. Coping with the financial difficulties,

experienced by most students but particularly self funding mature students,

can take its toll. Medical students are not immune to all the usual identity

crises that strike most other students at some stage nor the relationship

dramas. In some ways the pressure to conform that pervades medicine in

general, and in medical schools in particular, does nothing to make such

problems easier; the pressure on time, especially at exam times and in the

early years after qualification, can test even the strongest of personal

involvements.

Academic doubts

Academic doubts at medical school are common in the early years. As the

first set of exams or assessments approaches most students feel nervous

about the amount of work they should be undertaking. The subject matter

and the style of learning and of exams may be very different from previous

experience. The greater emphasis on self directed learning with less of the

DOUBTS

91spoon feeding by teachers that many students are used to from school can

be bewildering at first. It is also much more difficult initially to gauge the

amount of work to do from seeing other people working. As at school there

will always seem to be individuals who sail through exams with apparent

ease on minimal revision, while you spend months solidly slaving away just

to scrape a pass. You will also soon find out the weird and wonderful ways

some of your new friends have of studying. Some will stay up all night,

others will have done four hours work before breakfast, some seem to stay

up all day and all night, while one of your flatmates will still seem to be

going to hockey practice, then for a drink with friends, then coming home

for an early night. Of course, only the very exceptional cases do as little

work as they seem to, and the best way to dispel any doubts as to how

much work to do is to do as much as you can; the vast majority of people

who fail exams at medical school do so because they do too little too late.

You should remember you have already proved with your entrance

requirements that you are academically capable of getting through the

course, provided you apply yourself realistically to the task ahead.

Vocational doubts

Doubts of a very different nature often surface when you are faced with

dealing with patients. Often this is because of the perception of the student

that their need to learn from the patient without really contributing directly

to their management makes them feel they are intruding and that the

patient is resentful of their involvement. This is rarely the case, and a

student with more time to spend talking than busy junior doctors can make

a considerable contribution to the care of patients, most of whom also fully

recognise that we all have to learn somewhere and on someone. One

patient described her experience like this.

My student

There must come a time when books and lectures need to be supplemented

with real experience on real patients. Most people are happy to oblige; after

all they are altruistic enough to give blood and carry organ donor cards, and

it’s more agreeable to give students access to your live body than to donate it

for “spare parts”.

I was first examined by students during one of my pregnancies. I had to

rest in hospital for several weeks and was captive for any passing student to

listen to my heart murmur and my baby’s heart: two for the price of one.

Recently I was in hospital again. The relationship between student and

patient can be mutually beneficial. The student can be a comforting

presence, having more time to spend with the patient than the busy registrar

on his or her brisk ward round, and the student’s attention is a welcome

break in the crushing boredom of life in a hospital ward. Do not

underestimate the importance of a student’s interest in a patient. Other

LEARNING MEDICINE

92patients watch enviously as the curtains are swished closed round your bed,

ears strain to hear what is going on inside.

My student last time was a girl and quite young. She was extremely polite,

with a warm friendly approach which helped me to relax. My permission

was sought and I agreed to let her examine me, literally from head to toe. I

touched my nose; my eyes followed her pen as she moved it across my visual

field; I wriggled my toes for her, I must confess to a feeling of slight

amusement as she consulted her highlighted textbook as we completed each

test. She even admitted that it was the first time she had done this. I was quite

touched.

My student had to take my medical history and present it to the rest of the

team. She seemed to be very thorough, much more thorough than an earlier

student in her final year. She was relaxed and spoke confidently about my case

and having done her homework answered all the questions that were fired at

her. I felt she did well and that she already has a good bedside manner.

Occasionally it is possible to recognise a former student after they have

qualified. I was visiting a patient in hospital when this happened. The doctor

came to see the patient, and as she turned to go she actually remembered me;

I was so pleased. I could not help noticing that gone was her slightly hesitant

student manner, apologising for having cold hands; in its place was a brisk

confident doctor doing a great job in a busy hospital. How proud I felt to

have played a small part.

BS

Learning from patients, especially in the early years, can occasionally be

disturbing and unsettling. Coming to terms with blood, disfigurement,

suffering, disability, mental illness, incurable disease, and death is difficult

for all students, but most will overcome it without becoming hard and

completely detached. A few others find it hard to relate to patients, which is

then compounded by them failing to develop the essential skills in talking

to and examining patients. Usually the best remedy in these cases is to

engineer a greater degree of involvement and responsibility, but with more

and better communication skills teaching in schools now such students can

find a good deal of help available. Occasionally this gulf seems unbridgeable,

and the student may have to decide whether to change course or to press on

to qualification in the knowledge that many careers in medicine have limited

contact with patients.

Personal doubts

The number of young doctors leaving medicine is nothing like as high as

has been reported. Fewer than 5% change career in the first five years after

qualification. Any loss at this stage represents a substantial waste of public

money; but, more than that, any waste of bright, talented, motivated,

dedicated individuals with ideals and aspirations which led them to become

DOUBTS

93doctors in the first place and who, for whatever reasons, decide to give up

is a tragedy. The factors which lead to disillusionment in young doctors are

numerous (even if they do not leave medicine), and many of the issues,

particularly over long hours, have now been dealt with, with some success.

Some of the problem, however, lies with the junior doctors themselves. Too

many doctors admit they did not know what they were letting themselves

in for. Nor perhaps did they realise the limitations of medicine to meet the

high expectations of the public—or of themselves. The earlier the problem

is examined the better: perhaps the combination of an improvement in

working conditions and a generation of enlightened, well informed new

doctors with an understanding of what lies ahead will lead to better morale

and less waste.

Given the breadth of talent of most successful applicants to medical

school it should come as little surprise that a major concern for many

doctors is that they have “sold their soul to medicine” and are now

incapable of doing anything else. In reality, many simply feel trapped in a

job they begin to resent. They feel they have lost, or had knocked out of

them, all the dreams and potential they had when they arrived at medical

school. An old Chinese aphorism states, “You grow old not by having

birthdays, but by deserting ideals”, and being a tired, harassed, stressed

junior doctor makes you feel prematurely old. Perhaps there is much that

can be done within the structure of medicine to prevent “burn out” but

doctors sometimes need reminding that “the grass is always greener …”.

LEARNING MEDICINE

94There is no escaping the fact that medicine is not just a job but a way of

life. It is important to realise that far from being less likely than others to

have serious problems, doctors are in some ways more likely to. They need

to be prepared to discuss their problems and to seek appropriate help.

Susan Spindler, producer of the Doctors To Be series had this to say about

doubts and some ways of dealing with them:

The early years as a qualified doctor can be so tough that they test the

strongest of vocations. A supportive network of family and friends—people

on whom you can offload anxieties and with whom you can share traumatic

experiences—can make the difference between staying and quitting. You

need all the student qualities listed above [see pp. 23–25] plus initiative and

the ability to take decisions. A robust value system that isn’t driven by the

pursuit of riches—you’ll probably see school and university peers working far

shorter hours for far more money during your late 20s and early 30s. A need

to compromise on the wish to achieve all you can in your career and forge a

relationship/marriage and raise a family—a particular source of difficulty for

women in hospital medicine. A supportive partner or spouse certainly makes

life much easier. And, if you have managed to keep a circle of non-medical

friends, you’ll reap the rewards now: many doctors find themselves trapped

in a world of medical politics and socialising—it’s much easier to maintain a

balanced view of life if some of the people you spend time with are not

doctors.

Vocational doubts and academic failures occasionally occur during the

course because of psychiatric illness, which is sometimes the outcome of

relentless parental pressure to follow a career which a student either did not

want or for which he or she was unsuited. Depression is the usual response.

Expert advice is needed. Psychiatric illness may be self limiting but it may

be persistent or recurrent and incompatible with the standards of service

and judgment which patients have a right to expect.

The importance of seeking help and advice before problems become

overwhelming cannot be too strongly emphasised. Most difficulties tend to

grow if incubated. In the first place there is no substitute for sharing

problems with good friends, and that is one reason why a successful school

needs to be a happy, considerate community and not just an academic

factory. But the advice of friends may need to be supplemented by tutors,

other teachers, doctors in the students’ health service, pastors, priests, or

parents. Although it is true that a problem shared is a problem halved, a

problem anticipated can be a problem avoided. No problems are unique

and none insuperable. Very occasionally the right move is to change course,

in which case the sooner the better. To change direction for good reason is

the beginning of a new opportunity, not a disaster.

One thing is reasonably certain: decisions either to learn medicine or to

abandon the task should not be taken too quickly. As Lilian Hellman wrote

in The Little Foxes: “Sometimes it’s better to let the sun rise again.”

DOUBTS

95REMEMBER

• Doubts are a normal part of everyone’s life.

• Most doubts are about personal ability and career aspirations.

• Mature students, more than most, have moments when they question

whether they are doing the right thing.

• Anyone who has achieved the entry requirements to medical school need

have no doubts about academic ability. Academic failure normally only

results from working too little, too late, and in a disorganised way.

• The few who will have doubts about relating to patients can be helped

through communication skills training.

• Unrealistic expectations can lead to doubts but can be avoided, and

prevention lies in an honest appraisal of oneself and careful researching

before opting for the career.

• Occasionally the decision to enter medicine turns out to be a mistake.

Changing course or career is a brave move which can lead to a new and

more fulfilling life.

• The best remedy for doubts is to share them with someone; you will find

you are not alone.

LEARNING MEDICINE

9610. The house officer

Almost all medical students would agree that the final exams for

the qualification of Bachelor of Medicine and Bachelor of Surgery,

whatever the precise form they take,are the most terrifying and

daunting experience of their lives. That is until a few weeks later

when they walk onto the wards for the first time as a “proper

doctor”. After six years of preparing for this day you are thrust

headlong into the real world. To become a really proper doctor,

that is to be a fully registered medical practitioner,the General

Medical Council (GMC) requires a new doctor to complete a year

of satisfactory service in recognised,appropriately supervised

preregistration house officer posts.

The real world

In a white coat, never again to be so clean and tidy, with pockets bulging with

books, pens, notepads, and all manner of equipment you have little idea

how to use, you walk proudly on to your ward to be met by an enigmatic look

from the formidable Sister that expresses exasperation and pity all rolled into

one. A couple of hours later the sparkle of youthful enthusiasm has been

transformed into a downcast look of dread mixed with horror. You have been

introduced, albeit fleetingly, to your team, and one of them actually said

hello, or at least that was what you had assumed the registrar meant when he

growled at you.

Now for the patients. There are quite a few at the moment because the

team was on call at the weekend and it has become really busy since they

closed down the old infirmary up the road. You frantically try to write down

everything your predecessor is telling you, even though you have not a clue

what she means by half of it, and you haven’t time to ask any questions

because she is in a rush to get to her new job in the Shetland Islands, which

she was due to start three hours ago. Then your bleep goes off: a patient to

see in the accident and emergency department; he has already waited half an

hour and he’s shouting about the “Patient’s Charter”. Then you have to go

for your computer induction course but can’t find where it is. You also need

to go to the toilet but you can’t find that either. And your consultant’s

secretary has just rung you to tell you to take some notes to your boss in the

outpatient clinic. On the way you find a scruffy looking elderly gentleman

slumped in the corner of the lift. Is he drunk or just asleep? You are fairly sure

97he is actually breathing, but just in case you get out at the next floor and use

the stairs. Your bleep goes again: Mrs Smith needs some paracetamol, but

you don’t know the dose; Mr Jones needs a new drip siting, and you always

missed the vein as a student, at least he didn’t need a catheter, you have never

even attempted one of those, never mind a successful one. And Mr Patel’s

son has arrived and wants to talk to a doctor. And there is still that man in

A&E, and the consultant also wants an x ray fetched from the boot of his

Volvo.

It is now four o’clock in the afternoon, no lunch yet and come to think of

it you still haven’t found the toilet. Your registrar is now waiting on the ward

to go round all the patients to check you have finished all the jobs from this

morning. Never mind, you are on call tonight, so only another 26 hours at

work and then you can go home.

Suddenly after six years in the sanctuary of the medical school, this is the

real world, the world of what is officially called a house officer, but is more

generally called a houseman—regardless of sex—or even, more or less

affectionately, “housepixies”, “housedogs”, or “houseplants”.

SS

Preregistration year

House jobs are almost always undertaken immediately after qualifying, and

it is not a good idea to take time off at this stage, such as for travelling or

further study; better to get the year over and done with while all you have

learned is fresh in your mind.

LEARNING MEDICINE

98The year is usually split into two six month posts: one in a medical

specialty, which includes the care of medical emergencies of all sorts and

often includes some time working in a care of the elderly unit, and one in a

surgical specialty, which involves the care of acutely ill patients with surgical

emergencies, with special experience, for example, in orthopaedics, urology,

or vascular surgery. Increasingly, rotations are being introduced which

involve four months in general practice along with four months each in

medicine and surgery in hospital. Some new schemes include paediatrics or

gynaecology in place of general practice.

The houseman is the bottom rung of the medical ladder; it is no less

important for that. The houseman is normally based on the wards,

providing the regular, front line contact between the patients and the team

of doctors looking after them. Much of the time is spent talking to new

patients about the details of their illness (taking a history) and examining

them, ordering the initial investigations and collecting the results, carrying

out the management plan worked out with the more senior members of the

team, and coping with day to day problems such as pain control, fluid

balance, and organising discharge and follow up arrangements.

The houseman’s role requires good communication skills. Whether it is

listening to the patient’s story of their illness and drawing out all the

information needed to make an accurate diagnosis; explaining the patient’s

condition, treatment or progress; offering reassurance; or breaking bad

news when appropriate. While this is for many new doctors the hardest part

of their job, and often the one for which medical school has in the past least

prepared them, the intimacy of the doctor–patient relationship can be

thoroughly rewarding, if occasionally harrowing, like the patient dying of

renal cancer who told her houseman that his care and kindness was making

dying less frightening and lonely than she had expected.

In addition to the daytime work, a houseman is on call, usually on a rota

of one in six nights and weekends, living in the hospital to provide

emergency care for the patients on the wards and any new patients who

need to be admitted to hospital. In most cases, when as a houseman you

have worked a night, sometimes all night, you are expected to be at work as

normal the next day. You should be able to go off after the “post-take” ward

round, reviewing all the new patients with the consultant and registrar, and

after having tied up the loose ends of treatment, investigations, and

discharge, but this can take most of the day. On some firms the houseman

goes off at 10 am the next morning but then does not see what happens to

the patients admitted during the night and so misses the chance to learn

from the experience. This is very different from working night shifts like

nurses, for example, and is something almost all housemen find difficult to

cope with, especially in busy jobs. The dreadful feeling at 4 am of finally

climbing into your bed and reaching across to put out the light and hearing

the bleep go off again, summoning you back to the ward you had just left,

is something you will never forget. It is quite amazing how your bleep

seems to know exactly the wrong times to go off, such as just as you sit

THE HOUSE OFFICER

99down with the sandwich you have just managed to grab between seeing

patients, or just as you have stepped into the shower, or every time you try

to go to the toilet.

Every houseman has stories of how annoying some of these calls are,

such as the call from a nurse at 2 am to ask if she should wake up Mr Smith

to give him his sleeping pill, or the call at 5 am by the staff nurse just

showing a student how the bleep system worked. My “favourite” was the

patient I was called to see in the middle of the night because he was cold

and shivering. Concerned he may have developed a dangerous fever I raced

from my room across the snowy car park, my mind racing for possible

causes, only to find on my arrival a poor old soul lying in a bed with no

blankets and next to a window which was wide open to the freezing

December weather. “Six years at medical school just to close a bloody

window” was the comment I was heard muttering under my breath as I

stomped off back to bed.

Rotas or shifts

Some hospitals have introduced partial shift systems for their junior staff,

where a houseman may work three weeks of days followed by a week of

nights or may find they work split weekend shifts, so that the periods of

continuous on call are reduced. Often the intensity of work is much greater

and the disruption of shift work, both on continuity of patient care and

doctors’ personal lives, arguably outweighs many of the benefits of more

protected sleep time. These shifts vary greatly between hospitals and

LEARNING MEDICINE

100departments and consequently vary in their popularity among staff and

patients. On call arrangements are changing all the time, and it is worth

keeping in touch with developments in this area as before too long it may

have an important impact on your life. For example, many hospitals have

arrangements that all housemen go to bed at midnight when they are on call

and the senior house officers cover any emergencies at night. In other

hospitals, physicians’ assistants have been employed who can perform many

of the routine tasks that housemen are usually expected to do, such as filling

in basic forms, taking blood samples, and re-siting intravenous drips.

In theory the preregistration posts complete basic medical education and

training, with the houseman effectively on loan from the university to the

NHS. The long hours and heavy workload, often including tasks more

appropriate to non-medical staff, however, has in the past meant that this

training aspect of the job has been neglected. Much has recently been done

to attempt to reduce junior doctors’ hours and to limit repetitive tasks of

little educational value, with a formal structure for meeting and monitoring

the educational and training needs of housemen. Much more can still be

done, but all housemen should now expect to receive protected time for

formal teaching and a named tutor throughout their attachments.

With the initiatives from the government to reduce junior doctors’ hours,

housemen should not be on duty for more than an average of 72 hours a

week (including time on call), with not more than 56 hours actually worked

and continuous duty—for example, over a weekend on call not exceeding

32 hours. In practice, some doctors are still working on rotas which are

non-compliant with the latest New Deal for junior doctors. Regional

Pre-Registration House Officer Sub-Deans and New Deal Task Forces are

monitoring these conditions much more closely than ever before, largely

through doctors completing compulsory work diaries. Hospitals can face

THE HOUSE OFFICER

101stiff financial penalties if their doctors are found to be working inappropriate

duties or if conditions such as accommodation or catering are inadequate.

As with the training of housemen there is much more that can and is

being done to improve working conditions, but prospective housemen

should keep up to date with what is going on, either through the press or by

talking to current housemen when they are on work experience attachments.

Most teaching hospitals and district general hospitals employ house

officers in the major specialties of medicine and surgery. Many of these are

linked in schemes with particular medical schools which try to find jobs for

as many of their new graduates as possible, though some new doctors

prefer to find their own “off scheme” jobs, perhaps close to home or where

they hope to settle down. At present there are more house officer posts

available than there are United Kingdom medical graduates, so every new

graduate is effectively guaranteed a job somewhere.

Where to go

The experience gained in different types of hospitals varies greatly—for

example, between a small rural district hospital, which may offer a better

exposure to common, “bread and butter” medical conditions, and a large

inner city teaching hospital, which may have a much narrower range of

patients but with a chance of exposure to research and the most modern

technology. Prospective housemen look for jobs most suited to their

interests and career intentions, with most trying to achieve some variety

and balance. For example, an aspiring young surgeon may decide to do his

or her surgical house job in a high profile academic unit then a medical job

in a district general hospital, while a would-be general practitioner may

choose to do both jobs in a district general hospital in an area he or she

wants to practise in eventually. Often other factors are taken into account:

a keen surfer or sailor may well choose a job near the coast while an inner

city job may be more preferable for the keen theatre goer or night clubber!

Some people have special ties, for example, a spouse with or without

children who cannot readily move just for six months or even a season

ticket for the local football club.

Like most jobs in medicine, the preregistration house officer year

(PRHO) is extremely demanding, perhaps not intellectually, but certainly

physically and emotionally. The down sides are well known—long hours,

little sleep, poor conditions, unfamiliarity with the job, and little

recognition. Although the situation is improving, it is still not uncommon

for even the strongest character to be put sorely to the test during this time,

with the butchest rugby forward being reduced to tears, not to mention

the ladies’ hockey goalkeeper. At times like this the friendships and

camaraderie that typify medical students are worth their weight in gold.

It is not all doom and gloom though. The houseman is uniquely placed to

be able to develop good doctor–patient relationships, to be involved in close

teamwork, putting the last six years of theory into practice, and, not least, to

LEARNING MEDICINE

102have the feeling of actually being needed and being useful: something you

hardly ever feel as a medical student. The pay cheque at the end of the month

is, of course, rather welcome too but will not bowl you over.

It is interesting to note that while in the midst of their year most

housemen see their posts as a means to an end, something to be endured

which will soon be over; once they are over, however, and the doctor has

moved on to bigger and better things, a surprising number of them look

back on being a houseman as the happiest days, and nights, of their lives.

REMEMBER

• After passing finals and graduating in medicine all doctors are required to

spend a year of supervised experience as a house officer.

• Your medical degree qualifies you for provisional registration with the

General Medical Council. Successful completion of your house officer

posts entitles you to full registration.

• The year must contain both medicine and surgery, including care of acute

emergencies. Some posts containing general practice or other specialties

are increasingly available.

• House officers are normally not permitted to be on duty for an average of

more than 72 hours per week of which 56 hours is actual work, allowing

for rest periods while on call in the hospital; you should not undertake

more than 32 hours of continuous duty (56 at weekends) during which

you are entitled to at least eight hours’ rest. In practice, an appreciable

number of junior doctors are still having to work longer or more

intensively, and this is still a major cause of contention in the NHS.

• House officers are the first line in the medical team, and are responsible for

the day-to-day care of patients (under supervision), and the organisation of

investigations and treatment. Communication with patients  and their

relatives is a crucial part of the role.

• The type of job and its location depends partly on personal preferences

and career intentions.

• Being a house officer is one of the hardest years of your life. It is disruptive

of your personal life, physically and emotionally demanding, and leaves

almost everyone close to tears at least once in the year. It can also show

teamwork at its best, be good training, great fun, and immensely fulfilling.

THE HOUSE OFFICER

103104

11. Choosing a specialty

A candidate was asked at his medical school interview where he

saw himself in,say,20 years hence. “I want to be a brain

surgeon,” was the 17 year old’s confident reply. Few medical

students,and indeed newly qualified doctors,could be quite so

sure of their career intentions. Choosing a specialty provides

many young medics with the seemingly endless dilemmas of

balancing employment opportunities,specialty preferences,

personal and family circumstances,and choosing where,when

and with whom to settle down.

It is important to remember you are not alone in being

undecided,you are allowed to change your mind,you are allowed

a life outside your career,and eventually most doctors find their

niche and have a happy,fulfilled life and career.

Some specialties are much more difficult than others to reconcile with

family commitments or other interests, especially in the early postgraduate

years. Some can say with Dawn Adamson, recently qualified at the time,

“I don’t see being a doctor as a job—I see it as a way of life.” But others can

also be good doctors while keeping medicine in its place. Keeping medicine

in its place can be difficult and Julian Eyers, also a recent graduate, was

right to point out that public (and professional) expectations of doctors

may fail to recognise that doctors are human too: he referred to “… a

public misconception that doctors are some sort of breed apart of medical

soldiers, ready to be drafted into any situation. Doctors are actually human

beings. They have loved ones, emotions, and outside lives. The conditions

are frequently so inhuman that they take an unacceptable toll on their

private and professional lives!”

Not only a parent or the carer of elderly relatives, but also the dedicated

sportsman, musician, or enthusiast for a full life may wonder whether an

otherwise attractive specialty would unacceptably monopolise their lives

and stifle their interests. Given the structure of society and the traditionally

predominant responsibility of the mother for the family, many of the issues

particularly concern women in medicine, but many male doctors have

family responsibilities too and other time consuming interests.

Long hours, resident on call duties, and shift arrangements designed to

reduce hours but creating their own problems in turn, both for structured

life and for systematic postgraduate education, are at the centre of the

conflict. Doctors in accident and emergency departments usually work around the clock shift system, which involves a predictable and regular

commitment. Some other departments are beginning to work a partial shift

system, with several weeks on days interspersed with a week on night duty.

Other departments are forming larger teams to reduce the night and

weekend on call duties, within an otherwise traditional rota system. The

maximum permitted average contracted hours of duty for doctors in

training is now 56 hours a week, equivalent to being on call about one in

six if you are also responsible for covering colleagues when on holiday,

study leave, or during brief illness.

Becoming a thoroughly fulfilled doctor is compatible with domestic

commitments provided both partners are prepared to share fully the task of

house and home. The trouble is that more than half of married doctors are

themselves married to doctors, with all the difficulty that that entails,

including coordinating on call duties, finding geographically convenient

higher specialist training programmes, and eventually obtaining mutually

compatible career posts. There may simply not be two appropriate posts in

suitable locations within a reasonable time. If both partners are in the same

specialty the possibility of job sharing might arise. General practice is a

better bet than a hospital-based specialty, not least because home and

practice are often close together. One couple, for example, took over a

single handed country practice and successfully shared both the practice

and the home duties. Their patients benefited from continuity of care from

CHOOSING A SPECIALTY

105a close knit partnership, while the doctors’ own children had the attention

of both their parents.

There are several reasons why women are less well represented in some

specialties than in others. For one thing, some specialties appeal more to

men than women. Another is that some specialties are more demanding in

their unsocial hours and therefore more difficult to combine with regular

domestic responsibilities which bear harder on women. Women tend to

choose non-surgical specialties, with the exception of ophthalmology.

Paediatrics and public health are the only two specialties initially chosen by

women more commonly than men.

Both men and women doctors take time to arrive at their final choice of

specialty and most do not think very much about it until after they qualify.

Towards the end of the preregistration period choices for paediatrics,

general medicine, general surgery, and obstetrics and gynaecology exceed

opportunity. Preferences for pathology and radiology are about matched to

opportunity, and psychiatry, general practice, and public health are

undersubscribed. However, fashions change all the time in medical careers,

and there is a move back towards general practice in some parts of the

country, but job opportunities still exceed those wishing to take them up.

Over the subsequent few years 25–33% of doctors change their choices,

some more than once. About 40% of the changes of preference (and about

60% in women with children) are because of family commitments.

Specialties such as general practice now come into their own, being more

readily compatible with other responsibilities, both in flexibility of working

practice and in the earlier attainment of a settled home and secure income.

Hospital specialties which allow other commitments either through well

organised duty rotas or light on call responsibility or by providing good

opportunities for part time work include anaesthetics, accident and

emergency, psychiatry, pathology, radiology, oncology, medicine for the

elderly, rehabilitation medicine, and medical specialties such as

dermatology, genitourinary medicine, and palliative care. Public health also

offers regular and reasonable hours. Overall, a recent survey showed that

half of women and a quarter of men considered marriage to have been a

constraint on their career in medicine. Eventually, preconceived ambitions

have to be balanced against the practicalities of personal commitments and

professional training. In this, medicine is by no means unique.

A determined effort is being made to introduce good opportunities for

“flexible training”, but more still needs to be done to reduce the conflict

between family responsibilities and a career in medicine and to diminish

the relatively greater disadvantage of women. As Yvonne Noble, a

sociologist, has written:

Adjustments in the profession must be inevitable: when the adjustments are

made it is essential that they do not continue to disadvantage those (men as

well as women) who recognise their need for and responsibility to personal

partners and children.

LEARNING MEDICINE

106Practical measures being introduced include widespread provision of

crèches in the NHS and a means through tax allowances, of offsetting the

costs of assistance with child care. Better career advice is needed, both at

medical school and in the early postgraduate years, but it may be of rather

limited value until the circumstances of personal life unfold. Most doctors

eventually find their way through the maze but they and their families

deserve more readily available signposts and smoother paths to a

permanent post.

When should you decide

Some fortunate people decide on their careers as students (fortunate, that

is, if they have made a realistic decision), more decide as house officers, and

most decide in the next year or two while undertaking general professional

training in senior house officer posts. Many senior house officer posts are

not part of a specialist training programme but offer general training and

experience. They are vital feet-finding posts. Most students qualify with

little idea of the wide range of career opportunities open to them, an

ignorance which reflects badly both on medical schools for not opening

their students’ eyes and on students themselves for often lacking curiosity

about their own future. The hurdles of finals and house jobs completely

dominate their thinking.

Careers fairs are held annually in many parts of the country to display the

attractions of different specialties and to offer advice from doctors in all

major specialties on a personal and informal level. Advice is available in

medical schools from postgraduate sub-deans and in each district general

hospital from the clinical tutor or director of postgraduate medical

education and training. Each region of the NHS also has a regional

postgraduate dean who is responsible for overall coordination of

postgraduate training and career advice, supported by individual assistant

deans with special responsibility for each phase and area of postgraduate

medical education and training. Each Royal College also appoints regional

advisers and hospital Royal College tutors to whom trainees can turn.

Career decisions depend on many factors, but a clear idea of the wide

opportunities available is the first necessity. Most teachers of clinical

medicine are hospital physicians or surgeons who wittingly, or unwittingly,

give the impression that these are the only two worthy careers. House

officer posts are also dominated by these specialties. Consequently, for

years too many doctors have wanted to specialise in hospital specialties

such as general medicine and general surgery and too few in, for example,

pathology, psychiatry, geriatrics, and mental handicap. Most doctors,

whether deciding to work in or out of hospital, prefer to live in green

pastures not in inner cities. Until 15 years ago general practice was not a

common first choice. It then became very popular but currently

recruitment is not keeping pace with demand. Many see general practice as

CHOOSING A SPECIALTY

107more compatible than hospital specialties with a life of their own. At the

end of the day, not every doctor ends up in their specialty of first choice

because, in the words of George Bernard Shaw: “Up to a certain point

doctors, like carpenters and masons, must earn their living by doing work

that the public wants from them.” Or, put another way by the chief medical

officer of the Department of Health: “The aim of undergraduate medical

education is to produce doctors who are able to meet the present and

future need of the health services.”

Medicine is, however, a mine of opportunity. A range of different

specialties beckons all sorts of personalities and interests. Most of these

specialties are “clinical”, they primarily serve individuals; they do much for

a few and are in reserve for many. Other specialties, by contrast, are

population rather than person based; they do much for many and seek

health for all. Doctors in all specialties, whether focused primarily on

individuals or populations, have some way still to go in persuading the

public to take responsibility for preserving their own health.

Medicine is many things but nothing if not a service, in Britain a national

health service. The original vision which created it is very much alive,

despite relentless financial, organisational, and ethical pressures associated

with an aging population and advancing medical technology. Medicine and

the NHS have also never before been so much in the spotlight of the

national media, adding even more pressures to staff. A combination of

good clinical common sense, public restraint, and appropriate prioritisation

of national resources can still ensure that, as originally announced in 1944:

… every man, woman and child can rely on getting all the advice, treatment

and care which they need in matters of personal health: that what they will

get will be the best medicine and other facilities available: that their getting

them should not depend on whether they can pay for them or on any factor

irrelevant to the real need—the real need to bring the country’s full

resources to bear upon reducing ill health and promoting good health for all

its citizens. …

at least as far as a health service alone can achieve good health for all.

Perfect fits are for machines; more roughly crafted men and women and

evolving specialties are seldom made precisely for each other. But if the

interest and the will are there, the individual and the specialty can develop

together like partners in a successful marriage. Doctor and specialty is not

the only fit which matters. Spare a thought for the doctor–patient

relationship on the way, bearing in mind Dr Brotschi’s snapshots of “the

kind of doctors we shouldn’t be” in a letter to the New England Journal of

Medicine:

First, the ambitious climber take,

Who will the department chairman make;

Who toils to win Professors’ praise

And quotes the Journal, phrase by phrase,

But never reads the patients’ gaze.

LEARNING MEDICINE

108Next: the expert proud we find,

The latest saviour to mankind.

Cured patients speak to his renown,

But he leaves sick ones with a frown,

Because they let his image down.

Third, the jovial friend of all,

Who never heard perfection’s call.

His ken of medicine paper thin,

But patients’ trust he’ll always win:

They love him while he does them in.

And fourth, the well adjusted fellow,

Who seeks that all in life be mellow;

Who loves good music, wine and skis,

Resents his work but likes the fees,

And does not hear his patients’ pleas.

To start the series, here are four,

But surely there are many more,

Just let us seek and see what’s true

In what we are and what we do,

Lest we forget, we’re human too.

Every doctor becomes a specialist, even in something as general

sounding as general practice, perhaps better called “family medicine”,

which is as much a special art as any other part of medical practice.

Becoming a specialist may not seem that difficult, judged from the bogus

doctors who have remained undetected not just for a casual day or two,

which is not all that uncommon, but for years. A 64 year old man with a

stolen medical degree was sentenced at Leeds Crown Court after working

for 30 years as a general practitioner. Amazingly, neither his patients (who

demonstrated outside the court room in his support), nor his colleagues

rumbled him. A pharmacist in the chemist next door to the surgery raised

the alarm, not perhaps before time. “If one 5 ml spoonful of hair shampoo

is to be taken three times a day”, the pharmacist told the court, “You tend

to think there is something wrong. Time and again there were inhalers to

be injected, tablets to be rubbed in—all very unusual”. Very unusual!

General practice is not the only home of bogus doctors. Amaedeo Goria

of Canelli near Turin, practised for 13 years as a neurologist before he was

“unwittingly betrayed by his adoring wife after telling her one lie too many

about his professional prowess”. She passed on to the local newspaper his

story that he had brilliantly passed an examination in Rome, which

qualified him to become head of the neurology service at the local hospital.

This news sparked off an inquiry which revealed to the contrary that he was

a failed medical student who had forged his diploma.

It could be said that both profession and public need their gullible heads

examined, but they would be wise to take care who does it. About the same

CHOOSING A SPECIALTY

109time as Goria was unmasked, another failed medical student in Italy was

discovered, not because of surgical incompetence but because of

“corruption in appointing senior medical personnel”. He had practised for

10 years as a neurosurgeon without detection.

What makes a specialist

Specialties are a complex web of medical and surgical strands, of individual

and population focus, and of hospital and community base. They

interweave and overlap and can be excellently practised only by doctors

who know more than their own specialty both in broad approach to

difficult diagnosis and in management of the whole person. They also need

to have a perspective on the sometimes conflicting interests of individual

patients and the population as a whole. Specialists need to be more than

two dimensional cardboard cutouts blown over by the first unfamiliar

breeze. That is why it is fundamental that basic medical education and

training paints a picture of the whole canvas of health, disease, and human

behaviour, producing a doctor generally equipped to move into any

specialty, a product once described as “the uncommitted iatroblast”. That

is why the preregistration house officer year is designed to develop clinical

skills with both a medical and a surgical perspective and why moves are

being made not only to balance the specialty base but the context by

including a period in general practice within the preregistration year.

LEARNING MEDICINE

110The need to be able to think and work across specialty boundaries is not

new. The Lancet in 1827 quoted Mr Lawrence’s introductory lecture to the

spring course of surgery at the New Theatre in Aldersgate, London:

Thus, whatever course we take we arrive at the same conclusion, viz that they

are merely parts of one science and art; that the scientific principles are the

same and the same means must be used both by the physician and the

surgeon, because they have the same ends to accomplish. … A French

minister seems to have judged pretty correctly of the matter. The propriety of

separating physic and surgery was strongly represented to him; “I would

elevate”, said the advocate of the measure “A wall of brass between them”.

“Pray Sir”, rejoined the minister, “On which side of the wall do you propose

to place the patients?”.

Senior house officer posts

While the preregistration year is designed to consolidate and develop

further a broad range of clinical skills of wide application, the senior house

officer period was originally introduced to give a broad introduction and

foundation in a particular specialty area—medicine, surgery, obstetrics and

gynaecology, pathology, etc, in such a way as to enable the recent graduate

to discover whether somewhere within that specialty lay the career choice

for him or her. This usually involved an uncoordinated series of posts with

a new application to be made every six months, often in a different part of

the country as programmes of linked posts were few and far between. Some

doctors undertook this period of general professional training in the armed

services on a short service commission, and a few doctors made

arrangements to take approved posts overseas. If the specialty first tried was

not congenial, it was possible to use the training as a background for

general practice or as part of training in another specialty.

Senior house officer posts are now becoming more specialised and

therefore less suitable both for general training and as uncommitted career

thinking time. On the other hand, most are now linked together in a

designed sequence over about two years, avoiding the scramble for one job

after another. In some countries, specialty streaming starts in the

undergraduate course; in China, for example, students heading for careers

in paediatrics or public health take a different undergraduate clinical course

from other students.

While pressure to start specialisation early may be understandable in

terms of shortening training and concentrating expertise, it fails to

recognise the fundamental importance of a broad base as the foundation of

specialist education and training. As Dr Holly Smith, an American dean of

medicine, expressed it:

… in education as in biology, early differentiation (specialisation) leads to

maturation but not necessarily to growth. This premature type of

differentiation is like giving thyroxin to a tadpole. You get an instant frog but

unfortunately a rather small one.

CHOOSING A SPECIALTY

111Although the broad pattern of specialty training is becoming

standardised, the nature of the work and the higher qualifications required

are quite different in each specialty. Some specialties, such as general

medicine, general surgery, paediatrics, and obstetrics and gynaecology, are

in the front line of emergency care of patients and involve substantial

resident duties at nights and weekends (and are correspondingly better

paid at junior level than training posts in specialties such as pathology and

public health, which offer regular hours and no resident on call duties). At

consultant level, the basic NHS pay is the same in all specialties and extra

duty payments are not made. The opportunities for supplementing NHS

income in private practice in an agreed fraction of the consultant’s time are,

however, much better in some specialties (mostly surgical) and in some

parts of the country (mainly large cities and in particular London).

Preparation for all specialties, including public health, has now become

semistructured and organised, leading to registration as a specialist after

about five years of higher training, which begins two or three years after

qualification as a doctor. Specialist education is largely an apprenticeship

based on the everyday service responsibilities. More closely supervised

training is helping to overcome the criticism of a distinguished professor that

“experience, like age, receives more respect than its inevitability justifies”.

The shorter period of specialist training and the shorter working week for

doctors in training have introduced a conflict between the length of

specialist training and the acquisition of sufficient experience. An editorial

in the BMJ observed that “between them, the New Deal [on reducing junior

doctors’ hours] and the Calman Report [on the length of specialist training]

are reducing the time available to train a surgeon from 13 years at over

100 hours a week to eight years at 56 hours a week, a reduction of nearly

two thirds” and went on to say that “under these constraints, consultants

will have to extract even more teaching value from every case”. Surgery may

be an extreme example but the principle affects all specialties.

Membership of Royal Colleges

The Royal Colleges and specialist faculties determine standards of practice

and education in the specialties. They inspect and assess both training

programmes and placements. A syllabus outlines the broad areas of

knowledge, skills, and attitudes required. Regular assessments by

consultants nominated as clinical supervisors or tutors check the doctors’

progress. Examinations for the membership or fellowship (Table 11.1) of a

Royal College are taken during or, in medical specialties, before entering

the specialist registrar grade. In most specialties, part I of the Royal College

exams is taken early in the period of specialist training and part II serves as

an exit qualification. Many doctors also take a higher university degree—

MD or DM (Doctor of Medicine), awarded for a dissertation which is

usually based on clinical research in the course of postgraduate training or

MS or MChir (Master of Surgery), the surgical equivalent.

LEARNING MEDICINE

112The specialist register

Satisfactory completion of a programme of appropriate specialist training

complying with the requirements of the European Medical Directive leads to

a Certificate of Completion of Specialist Training (CCST), which confers

specialist status throughout the European Union. The Specialist Training

Authority (STA) of the Royal Colleges and the Joint Committee on

Postgraduate Training for General Practice (JCPTGP) are statutorily

responsible for certificating the satisfactory completion of training for entry

to a specialty. In the United Kingdom the certificate then has to be registered

with the GMC, which is responsible for keeping the specialist register. Each

programme and rotation of training posts must be approved by the Royal

College appropriate to the specialty. Specialists trained overseas who have

had training equivalent to the CCST standards and doctors who have had a

more research-based training but are considered to have CCST level still can

be entered on the specialist register on recommendation of the STA without

going through a standard programme. Since January 1997, being on the

specialist register has been a legal requirement before a doctor may take up

a consultant (specialist) appointment in the United Kingdom.

Appointments to the specialist registrar grade are made in open

competition on a regional basis organised by the postgraduate dean in that

region, apart from specialist training programmes in the armed forces for

which special arrangements apply. On entry into a specialist training

programme a doctor receives a national training number (NTN) which is

retained throughout training even if part of the training is taken in approved

research at home or in approved posts abroad. The number may also be

retained for a limited time after acquisition of the CCST if the new specialist

remains in a training post before obtaining a consultant appointment.

The training numbers act as a passport to education in that specialty,

guaranteeing a continued training post subject to satisfactory progression.

CHOOSING A SPECIALTY

113

Table 11.1—Major professional higher qualifications

Diploma Full title

MRCP* Member of the Royal College of Physicians of the United Kingdom

MRCS** Member of the Royal College of Surgeons

FRCAnaes Fellow of the Royal College of Anaesthetists

FRCR Fellow of the Royal College of Radiologists

FRCOphth Fellow of the Royal College of Ophthalmology

MRCOG* Member of the Royal College of Obstetricians and Gynaecologists

MRCPsych* Member of the Royal College of Psychiatrists

MRCPath* Member of the Royal College of Pathologists

MRCGP*** Member of the Royal College of General Practitioners

MFPHM* Member of the Faculty of Public Health Medicine of the Royal College

of Physicians

MRCPCH* Member of the Royal College of Paediatrics and Child Health

*Fellowship is by election after an interval of several years.

**Fellowship follows further higher exams and training.

***Fellowship can be by election or assessment.Many specialist training programmes lead to a dual CCST, for example in

general and vascular surgery or general medicine and gastroenterology.

Having the general certification is important for those helping to provide

the acute emergency intaking service. Few hospitals have so many

specialists on the staff that they can afford the luxury of specialists who do

not at the same time also have the ability to look after acute emergencies

competently as part of their task. Very few doctors specialise solely in acute

emergency medicine at present, not to be confused with accident and

emergency (A & E) doctors who see patients in the accident and emergency

department and then pass them on for admission and management by the

duty specialist team, if necessary. Some accident and emergency

consultants look after these patients for the first 24 hours in an observation

ward from which they are then either discharged or admitted under a

specialist team.

Overseas doctors without the right of indefinite residence or settled

status in the United Kingdom or who do not benefit from European Union

rights (regardless of where they obtained their medical qualification) may

compete for a place on specialist training programmes which confer a fixed

term training appointment (FTTA) and which are open only to overseas

doctors. At present, these doctors may stay in the United Kingdom for only

four years of postgraduate training. Such programmes do not lead to a

CCST but the doctor is entitled to a certificate recording the specialist

training undertaken.

Part time (flexible) training is possible for CCST. These programmes are

aimed particularly but not exclusively at women doctors who wish to

combine specialist training with family responsibilities, retaining their

interests and skills in a specialist career. Doctors wishing to enter a

specialist training programme as flexible trainees must satisfy the

postgraduate dean that training on a full time basis would not be

practicable. Full time trainees can apply to become flexible trainees and

flexible trainees can apply to revert to full time training at any time. The

United Kingdom health departments have required postgraduate deans to

maximise flexible training opportunities. The total duration and quality of

training must be not less than that required for full time trainees.

Before they even reach the stage of competing for a specialist registrar

post many women doctors take advantage of the doctors’ retainer scheme

established to encourage those temporarily unable to practice because of

domestic commitments to remain in touch with medical activity and

continue their training to return eventually to substantial practice. They are

expected to work up to a maximum of two paid sessions weekly in hospital

or in general practice to a total of at least 12 sessions a year for which they

receive in addition to their pay for these sessions an annual retainer which

covers their subscription to the GMC (essential to maintain registration)

and a subscription to a professional journal. They are also expected to

attend at least seven educational sessions annually.

LEARNING MEDICINE

114All specialties have specialist registrar training schemes designed

essentially for doctors who will become consultants or general practitioners

in the NHS. A much smaller parallel stream of clinical lecturer/honorary

specialist registrar combines NHS clinical experience in a university

teaching hospital with a much larger research and teaching opportunity.

As the CCST requires a strongly service-based training to ensure high

standards of clinical practice, those proceeding through the academic route

will usually take longer to obtain their certificate. Their training may also

be prolonged by two or three years for whole time study leading to a PhD,

awarded for a thesis based on laboratory research, but this is often

completed before they start specialist clinical training.

Consultants

After obtaining the CCST, doctors compete for a consultant post. Insofar

that the term implies giving advice rather than hands-on examination and

treatment as part of a team, the term is outdated and misleading. Senior

doctors with full responsibility would more precisely be described as

specialists, whether in hospital, general practice, or public health. There

would be logic in progressing from specialist registrar to specialist, rather

than to consultant, but the profession is not always governed by logic.

Doubtless it will come eventually and no one will then understand why

there was ever a problem. 

Currently, the relationship between consultant vacancies and the number

of specialist registrars nearing the end of their training differs greatly

between specialties. In most specialties newly qualified specialists have no

difficulty in finding a consultant job, particularly if they are prepared to

move to another part of the country. Doctors who have taken their specialist

training in academic units often continue in university hospitals either as

senior lecturers with honorary consultant status or as NHS consultants,

some become NHS consultants in district general hospitals, and a few go

into clinical research or management in the pharmaceutical industry. Senior

lecturers may be promoted in due course to reader or professor.

The NHS does not have different levels of seniority of consultant but it

does reward exceptional service and scientific distinction with distinction

awards, salary supplements which at the highest level are substantial in

relation to the basic salary. Not all doctors in the hospital service aspire to

become consultants; they may become an associate specialist, part time

medical officer (clinical assistant), hospital practitioner, or staff doctor, a

grade established for those who have not completed a formal specialist

training programme or do not wish to have the full range of responsibilities

of a consultant. These posts are advertised nationally in the same way as all

other medical posts in the NHS, with the exception of preregistration

house officer posts linked with particular medical schools which are filled

internally.

CHOOSING A SPECIALTY

115Consultants may undertake private practice alongside their NHS

responsibilities. If their earnings from private practice exceed more than

10% of their NHS salary, they must give up part of their NHS salary. Their

status as a specialist in private practice is underwritten by the fact that they

have obtained a consultant post in open competition after a full period of

rigorous training. A curious and peculiarly English myth has long

promoted the public belief that solely private practitioners in Harley Street

are the best. The reverse is likely to be true because most practitioners

who do not also work as consultants in the NHS have not completed

an accredited specialist training or, if they have, have not obtained a

consultant post in open competition, with the exception of a few who have

already been NHS consultants and have given up their public service to

work solely in private practice. There is nothing to stop any doctor fully

registered with the GMC from setting up as a private specialist, but in

future doctors not listed on the  specialist register will not be eligible for

payment as a specialist through insurance schemes. They may also find it

difficult to satisfy Royal College’s expectations that they are regularly

keeping up to date in their relatively isolated position.

Appraisal and revalidation

Whatever the specialty, all registered medical practitioners will in future be

regularly appraised in the context of their work to ensure that they are

maintaining satisfactory standards. This has become the norm in other

professions and there is no reason for doctors to be an exception, except

that it has been difficult to devise an appropriate and efficient way of

undertaking appraisal in clinical specialties without creating a whole new

work agenda for very busy people. 

Every five years, the portfolio of a doctor’s appraisals will be submitted

as evidence for revalidation of registration with the GMC. Again, there is a

formidable need to devise a system which is practical, cost effective, and

sufficient to maintain confidence in the profession.

LEARNING MEDICINE

116REMEMBER

• Medicine offers secure, relatively well paid employment in a large variety

of possible careers.

• Students should start to consider their career options by their fourth or

fifth year at medical school. Many have no firm intentions at this stage

beyond knowing a few areas which they have discounted.

• Most doctors choose their specialty towards the end of their house officer

year but around a third will change their mind over the next three years,

sometimes more than once. The commonest reason for changing choice

is personal and family commitments.

• Specialties vary substantially in the amount of emergency work, and

therefore in the disruption of personal life.

• “Flexible” part time training is possible in most specialties for those for

whom full time training is not practicable.

• Some specialties are more popular than others, and this is ever-changing.

It pays to explore all the options.

• Some doctors are able to combine more than one specialty, such as

general practice and a clinical assistantship in a hospital discipline or

public health or medical journalism.

• All doctors in the NHS—whether consultants or principles in general

practice—need to obtain a Certificate of Completion of Specialist

Training or Certificate of Prescribed Training in General Practice.

• An increasing number of junior doctors spend time out of the NHS,

travelling, working abroad, working in a different field or just taking out

a gap year. For most this gives them time to settle on their intended career

options and keep a healthy perspective on their life, and it is no longer

regarded unfavourably by many employers.

• In future all doctors, whatever their chosen specialty, will have to undergo

a system of appraisal of their knowledge and skills every five years, which

will be compulsory for revalidation of their GMC registration.

CHOOSING A SPECIALTY

117118

12. Career opportunities

Medicine offers an amazing range of different career options.

Most doctors end up in general practice,hospital specialties,or

public health.Medical students are well advised to take a careful

look at the very broad canvas of opportunity before they qualify.

Most people finally choose their specialty within two or three

years of graduation. However an increasing number of doctors

choose careers which are more varied,include other interests,

and are flexible enough to allow them to fit their career around

their life,not the other way round.

General practice (Figure 12.1)

To become a principal in general practice, a doctor must complete three

years’ vocational training. This includes at least 12 months as a GP

registrar; two periods of at least six months each in educationally approved

training posts drawn from a list of hospital specialties particularly relevant

to general practice, such as paediatrics, care of the elderly, obstetrics and

gynaecology, psychiatry, and accident and emergency; and the remainder

of the time in hospital or community medicine. Any or all of the training

may be undertaken part time provided the whole process is completed

within seven years. Training is carefully and continuously supervised by

specially trained and accredited general practitioners, who guide and

monitor training through a process of summative assessment. This

assessment includes written examinations, discussion of videos of their own

consultations, an audit project, and a report from the trainer; experience is

recorded in a log book. Successful completion of the training is marked by

the award of a Certificate of Prescribed Experience in General Practice

issued by the Joint Committee on Postgraduate General Practice Training.

Optional

Preregistration

house officer 

Medicine/surgery

1 year

Senior

house officer    

Any specialty

1–2 years

Senior

house officer     

Relevant specialties

2 years

General practice

reg

General practice

1 year

General practice

principal   

General practice

Career post

Vocational training

Figure 12.1—Structure of training for a career in general practice.General practitioners are still in short supply in some parts of the country

and most new GPs eventually join a partnership of established GPs.

However an increasing number of newly qualified GPs work in a variety of

shorter term jobs for several years before committing to joining a practice.

A growing number of salaried GP posts exist, some combining general

practice with teaching or research, or work in a different clinical field such

as accident and emergency or a medical specialty outpatient clinic. Job

vacancies of all types are advertised in the medical press, such as the BMJ,

and are filled in open competition.

General practice (family medicine) is a demanding but fulfilling career.

As a new GP you can choose how many sessions you wish to work each

week which allows you greater flexibility to combine being a GP with

outside interests such as raising a family or developing skills in research or

another clinical area in a hospital clinical assistant post. It offers the

prospect of a settled home and higher income at an earlier stage than a

career in the hospital service. General practitioners who live (as most do)

in the district in which they practise, naturally become very much part of

their local community and have the satisfaction of giving long term

continuity of care, unless practising in an inner city where the population

is continuously changing and where as many as a third of the general

practitioner’s patients may change each year. GPs are taking on an

increasing role in the planning of all hospital and community services

through Primary Care Trusts which are changing the way GPs work all

across the country.

After completing a three year training scheme, or after being fully

registered for four years of which two have been spent in general practice,

a doctor may take the examination for membership of the Royal College of

General Practitioners (MRCGP) but it is not an essential qualification.

There are also a number of other postgraduate diplomas which can be

taken, such as the DCH (Diploma in Child Health) and the DRCOG

(Diploma of the Royal College of Obstetricians and Gynaecologists). An

increasing number of GPs study for a Masters Degree; a few undertake

research for an MD. The only essential qualification is a Certificate of

Prescribed Experience in General Practice.

Hospital specialties (Figure 12.2)

The broad structure of specialist training leading to the Certificate of

Completion of Specialist Training (CCST) is similar in all hospital

specialties. From qualification to recognition as a specialist normally takes

about seven years: the final year of basic medical education and training

(the preregistration house officer year), about two years general

professional training (at senior house officer level), and a four year

specialist registrar programme. Specialties such as cardiology and cardiac

surgery, which are particularly dependent on practical skill, take the

longest.

CAREER OPPORTUNITIES

119Accident and emergency

People with acute injuries or sudden acute illness often dial 999 for the

ambulance service, are picked up from the street, or are urgently sent to

hospital by their doctor. Others taken less acutely or seriously ill, who for

one reason or another do not want to or cannot call their general

practitioner, take themselves straight to hospital. Many accident and

emergency departments include both a minor injuries unit run entirely by

nurse practitioners and the consultant led medical team who provide for

the patients requiring acute resuscitation, full medical assessment, or more

complicated medical treatment. The consultants are in overall charge of

the whole team, but the initial sorting of cases is the responsibility of an

experienced nurse who also ensures appropriate destination and priority for

each individual.

Dealing with anything and everything serious, not so serious, or difficult

to discern requires special skill, training, and experience, useful whatever

medical specialty a doctor eventually ends up in. For that reason, many

senior house officer training programmes in medicine, surgery, and several

other specialties now include a period of several months in the accident

and emergency department to develop this core dimension of practical

professional skill. Telling the difference between the apparently trivial and

a medical or surgical time bomb is an art fully learnt only through active

service in front line trenches; getting it right, or at least not sending the

patient home without fail safe follow up, can save tens of lives and

hundreds of thousands of pounds in medical litigation fees and damages.

LEARNING MEDICINE

120

Preregistration

house officer   

Medicine/

surgery

1 year

General

professional/

basic specialist

training

About 2 years

Specialist

training

Lecturer

Specialist

registrar

Specialty of choice

4 years

Senior lecturer

Reader

Professor

NHS

Academic

Senior

house officer    

Any specialty

Consultant/

specialist*

Specialty of choice

Figure 12.2—Structure of training for a hospital specialty in either the NHS or

clinical academic (university) posts.

*Some specialists choose not to take on consultants’ responsibilities such as out of hours

on call and work as Associate Specialists or Staff Grade Specialists. These are often part time

and less well paid than consultants.Accident and emergency consultants have in the past usually had a

background in surgery, medicine, anaesthetics, or general practice. Specific

training programmes now exist leading to becoming a Fellow of the Faculty

of Accident and Emergency Medicine (FFAEM). Accident and emergency

is one of the few clinical specialties which readily lends itself to shift

working. Most patients are treated and referred back to their GPs so there

is little call for continuity of care. Learning from experience is assured by

regular meetings of the whole team to review successes and failures.

Anaesthetics

Anaesthetics is another specialty in which continuity of care is limited:

preoperative assessment, the operation itself, the early recovery period, and

intermittent periods of responsibility for supervising the intensive care unit.

It is a very hands on specialty and if you are up all night provision is normally

made for you to be off for at least part of the next day. The work of an

anaesthetist falls fairly tidily into regular and carefully defined commitments.

Providing pain relief or anaesthesia during surgical operations,

childbirth, and diagnostic procedures is the major task of an anaesthetist.

Most also take turns in charge of the intensive care unit and an increasing

number confine themselves to such work. Anaesthetics is a large and

expanding specialty.

The primary examination for Fellowship of the Royal College of

Anaesthetists (FRCAnaes) can be taken 18 months after graduation,

usually taken during a senior house officer post in anaesthetics, and is a test

of knowledge of the scientific basis of anaesthetics and anaesthesia. The

final part of the FRCAnaes is taken after one year as a specialist registrar.

Medicine

Specialists in medicine in the United Kingdom are known as “physicians”.

On the whole, medicine and surgery attract different personalities: physicians

tend to be more reflective; surgeons more executive. The difference is

reflected in the respective Royal Colleges as Dr John Rowan Wilson observed

some years ago but nothing much has changed:

The Royal Colleges are, of course, much the smarter end of the profession;

they represent the big time. However, the two main colleges, the Physicians,

and the Surgeons, are very different in character. The Royal College of

Physicians, like the Catholic Church, is ancient and obscurely hierarchical. It

occupies a tiny Vatican in Regents Park, whose benign soft-footed cardinals

pad around discussing preferment of one kind or another. To be a Member

of the College (achieved by examination) counts for nothing at all. One must

be elected a Fellow. … In turning to the College of Surgeons one moves from

the episcopal to the military. Surgeons are brash, extrovert characters who

pride themselves on energy rather than subtlety. Fellowship is decided by

examination, and theoretically all Fellows are equal, just as theoretically all

officers are gentlemen.

CAREER OPPORTUNITIES

121Some physicians are narrow subspecialists in a subject such as

dermatology (skin diseases) or rheumatology (joint and muscle disorders)

but most have dual certification in general medicine and a subspecialty.

“Internal” is sometimes added to the title of general medicine because that

is the North American term for the specialty.

The “general” label, means that the physician can successfully bat any

acute medical emergency balls—at least hitting them towards an appropriate

fielder. In practice, this requires the ability to cope with any and every acute

medical emergency, at least in the initial stage, and the ability to deal with

unstructured diagnostic problems not falling obviously into any particular

subspecialty at an early stage. Most British hospitals are not large enough

either to have a specialist in each subspecialty of medicine or to maintain an

acute medical emergency rota for patients who need to be admitted to

hospital at any hour of the day or night without the participation of most of

the specialist physicians. The position is similar in surgery.

Time and again, hospital specialist practice requires well informed

clinical common sense rather than intensely specialised knowledge.

Professor J R A Mitchell told the story of a patient who reappeared in his

outpatient clinic, having being referred from specialist to specialist, saying,

“there is no point in sending me to another specialist, doctor, it is not my

special parts which have gone wrong but what holds them together”.

Membership of the Royal Colleges of Physicians of the United Kingdom

(MRCP (UK)) is the professional diploma needed before you embark on

LEARNING MEDICINE

122specialist training in any of the specialties listed under medicine in

Table 12.1. The Royal Colleges of Physicians in London and Edinburgh

and the Royal College of Physicians and Surgeons in Glasgow hold a

common membership examination. Election to fellowship normally follows

about 10 years after passing the examination for membership.

The MRCP diploma is a necessary entry qualification but confers no right

to a training number in a medical specialty. Although the examination is

difficult and the pass rate low, more doctors are successful in the examination

than can become specialists in medicine. Some deliberately acquire the

diploma as an additional qualification before entering another hospital

specialty or general practice. Part I of the examination can be taken

18 months after graduation and comprises multiple choice questions

covering a wide range of medicine and the sciences immediately relevant to

it. Part II can be taken after one year in approved posts providing experience

of responsibility for acute general medical emergencies and consists of a

written section, including questions on interpretation of case histories and

slides, and a searching clinical examination. The clinical and oral

examinations were previously taken either in adult medicine or paediatrics

but there is now a separate diploma of MRCPCH—Membership of the

Royal College of Paediatrics and Child Health (see below).

The MRCP examination is, above all, a test of clinical skills: it covers

similar ground to the final MB examination in medicine but at a more

demanding and discriminating level. It is necessary to know about rarities

but it is even more important to have sound clinical skill and common

sense, based on expertise in managing everyday medical emergencies.

Paediatrics and child health

The care of children, especially of the newborn, has become immensely

specialised. Forty years ago, paediatrics was part of general medicine, but

not now. The skills required are very different from those required in adult

medicine and so too is the spectrum of disease. Until recently, the specialist

qualification for entry to paediatrics was the MRCP(UK), which could be

taken specifically in paediatrics as well as in adult medicine. The special

nature of paediatrics, its role and range across the divide between hospital

and community and the interplay of medical, psychiatric, and social factors

in child care was finally and formally recognised by the founding of the Royal

College of Paediatrics and Child Health in 1996, which has developed its

own membership examination.

Paediatric subspecialties are less well developed than those in adult

medicine and practically all paediatricians working at any but the very

largest and most specialised hospitals need to participate also in a general

emergency service, either in neonatal intensive care, acute paediatrics, or

child protection. Paediatrics is a specialty in which consultants have a

particularly large personal hands on involvement in the acute emergency

work. Specialist training is likewise very practically intensive. Children

CAREER OPPORTUNITIES

123LEARNING MEDICINE

124

Table 12.1—Major specialties and their required professional higher qualifications

Specialty Qualification

General practice MRCGP*

Hospital specialties

Accident and emergency FFAEM

Anaesthesia FRCAnaes

Medicine MRCP

General (internal) medicine

Cardiology

Clinical immunology (see also pathology)

Clinical pharmacology

Communicable (infectious) diseases

Dermatology

Endocrinology and diabetes

Genitourinary medicine (venereology)

Care of the elderly

Haematology (see also pathology)

Metabolic medicine

Neurology

Oncology (see also radiotherapy)

Renal disease (nephrology)

Respiratory disease

Rheumatology

Tropical medicine

Obstetrics and gynaecology MRCOG

Ophthalmology FRCOphth

Pathology MRCPath

Clinical biochemistry

Haematology

Blood transfusion

Histopathology

Immunopathology

Medical microbiology

Forensic pathology

Clinical immunology

Paediatrics MRCPCH

Psychiatry MRCPsych

Adult psychiatry

Child psychiatry

Forensic psychiatry

Mental handicap

Psychogeriatrics

Psychotherapy

Diagnostic radiology FRCR

Radiotherapy and oncology FRCR (MRCP)

Rehabilitation MRCP, FRCS

Surgery MRCS/FRCS

General surgery

Neurosurgery

Orthopaedics

Otorhinolaryngology (ENT)

Paediatric surgery

Plastic surgery

Urology

Public health medicine MFPHM

Other specialties

Occupational medicine MRCP, MFOM

Armed services

Pharmaceutical industry

Full time research

Basic medical sciences

Medical journalism

*MRCGP is not essential for entry to general practice.become seriously ill very quickly and, with immediate intervention, can

improve just as fast. More and more hospital based paediatrics is spreading

out into the care of children in the community, an aspect of the specialty

given the American style name of “ambulatory” paediatrics.

Obstetrics and gynaecology

Obstetrics and gynaecology is one specialty with two different aspects.

Obstetrics offers a balance between medicine and surgery with the

attraction of usually young and healthy patients and a happy outcome to

the encounter. Gynaecology (diseases specifically of women) also demands

both surgical and medical skills.

Specialists in this field become members of the Royal College of

Obstetricians and Gynaecologists (MRCOG). Part I of the examination, a

multiple choice paper on the basic sciences, is related to the specialty and

may be taken at any time after full registration. Part II is taken after at least

three years in approved posts and includes written, clinical, and oral

examinations, together with preparation of case records and commentaries.

Instruction in family planning is included in the training. Some obstetricians

train first in general surgery and obtain the Fellowship of a Royal College of

Surgeons (FRCS) to acquire a much wider surgical ability than their limited

surgical specialty necessarily demands; a few start in medicine (particularly

endocrinology) and first pass the MRCP; an occasional brilliant workhorse

obtains both these diplomas and the MRCOG.

Pathology

The specialties within pathology provide a wide range of laboratory

diagnostic services which are an essential part of everyday clinical practice.

The clinical biochemist is an expert in the biochemical mechanisms and

diagnosis of disease; the histopathologist and cytologist is an expert in

diagnosing disease from changes in tissue or cell structure; and the medical

microbiologist (a title which includes bacteriologist, virologist, and

mycologist) is an expert in the culture and identification of bacteria,

viruses, fungi, and other communicable causes of disease. Some medical

microbiologists combine this diagnostic function with the detection,

epidemiological monitoring, and control of outbreaks of infection, based in

one of the laboratories of the Public Health Laboratory Service.

The haematologist is concerned with disorders of the blood and with blood

transfusion; some haematologists specialise entirely in blood transfusion and

work for the National Blood Transfusion Service. Clinical immunology is a

small but expanding specialty which spans laboratory science and clinical

medicine. It is concerned particularly with the role of immune reactions in

disease. Although based in the laboratory, pathologists often consult on

patients at their colleagues’ request. The medical microbiologist for example

should be in a position to give expert advice on antibiotic treatment of serious

infections and on the control of the spread of infections in hospital.

CAREER OPPORTUNITIES

125Haematologists normally have patients under their care in wards and

outpatients. Besides having scientific and clinical skills, the consultant

pathologist needs to be capable of becoming a good director of a laboratory.

For a career in all these pathology specialties, with the exception of

clinical immunology for which the MRCP may be more appropriate and

haematology for which it is customary to have both memberships, it is

necessary to become a member of the Royal College of Pathologists (MRC

Path). The part I examination is taken after three years in one of the many

specialties of pathology. It is no longer a test of all branches of pathology.

Part II is taken at a minimum of two years after part I and is limited to the

chosen specialty. Unlike the MRCP, which is in effect an entry qualification

to specialisation in medicine, acquisition of the MRC Path marks the

completion of training as a pathologist. The FRC Path is granted about

12 years later.

Psychiatry

Psychiatry is an expanding specialty which is changing rapidly, not least

because new treatments are substantially reducing the need for inpatient

treatment, especially the need for long stay mental hospitals. Political

policy has also moved many long term psychiatric patients out of hospital

into a community which unfortunately cannot always cope with them or

they with the community. Psychiatry includes the subspecialty of mental

handicap, a Cinderella subject with the task of deploying a range of medical

and engineering skills, together with human insight to help handicapped

patients realise their own potential. The emphasis in their care is shifting

towards rehabilitation in small units before they attempt to return to their

own homes.

The examination for membership of the Royal College of Psychiatrists

(MRC Psych) may be taken after three years of approved experience, most

of which has to be in psychiatry. This means working as a specialist

registrar in a psychiatric hospital looking after both emergency and long

stay patients, besides seeing patients in the psychiatric outpatient clinic. It is

possible to specialise in either adult or child psychiatry but all psychiatrists

are expected to have some experience of both.

A good knowledge of medicine is valuable in psychiatry, and some

psychiatrists acquire the MRCP in the early years of their training.

Diagnostic radiology

Like pathologists, radiologists need to be good organisers because sooner

or later they are likely to have to manage all or part of a department. They

need to be skilled with their hands in performing invasive investigations,

such as cannulation of internal vessels and biopsy of deep seated lumps

under screening, and in interventional techniques, such as angioplasty

(dilatation of narrow blood vessels). They also need to be sharp with their

LEARNING MEDICINE

126eyes and quick with their brains in interpreting  x ray films and scans.

Responsibility for radioisotope investigations normally also falls within the

responsibility of the radiologist. Many radiologists obtain the MRCP or

occasionally the FRCS while gaining clinical experience before taking up

radiology. Diagnostic radiology serves all clinical departments and often

provides an open access service for general practitioners as well. Advances

in radiology, particularly computerised scanning, have transformed clinical

practice in many specialties. Radiologists therefore have a natural link with

most of their colleagues. They also have contact with patients but without

overall clinical responsibility for their treatment. Out of hours duties are

generally not heavy with the exception of subspecialties such as

neuroradiology.

Fellowship of the Royal College of Radiologists (FRCR) is a necessary

qualification. Part I is taken after at least one year in a recognised specialist

training post and part II after at least three years of training.

Radiotherapy and oncology

Cancer is treated by radiotherapy, drugs, and surgery. Treatment of cancer

by irradiation (radiotherapy) or by drugs (chemotherapy) falls to different

specialists: the clinical oncologist (previously called radiotherapist) and the

medical oncologist, respectively. They undertake overlapping but partly

different training, leading to the FRCR (and may also obtain the MRCP).

Successful treatment of cancer requires teamwork, and clinical oncologists

and medical oncologists not only work closely with each other but also with

other specialties, especially with surgeons, physicians, and gynaecologists.

Part I of the FRCR examination is common to diagnostic radiology and

radiotherapy, but they have a different part II examination.

Rehabilitation

Rehabilitation is concerned with the active and optimistic management of

disability, both acute after stroke or serious injury and chronic disability. The

specialty requires the ability to encourage, motivate, and inspire both clients

and their families. The ability to earn the respect of a multidisciplinary team

of doctors, nurses, physiotherapists, and social workers is invaluable. It is

useful to be good with your hands, and to have an understanding of the

potential of both electrical and mechanical engineering as well as computer

science. A professional background in neurology or orthopaedics may be

particularly appropriate but above all the specialty requires humanity,

perseverance, realistic optimism, and boundless energy.

Surgery

Surgery was once considered a craft rather than as a now well established

intellectual and practical art. Surgical specialties are, in a manner of speaking,

more cut and dried than medical specialties, as Henri de Mondeville

observed in the 13th century:

CAREER OPPORTUNITIES

127Surgery is superior to Medicine, because among other things it is more

lucrative. To receive gifts or money, a surgeon dare not fear stench, must be

able to cut like an executioner, politely lie and be clever. … The sick above

all want to be cured; the surgeon to be paid.

Surgical training is divided into two parts: basic surgical training

applicable to all surgical specialties and subspecialty training. Surgeons

often obtain dual certification in general surgery and a subspecialty because

most consultant surgeons are expected to cover acute surgical emergencies

and undertake some relatively unspecialised surgery besides having a

special field of expertise.

Basic surgical training follows preregistration house officer appointments

with about two years in the senior house officer grade. At the end of that

time the trainee should have sufficient knowledge and skills to pursue

career training in surgery as a specialist registrar. Basic training includes

study of the basic medical sciences, together with experience in general

surgery, accident and emergency, and orthopaedic surgery. The MRCS

examination is taken at the end of this period.

The trainee then competes for a surgical specialist registrar post, which

provides training in both general surgery and a subspecialty, except for those

who concentrate entirely on becoming ear, nose, and throat (ENT) or eye

(ophthalmic) surgeons. There are seven recognised surgical subspecialties at

present (see Table 12.1, p. 124). Towards the end of this period of surgical

specialist training there is a further examination, the FRCS, which is an

examination run by the four surgical colleges of Great Britain and Ireland.

The examination particularly tests clinical skills and, together with the

necessary years of experience, qualifies the trainee for the CCST.

Public health medicine

Public health is the medical specialty which is concerned with the

improvement of the health of populations—by health promotion and disease

prevention and by commissioning high quality, cost effective health care

from providers of health care, mainly hospitals and general practitioners.

Public health doctors work closely with doctors in many specialties and with

other health professionals, with managers, and with governmental and

voluntary organisations. Public health recognises that health requires more

than individual patient care. If all members of society are to achieve a better

and more equitable health status and health experience, collective action is

essential.

It is worth remembering that public health doctors have had every bit as

great, if not greater, impact on improving health than physicians and

surgeons. A tablet to William Henry Duncan, Medical Officer of Health of

Liverpool, who died in 1863, records that “... under the blessing of God he

succeeded in reducing the rate of mortality in Liverpool by nearly one third”.

Epidemiology, the discipline concerned with describing and explaining the

LEARNING MEDICINE

128occurrence of disease in populations (originally epidemics of infectious

disease) and of the outcome of measures to improve health and prevent

disease, is the science fundamental to public health medicine and indeed to

a substantial proportion of modern medical research. Public health doctors

also require a range of other skills, most crucially those associated with

management, interpersonal, and political skills in representing the need for

more resources for health care and for better use of them.

Public health physicians work in a number of settings within the NHS,

the university, central government, and national agencies, such as the

Health Education Authority and the Communicable Diseases Surveillance

Centre (which is part of the Public Health Laboratory Service (PHLS)).

Two years of general professional and early specialist training culminate

in part I of the examination for membership of the Faculty of Public Health

Medicine (MFPHM of the Royal College of Physicians of London), which

covers epidemiology, statistics, social and behavioural sciences, the

principles of prevention of disease and promotion of health, assessment of

health needs and audit of services provided, environmental health, and the

management and organisation of health services. It is a rapidly expanding

specialty. During three years of higher specialist training, the trainee in

public health medicine writes a report on practical projects as part of the

requirement for part II of the MFPHM examination.

Community health

Doctors working in community health are clinical specialists providing a

wide range of services, including child health; family planning; mental and

physical handicap; genetic counselling; occupational, environmental, and

port health; and community services for the elderly. A relevant clinical

specialist training or general practitioner vocational training is the usual

qualification for this work, but there are, as yet, no formal relevant

community higher specialist training programmes or qualifications.

Most of the doctors are in the grades of clinical medical officer (CMO)

and senior clinical medical officer (SCMO). A small but increasing number

of consultant posts have been established in these community specialties

and training programmes for such posts are being developed.

Other specialties

Clinical academic medicine

A degree of creative tension often exists between the NHS consultants and

clinical academic (university) staff, well expressed by the Royal

Commission on Medical Education in 1968:

There are still full-time academic teachers who see the part-timer as a

prosperous busy practitioner who owes his success to clinical acumen rather

than painstaking investigation, whose teaching is based on personal dogma

CAREER OPPORTUNITIES

129rather than scientific fact and whose interests require the whims of private

patients to take priority over the needs of his students. There are still part-time

teachers who see the full-timer as a desiccated preacher more interested in the

advancement of medicine than in the welfare of his patients and unable to

offer his students any guidance to the realities of life outside the ivory tower.

There is a smattering of truth in each perspective to the extent that the

clinical academic physician or surgeon was described by Dean Holly Smith

as “an uneasy hybrid who constantly feels attenuated at both ends”.

An academic career in university posts is possible in practically all

hospital specialties, general practice, and public health, though the number

of posts is small. Clinical senior lecturers, readers, and professors all

normally have NHS consultant responsibilities, but they generally have less

clinical service work and relatively more time than NHS consultants for

teaching and research.

Basic medical sciences

It is widely but not universally believed that medical students benefit from

being taught anatomy, physiology, biochemistry, and pharmacology by

medical graduates because they best understand the clinical context of

these sciences and their relevance to clinical medicine. Few medical

graduates, however, now work in these university departments, not least

because salaries are lower than those of clinical academics and of other

doctors working in the NHS.

Full time research

A small number of full time research posts are available to medical

graduates, mainly in institutions of the Medical Research Council or in the

pharmaceutical industry.

Occupational medicine

Doctors have long been involved in the understanding and preventing of

health risks in the workplace but only recently has occupational medicine

developed as a clinical specialty rather than as a branch of public health. It

includes the former discipline of industrial medicine. The specialty is

concerned with identifying and investigating the medical problems

associated with different working environments and with advising both

management and employees on the prevention of occupational medical

hazards.

The examination for membership of the Faculty of Occupational

Medicine (MFOM) of the Royal College of Physicians of London is taken

after four years of training and experience in occupational medicine; a

formal higher specialist training programme leads up to it. Occupational

medicine is another specialty suitable for part time service.

LEARNING MEDICINE

130Armed services

The three major branches of the armed services offer careers for both

hospital specialists and general practitioners on long or short term

contracts. Many doctors begin a service career with a short service

commission while they are medical students. In return for a good salary

during clinical training and the preregistration year these doctors are

required to serve for a further five years in the armed services.

Pharmaceutical industry

The pharmaceutical industry employs an increasing number of doctors in

clinical research and in an advisory capacity. Most doctors entering the

industry have a good background in clinical pharmacology or specialist

medicine.

Medical journalism

The BMJ, the Lancet, and a number of other publications have full time

medically qualified editors, together with some who are not medically

qualified. Many specialist medical journals have part time medical editors,

as do several newspapers and industrially sponsored medical publications.

Freelance opportunities in journalism, radio, and television abound for

fluent doctors with lively minds, even if they are not Jonathan Millers. You

might even become a novelist or playwright along with Somerset Maugham,

Chekhov, and many others by dipping your creative pen into your medical

life experience.

CAREER OPPORTUNITIES

131REMEMBER

• The broad choice is between hospital-based specialties, general practice

or public health.

• General practice allows greater continuity of care of families and

individuals in a community over a long period. It also offers more flexible

working hours, the chance to be “more your own boss”, a settled home

and a higher income and at an earlier stage.

• The major hospital specialties are accident and emergency, anaesthesia,

medical specialties (for example, cardiology, care of the elderly,

gastroenterology, dermatology), obstetrics and gynaecology, paediatrics,

psychiatry, pathology, diagnostic radiology, radiotherapy and cancer,

ophthalmology, and surgical specialties (for example, colorectal surgery,

orthopaedic surgery, ear/nose/throat surgery).

• Increasing opportunities exist for non-consultant senior grades in some

hospital specialties.

• Public health medicine is concerned with the improvement of the health

of populations rather than individuals, and with the organisation of health

service provision.

• Clinical academic medicine combines specialist training with enhanced

opportunities for teaching and research.

• A few doctors follow careers in a variety of other fields, for example, the

armed forces, occupational medicine, the pharmaceutical industry, or

the media.

LEARNING MEDICINE

132Postscript

On the decision to become a doctor rests the whole design and

course of your life.

Being a doctor is something of a love–hate relationship. A recent graduate,

who had had more than her fair share of difficulties as a student, described

the feeling like this: “I am now working in a friendly district general

hospital and I love it. I love being a doctor—at least I hate some of it but I

am glad I went through medical school, resits and all.”

We too are glad to be doctors, one up and coming, the other here and

going. We have had our doubts: one of us seriously considered a career on

the stage, the other as a historian (no prizes for guessing who was which).

These remain our hobbies, unlike the famous cricketer, WG Grace, who

took 10 years to qualify as a doctor, saying: “Medicine is my hobby, cricket

is my profession.” Those days are past.

133We cannot say what is right for you. We can only hope that we will have

helped you towards your own well thought out decision. If you do decide

that medicine is the career for you and are successful in gaining a place at

medical school, we hope that this book will be your friend, guide, and

encouragement throughout your student days.

For the last words we turn first to Susan Spindler, original  producer of

the BBC documentary series Doctors to Be, who once thought of becoming

a doctor but decided against:

Having observed hundreds of students and doctors over the past decade,

I have a check list of qualities I look for in my doctors. I should like you to

be kind, clever, and competent. I want you to know your way around the

system, both in hospital and in the community. I hope you will like and will

empathise with your patients wherever humanly possible and fight to give

them the best treatment. And I’d like to think that you’ll have managed to

hang on to some of the ideals which drew you to medicine in the first place.

And finally, to Dr Farhad Islam, who as a student contributed his

impressions of his first delivery (p. 80) and recently showed so graphically in an

article reproduced here by courtesy of the British Medical Journal, how the years

of learning medicine come together to make a competent and humane doctor,

not forgetting in a moment of drama the need to be the patient’s friend:

This time it was not a drill*

The phone rang. It was ten past nine in the morning and I wasn’t due to start

work in the casualty department at St Mary’s Hospital until the afternoon.

“Where are you? It’s Dad here. There’s been a major rail crash just down

the road from you. Hundreds are injured.”

I quickly changed and ran downstairs. I weaved in and out of the traffic on

my bicycle, and within two minutes I was at the police cordon. I flashed my

identity badge and was led to the scene of the disaster.

“Keep your bicycle helmet on, Doc. The paramedics are over there with

some of the wounded.”

One hour had passed since the fatal collision and already a slick rescue plan

was in operation. There were five commuters lying on the ground, each white

with fear, shivering, although it was not cold. They lay with charred or

bloodied faces. Looking dazed and frightened, but all uncomplaining—happy

just to be alive.

I approached the trauma triage coordinator.

“Hello, I’m a casualty officer. How can I help?”

I was directed to two wounded passengers yet to see a doctor. I felt as if I

was on autopilot, driven by all the procedures that I had been taught and all

the duty that had been ingrained in me. That feeling would continue for most

of the day. Basics first—airway, breathing, circulation. I assessed a man with

a blackened face. He was obviously in pain with a deformed broken lower

LEARNING MEDICINE

134

*Taken from BMJ 1999;319:1079.right leg. A paramedic was squeezing a bag of fluid into his veins to prevent

shock. It was soon emptied and we had to wait for the next fleet of

ambulances for more bags. He was stabilised and put into an ambulance, all

the while thanking those around him.

I caught sight of a woman on the ground being comforted by a friend.

She was visibly shaking. I peered into a large gash in her forehead. We

immobilised her spine and put her in an ambulance.

The coordinator told me that it was unlikely that anyone else would be

brought out alive from the wreckage. It was time to go to Mary’s now. I

grabbed my bike and sped down the main road still feeling as if some kind of

compelling force was driving me. The whole experience was just so surreal. I

had read the major incident plan two years before and remember being

impressed by the precision and detail. There would be a press room; one

room would be set up as a mortuary. I was reminded of the mock simulations

of major incidents in my student days. Then volunteer students had been

daubed in make up blood to act as casualties.

The accident and emergency department was a hive of activity. What

struck me was that there seemed to be order, there seemed to be a plan—and

it was working. It quickly dawned on me why I had not been rung. Doctors

from all departments and specialties had rushed to help.

I was allotted a patient to look after and immediately recognised her as the

woman I had attended at the scene. Now, like all the other patients, she had

a number and I would be responsible for her. Around every patient was a

dedicated team of doctor plus nurse.

Never had I imagined a major incident running so efficiently, especially

with the horrific severity of injuries. The major incident packs, used for the

first time, had all the necessary forms. Medical students stood ready to rush

blood samples to the laboratories. I glimpsed the sight of patients with major

burns being whisked away for emergency surgery.

My duty was to stay with my patient to continually assess her condition,

anticipate potential problems, investigate and repair her wounds and be her

friend. She had a nasty head injury and remained pale and cold. My main

concern after establishing that her airway, breathing, and circulation were

stable was to recognise that she might have a skull fracture and underlying

serious head injury. The appropriate monitoring and tests were done.

It is funny how little things impress on your mind—hearing about members

of the public ringing to donate blood, the catering department sending down

sandwiches and drinks for exhausted staff, the gratitude of patients. All the

while I was with my team, other teams were treating their own patients. Some

were dreadfully burned, others had fractured limbs, ruptured spleens, or

head injuries. I stitched up my patient’s wounds with the help of a medical

student. The nurses dressed her other wounds and we transferred her to the

adjoining ward.

Suddenly the department was quiet and then the debriefing—lots of

emotion, satisfaction, and pride on all sides for the sheer professionalism

shown not just by the medical and nursing staff but by the porters,

receptionists, police, security, and caterers.

FI

POSTSCRIPT

135136

Appendices

Appendix 1 The core outcomes of basic

medical education

The principles of professional practice

The principles of professional practice set out in Good Medical Practice must

form the basis of medical education.

• Good clinical care. Doctors must practise good standards of clinical care,

practise within the limits of their competence, and make sure that

patients are not put at unnecessary risk.

• Maintaining good medical practice. Doctors must keep up to date with

developments in their field and maintain their skills.

• Relationships with patients. Doctors must develop and maintain

successful relationship with their patients.

• Working with colleagues. Doctors must work effectively with their

colleagues.

• Teaching and training. If doctors have teaching  responsibilities, they

must develop the skills, attitudes, and practices of a competent teacher. 

• Probity. Doctors must be honest.

• Health. Doctors must not allow their own health or condition to put

patients at risk. 

The following curricular outcomes are based on these principles. They set

out what is expected of graduates. All curricula must include curricular

outcomes that are consistent with those set out below.

Outcomes

Graduates must be able to do the following.

Good clinical care

(a) Know about and understand the following.

(i) Our guidance on the principles of good medical practice and the

standards of competence, care, and conduct expected of doctors

in the UK.

(ii) The environment in which medicine is practised in the UK.

(iii) How errors can happen in practice and the principles of

managing risks.(b) Know about, understand, and be able to apply and integrate the clinical,

basic, behavioural, and social sciences on which medical practice is

based.

(c) Be able to perform clinical and practical skills safely.

(d) Demonstrate the following attitudes and behaviour.

(i) Recognise personal and professional limits, and be willing to ask

for help when necessary.

(ii) Recognise the duty to protect patients by taking action if a

colleague’s health, performance, or conduct is putting patients at

risk.

Maintaining good medical practice

(a) Be able to gain, assess, apply, and integrate new knowledge and have

the ability to adapt to changing circumstances throughout their

professional life.

(b) Be willing to take part in continuing professional development to

make sure that they maintain high levels of clinical competence and

knowledge.

(c) Understand the principles of audit and the importance of using the

results of audit to improve practice.

(d) Be willing to respond constructively to the outcomes of appraisal,

performance review, and assessment.

Relationships with patients

(a) Know about and understand the rights of patients.

(b) Be able to communicate effectively with individuals and groups.

(c) Demonstrate the following attitudes and behaviour.

(i) Accept the moral and ethical responsibilities involved in

providing care to individual patients and communities.

(ii) Respect patients regardless of their lifestyle, culture, beliefs,

race, colour, gender, sexuality, disability, age, or social or

economic status.

(iii) Respect the right of patients to be fully involved in decisions

about their care, including the right to refuse treatment or to

refuse to take part in teaching or research.

(iv) Recognise their obligation to understand and deal with patients’

healthcare needs by consulting them and, where appropriate,

their relatives or carers.

Working with colleagues

(a) Know about, understand and respect the roles and expertise of other

health and social care professionals.

(b) Be able to demonstrate effective teamworking and leadership skills.

(c) Be willing to lead when faced with uncertainty and change.

APPENDICES

137Teaching and training

(a) Be able to demonstrate appropriate teaching skills.

(b) Be willing to teach colleagues and to develop their own teaching skills.

Probity

Graduates must demonstrate honesty in all areas of their professional work.

Health

Graduates must be aware of the importance of their own health, and its

effect on their ability to practise as a doctor.

From Tomorrow’s Doctors, 2nd edition, GMC, 2002.

Appendix 2 The aims of the Preregistration

House Officer (PRHO) year (“general clinical

training”)

• When universities grant a registrable degree, they are certifying that their

graduates have attained the goals of undergraduate medical education,

as set out in the GMC’s Recommendations on Undergraduate Medical

Education,  Tomorrow’s Doctors, and that they have demonstrated

competence in their published list of procedures.

• General clinical training is an integral part of basic medical education.

Many of its aims are similar to those for undergraduate education and

for the later stages of professional training, since medical education is a

continuum. General clinical training builds on the attitudes, skills and

knowledge graduates have developed and should enable them, as new

doctors, to:

(a) appreciate the centrality to the consultation by developing their

competence in history taking, clinical examination, and the

selection and interpretation of diagnostic tests

(b) develop competence at diagnosis, decision making, and the

provision of treatment, including prescribing

(c) keep accurate records

(d) refine the skills needed for the technical and practical procedures

which any doctor should be able to perform

(e) communicate effectively, both orally and in writing, with those

with whom their professional practice brings them in contact:

patients, relatives, healthcare professionals, and people in the

community

(f ) develop and maintain respect for the dignity, privacy, and rights of

patients, and concern for their relatives

(g) work in a team and accept the principles of collective responsibility

APPENDICES

138(h) be aware of their own limitations and ready to seek help when

necessary

(i) develop their knowledge and understanding of disease processes,

including their natural history, the role of occupation in disease,

and the possibilities for rehabilitation

(j) deepen their awareness of legal and ethical issues

(k) apply the principles of professional confidentiality in everyday

practice

(l) understand the principles of evidence-based medicine

(m) understand the relationship between primary and social care and

hospital care

(n) recognise and use opportunities for disease prevention and health

promotion

(o) understand and use informatics as a tool in medical practice

(p) understand the purpose and practice of audit, peer review, and

appraisal

(q) recognise self-education and professional development as a lifelong

process

(r) develop appropriate attitudes towards personal health and

well-being

(s) manage time effectively

(t) make the best use of laboratory and other diagnostic services

(u) follow safe practices (as detailed in their employer’s occupational

health and safety policy), relating to chemical, biological, physical,

and psychological hazards in the workplace.

From  The New Doctor—Recommendations on General Clinical Training,

General Medical Council, 1997.

Appendix 3Guidance to doctors

Being registered with the General Medical Council gives you rights and

privileges. In return you must meet the standards of competence, care and

conduct set by the GMC.

The duties of a doctor registered with the General Medical

Council

Patients must be able to trust doctors with their lives and wellbeing. To

justify that trust, we as a profession have a duty to maintain a good

standard of practice and care and to show respect for human life. In

particular as a doctor you must:

• Make the care of your patient your first concern

• Treat every patient politely and considerately

APPENDICES

139• Respect patients’ dignity and privacy

• Listen to patients and respect their views

• Give patients information in a way they can understand

• Respect the rights of patients to be fully involved in decisions about

their care

• Keep your professional knowledge and skills up to date

• Recognise the limits of your professional competence

• Be honest and trustworthy

• Respect and protect confidential information

• Make sure that your personal beliefs do not prejudice your patients’ care

• Act quickly to protect patients from risk if you have good reason to

believe that you or a colleague may not be fit to practice

• Avoid abusing your position as a doctor

• Work with colleagues in the ways that best serve patients’ interests.

In all these matters you must never discriminate unfairly against your

patients or colleagues. And you must always be prepared to justify your

actions to them.

From Good Medical Practice—Guidance from the General Medical Council,

2001.

Appendix 4 Suggestions for further reading

Getting into Medical School by Jim Burnett. Trotman, 7th edition, 2002.

Insiders Guide to Medical Schools by Ian Urmston, Debbie Cohen, Richard

Partridge. BMJ Books, 4th edition, 2001.

So You Want To Be a Doctor? by David Hopkins. Kogan Page, 1998.

A Career in Medicine. Do You Have What It Takes? by Harvey White. Royal

Society of Medicine Press Ltd, 2000.

So You Want To Be A Brain Surgeon? A Medical Careers Guide by Chris

Ward, Simon Eccles. Oxford University Press, 2nd edition, 2001.

Getting Into Medicine: The Essential Guide To Choosing A Medical School And

Obtaining A Place by Andrew Houghton, David Gray. Hodder & Stoughton

Educational, 1997.

Doctors To Be by Susan Spindler. BBC Books, 1992.

See also UCAS website and bookshop (www.ucas.ac.uk) for more

information and suggested reading.

APPENDICES

140Appendix 5 Website addresses for UK

medical schools

These sites give up-to-date information on contacts, admissions, entry

requirements, and the course structure.

In some cases the web address listed will take you directly to the medical

school homepage; in others you will have to navigate your way to the

medicine section, usually by clicking on courses or departments on the

university homepage. 

Appendix 6 Addresses of professional and

specialty organisations

College of Anaesthetists, 35–43 Lincoln’s Inn Fields, London WC2A 3PN.

Faculty of Public Health Medicine of the Royal Colleges of Physicians of

the United Kingdom, 28 Portland Place, London W1N 4DE.

APPENDICES

141

Birmingham www.bham.ac.uk

Brighton and Sussex www.brighton.ac.uk

Bristol www.medici.bris.ac.uk

Cambridge www.med.cam.ac.uk

East Anglia www.uea.ac.uk

Hull–York www.hyms.ac.uk

Leeds www.leeds.ac.uk

Leicester–Warwick www.lwms.ac.uk

Liverpool www.liv.ac.uk

Imperial College, London www.ic.ac.uk

King’s College, London (Guy’s, www.kcl.ac.uk

King’s, St Thomas’)

Queen Mary’s, London (Bart’s www.mds.qmw.ac.uk

and Royal London)

St George’s, London www.sghms.ac.uk

University College, London (Royal www.ucl.ac.uk/medical

Free and University College)

Manchester www.medicine.man.ac.uk

Newcastle www.newcastle.ac.uk

Nottingham www.nottingham.ac.uk/medical-school

Oxford www.medicine.ox.ac.uk/medsch

Peninsula www.pms.ac.uk

Sheffield www.shef.ac.uk/-medsch

Southampton www.som.soton.ac.uk

Aberdeen www.aberdeen.ac.uk

Dundee www.dundee.ac.uk/medicalschool

Edinburgh www.med.ed.ac.uk

Glasgow www.medicine.gla.ac.uk

St Andrew’s www.st-andrews.ac.uk

University of Wales College www.cf.ac.uk

of Medicine, Cardiff

Queen’s University, Belfast www.qub.ac.ukFaculty of Occupational Medicine (see Physicians).

Medical Research Council, 20 Park Crescent, London W1N 4AL.

Royal College of General Practitioners, 14 Princes Gate, London SW7 1PU.

Royal College of Obstetricians and Gynaecologists, 27 Sussex Place,

London NW1 4RG.

Royal College of Pathologists, 2 Carlton House Terrace, London SW1Y 5AF.

Royal College of Paediatrics and Child Health, 11 St Andrews Place,

London NW1 4LE.

Royal College of Physicians, 11 St Andrews Place, London NW1 4LE.

Royal College of Physicians of Edinburgh, 9 Queen Street, Edinburgh

EH2 1JQ.

Royal College of Physicians and Surgeons of Glasgow, 234–42 St Vincent

Street, Glasgow G2 5RJ.

Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG.

Royal College of Radiologists, 38 Portland Place, London W1N 3DG.

Royal College of Surgeons of Edinburgh, 18 Nicholson Street, Edinburgh

EH8 9DW.

Royal College of Surgeons of England, 35–43 Lincoln’s Inn Fields,

London WC2A 3PN.

Armed forces medical services

RAMC Officer Recruiting Team, Regimental Headquarters RAMC, Royal

Army Medical College, Millbank, London SW1P 4RJ.

The Medical Director General (Naval), (Attention Med P1(N)), Ministry

of Defence, First Avenue House, 40–48 High Holborn, London

WC1V 6HE.

Ministry of Defence MA1 (RAF), First Avenue House, 40–48 High

Holborn, London WC1V 6HE.

Appendix 7 Grant making bodies for mature

students

The Kate Adnams Charitable Trust (Nottingham Area). Browne Jacobson

Solicitors, 44 Castle Gate, Nottingham NG1 7BJ.

Ashby Charitable Trust, R Goodwin. 7 New Street, Ledbury,

Herefordshire HR8 2DX.

Lawrence Atwells Charity (Skinner’s Company), The Clerk to Lawrence

Atwells Charity, Skinners Hall, 8 Dowgate Hill, London EC4R 2SP.

The Blakemore Foundation, I McCauley and AF Blakemore and Son

Ltd, Longacres Industrial Estate, Rosehill. Willenhall, West Midlands,

WV13 2JP.

BMA Charitable Trusts, BMA House, Tavistock Square, London

WC1H 9JP.

APPENDICES

142Dorothy Burns Charity, AJM Baker, Fladgate Fielder, Heron Place, 3 George

Street, London W1H 6AD.

Clothworkers Company (Mary Datchelor Trust), Clothworkers Hall,

Dunster Court, Mincing Lane, London EC3R 7AH.

Elizabeth Nuffield Educational Trust, 28 Bedford Square, London WC1B

3EG. (Women Only)

Foulkes Foundation Fellowships, 37 Ringwood Avenue, London N2 9NT.

Foundation of St. Mathias, The Trustees, Diocesan Church House,

23 Great George Street, Bristol BS1 5QZ.

George Drexler Foundation, PO Box 338, Granborough, Bucks HP20 2YZ.

Girls of the Realm Guild, The Secretary, 2 Watchoak, Blackham,

Tunbridge Wells, Kent TN3 9TP.

Hilda Martindale Educational Trust, c/o The Registry, Royal Holloway

and Bedford New College, Egham Hill, Egham, Surrey TW20 0EX.

(Women Only)

PM Holt Charitable Trust, Ocean Transport and Trading Ltd, India

Buildings, Liverpool L2 ORB. (Merseyside Residents Only)

Hooks Mills Educational Foundation, The Secretary, c/o Bristol Municipal

Charities, Orchard Street, Bristol BS1 5EQ. (Education in Bristol)

Leathersellers Company Charitable Trust, 15 St Helen’s Place, London

EC3A 6DQ.

Miners’ Welfare National Educational Trust, 27 Huddersfield Road,

Barnsley, South Yorkshire. (Dependants of miners only)

Richard Newitt Fund (Kleinwort Benson (Trustees) Ltd), c/o University of

Southampton, Finance Dept, Highfield, Southampton, Hants SO17 1BJ.

Newby Trust, The Secretary, Hill Farm, Froxfield, Nr Petersfield,

Hampshire GU32 1BQ.

Royal Medical Foundation, Secretary’s Office, Epsom College, Epsom,

Surrey.

Royal Scottish Corporation, 37 King St, Covent Garden, London EC2E

8JS. (If born in Scotland, or at least one parent born in Scotland)

Sidney Perry Foundation, The Trustees, Atlas Assurance Co Ltd, Civic

Drive, Ipswich, Suffolk IP1 2AN.

Sir Richard Stapely Educational Trust, 1 York Street, Baker Street,

London W1H 1PZ.

Sir William Boreham’s Foundation, The Drapers Company, The Clerk,

The Drapers Hall, Throgmorton Street, London EC2.

Society for Promoting the Training of Women, Rev B Harris, Bent Lane,

Warburton, Lymm, Cheshire WA13 9TQ. (Women Only)

St Marylebone Educational Foundation, c/o The Parish Administrator,

St. Peter’s Church, 119 Eaton Square, London SW1 9AL.

The Mercers’ Company Educational Trust Fund, Mercers’ Hall,

Ironmonger Lane, London EC2V 8HE.

The Thomas Wall Trust, c/o WB Cook, Charterford House, 75 London

Road, Headington, Oxford OX3 9AA.

APPENDICES

143William Akroyd’s Foundation, Duncombe Place, York YO1 2DY.

(Educated in Yorkshire)

Further details of trusts can be found in the following: The Educational

Grants Directory. The Grants Register. Directory of Grant Making Trusts. It

is especially worthwhile checking for charities in your local area.

APPENDICES

144A levels 27

academic ability 23

academic achievement 11, 27–9

academic doubts 91–2

academic failures 95

access, to medical schools 11

accident and emergency departments 78,

84, 104–5, 120–1

accommodation 35

accomplishments 47

achievements, outstanding 48

activities, UCAS forms 46

“affirmation of a new doctor” 5

age, medical students 14

alcohol abuse 26–7

alternative medicine 59, 85

anaesthetics 121

anatomy 60, 61–2

Andrew, Dr Susan 13

applicants 11, 19

application and selection 44–51

obtaining an interview 48–50

personal details 45–6

when to apply 50–1

appraisals, specialists 116

armed services 131

arrogance 5, 73

AS levels 27

Asian women students 14

assessments

early years 69–70

later years 88–9

attachment schemes 63

attitudes, formation of 72–3

balance 25

basic medical sciences 130

bedside manner 67

Bingham, Sir Thomas 4–5

biochemistry 60

biology 28–9

Blifil, Dr 9

blood transfusion 125

body, interest in functions of 2–3

bogus doctors 109

Brighton and Sussex Medical School 36

Brotschi, Dr 108–9

bursary schemes 39

Cambridge 35–6, 59–60, 69

career fairs 107

career opportunities 107–8, 118–32

casualty, personal tale 78–9

Certificate of Completion of Specialist

Training (CCST) 113–14, 119

Certificate of Prescribed Experience in

General Practice 118

certificate of sixth year studies (CSYS) 29

Charles, Prince of Wales 58, 59

chemical pathology 85

chemistry 27, 28

children, care of 123–5

choices, university courses 46

clinical academic medicine 129–30

clinical firms 81

personal tale 75–7

clinical meetings 72

clinical skills, assessment of 88

clinical subjects 80–6

colleagues, working with 137

communication skills 5, 67–8, 99

community health 129

community-based services 81–2

compassion 23–4

complaints, learning from 73

complementary medicine 59, 85

confidence 5

confidential reports 47–8

consultant appointments committees 21

consultants 115–16

continuous assessment 23, 70, 88

conversation, at interviews 55–6

country practice, married doctors 105–6

Craig, Dr Oscar 70

current affairs, knowledge of 55

curriculum 35, 59–60

debt 38

decisions

choosing medicine 8–9

choosing specialties 107–10

dedication, to needs of others 4

deferred entry 40

delivery, personal tale 80

demeanour, at interviews 54

determination 24

diagnostic radiology 126–7

145

IndexDiploma in Child Health (DCH) 119

Diploma of the Royal College of

Obstetricians and Gynaecologists

(DRCOG) 119

disability 26–7

disease, interest in 2–3

disillusionment, young doctors 94

diversity, in curriculum 35

doctor–patient relationships 4, 108–9, 137

doctors

guidance to 139–40

professionalism 4–5

see also house officers; junior doctors;

women doctors; young doctors

doctor’s retainer scheme 114

doubts 90–6

academic 91–2

personal 93–5

vocational 92–3

down to earth ability 25

dress, at interviews 54

drug abuse 26–7

Duncan, William Henry 128

dyslexia 26

elective 86

personal tale 86–7

Eliot, George 3

endurance 24

entrance requirements 39–40

equal opportunities 20–1

ethical issues 55

ethnic minorities 13–14

European Baccalaureate 29

examinations

academic ability 23

later years 88–9

results 27, 46

expectations, of women doctors 20–1

experiences, choosing medicine 6–7

family commitments, choosing

specialties 106

family medicine see general practice

fees, overseas students 19

Fellow of the Faculty of Accident and

Emergency Medicine (FFAEM) 121

Fellowship of the Royal College of

Anaesthetists (FRC Anaes) 121

Fellowship of the Royal College of

Radiologists (FRCR) 127

Fellowship of a Royal College of Surgeons

(FRCS) 125

final examinations 23, 88

finances 38–9

Financial Help for Healthcare Students 39

first aid training 63

fixed term training appointment

(FTTA) 114

flexible training 106, 114

foundation course 60

Fox, Sir Theodore 4

full time research 130

GAMSAT (Graduate Australian Medical

School Admissions Test) 30

gap years 40

General Medical Council (GMC) 5,

139–40

general medicine 122

general practice

career opportunities 118–19

married partners 105–6

personal tale 82–3

popularity of 107–8

glass ceiling 21

good medical practice, maintaining 137

Good Medical Practice (GMC) 5

graduate students

bursary scheme 39

choice of medical school 40–1

four year course for 36

requirements for entry 30

Grand Rounds 72

grant making bodies, mature students

142–4

grants, honours degrees 69

guidance, to doctors 139–40

gynaecology 125

haematologists 125–6

healing 6

Hellman, Lilian 95

hepatitis B 26

hepatitis C 26

higher mathematics 28

higher university degrees 112

Hippocratic oath 5

histopathology 85

honours degrees, intercalated 69

hospital specialties 106, 119–28

hours of work 7, 101–2

house officers 97–103

preregistration year 98–100, 138–9

rotas or shifts 100–2

where to go 102–3

see also senior house officer posts

Hull–York Medical School 36

human behaviour, foundation

course 60

LEARNING MEDICINE

146identity, medical schools 34–5, 37

ill health, management of 3

illness, experience of 6

immunology 85

Imperial College School of Medicine

30, 69

Indian women students 14

informal teaching, from junior

doctors 77

Inglefinger, Dr F.J. 6

interest, in health and disease 2–3

interests 47

internal general medicine 122

International Baccalaureate 29

interviews 41–2

conversation 55–6

dress and demeanour 54

obtaining 48–50

offers 56

panels 53–4

purpose of 53

Irvine, Sir Donald 7

Islam, Dr Farhad 134

Joint Committee on Postgraduate Training

for General Practice (JCPTGP)

113, 118

journalism, medical 131

junior doctors

informal teaching from 77

initiatives to reduce hours 101–2

Kennedy, Sir Ian 11, 73

late applications 50

Learning from Bristol 11

letters of recommendation 49–50

Lincoln, Abraham 2

link friends 62

Little Foxes, The 95

living anatomy 61

local education authorities (LEAs),

fee status 19

location, choice of medical school 38

Manchester University 69

married doctors, country practice 105–6

mathematics 28, 29

mature students 14–16

bursary scheme 39

choice of medical school 40–1

grant making bodies 142–4

personal tale 16–19

medical degrees

acceptance overseas 39–40

costliness of 1

see also higher university degrees; honours

degrees

medical diagnosis 3

medical education, outcomes 136–8

medical journalism 131

medical schools

applicants 11

application and selection 44–51

choosing 33–43

early years 58–71

interviews 52–6

later years 72–89

requirements for entry 23–32

website addresses 141

medical students, public image 33–4

medicine

choosing as a profession 1–10

specialists in 121–3

way of life 95

membership, Royal Colleges 112–13

Membership of the Faculty of Occupational

Medicine (MFOM) 130

Membership of the Faculty of Public Health

Medicine (MFPHM) 129

Membership of the Royal College of

General Practitioners (MRCGP) 119

Membership of the Royal College of

Obstetricians and Gynaecologists

(MRCOG) 125

Membership of the Royal College of

Paediatrics and Child Health

(MRCPCH) 123

Membership of the Royal College of

Pathologists (MRC Path) 126

Membership of the Royal College of

Psychiatrists (MRC Psych) 126

Membership of the Royal Colleges of

Physicians of the United Kingdom

(MRCP (UK)) 122–3

meningococcal meningitis 26

mentors 62

microbiology 85

Middlemarch 3

Mitchell, Professor J R A 122

Mondeville, Henri de 127–8

Moran, Lord 24

National Blood Transfusion Service 125

national training number (NTN) 113

NHS consultants 115

Nicol, Dr Anne 21

Noble, Yvonne 106

non-science subjects 28

Nottingham University 69

INDEX

147Objective Structured Clinical Exams

(OSCEs) 88

obstetrics 125

occupational medicine 130

offers 56

oncology 127

open days 42

opportunities

ethnic minorities 13–14

mature students 14–16

overseas applicants 19

for women 12–13

see also career opportunities; equal

opportunities

oral examinations 88

outcomes, medical education 136–8

overseas applicants 19

overseas doctors 114

overseas practices 8

overseas students 38, 39–40

Oxford 30, 35–6, 59–60, 69

paediatrics 123–5

Paget, Sir James 2

palliative medicine 85

part time training, specialties 20, 114

partial shift systems 100

partnerships

general practice 119

with patients 73

pastoral role, medicine 4

pathology 84–5, 125–6

patients

early contact with 63

learning from 73, 77, 93

partnership with 73

personal tale 73–5

as teaching subjects 81

see also doctor–patient relationships

Peninsula Medical School 36

perseverance 24

personal details, UCAS forms 45–6

personal doubts 93–5

personal experiences, choosing

medicine 6–7

personal health 26–7

personal statements, UCAS forms 46, 55

Personal View 58, 59

pharmaceutical industry 131

pharmacology 62, 85

physical science 27

physicians 121–3

physiology 62

play 70–1

political issues 55

postgraduate diplomas, general

practice 119

postgraduate training 2, 20

practical sessions 62

prediction of performance 47–8

preregistration year 98–100, 110, 138–9

Primary Care Trusts 119

private practice, consultants 116

problem–based learning course 63–7

problems, sharing 95

professional organisations, addresses 141–2

professional practice 136

professionalism 4–5

psychiatric illness, doubts and academic

failure 95

psychiatry 126

public confidence, loss of 7

public health medicine 128–9

public image, medical students 33–4

qualifications see academic achievement

qualities 23–5

radiological anatomy 62

radiology 126–7

radiotherapy 127

rehabilitation 127

Reichenberg, Fran 20

requirements for entry 23–32

academic achievements 27–9

broader requirements 23–5

graduate students 30

personal health and disability 26–7

resits 30–1

research

full time 130

knowledge of current 55

resits 30–1

respect, for others 5

revalidation, specialists 116

rotas, house officers 99, 100–2

Royal Colleges, membership 112–13, 119,

122–3, 123, 125, 126

Royal Free and University College London

School of Medicine 30, 69

St Andrews 35–6, 69

St George’s 35

salaries 7

scholarships, honours degrees 69

science subjects 27–8

Scottish Highers 29

security 7

selection see application and selection

self directed learning 77, 91–2

LEARNING MEDICINE

148senior house officer posts 111–12

shifts 100–2

shortlisting, of candidates 48–50

size of intake 34

Smith, Dr Holly 111

Smith, Richard 90

social position 7

special study modules (SSMs) 63

specialist register 113–15

Specialist Training Authority (STA) 113

specialist training programmes 114

specialists 110–11

specialties

choosing 104–16

house officers 102

organisations 141–2

student training 84

Spindler, Susan 31, 95

spirit, of medical schools 34–5, 37

standards 4

Students Guide to Entry to Medicine (UCAS)

27, 48

subjects

clinical 80–6

early years 60–1

see also non-science subjects; science

subjects

supervised learning 63

surgery 127–8

survival ability 31

systems approach 60–1

teaching

early years 61–3

later years 72

television programmes 2, 25

testimonials, unsolicited 49–50

Todd, John 46

Tom Jones 9

topics, early years 60–1

training

general practitioners 118

specialties 20, 84, 106, 112,

113–14, 119

see also first aid training; postgraduate

training

tuberculosis 26

tutorials 62

UCAS forms

choices 46

deferred entries 40

other information 46–8

personal details 45–6

visits 42

vocational doubts 92–3, 95

Wilson, Dr John Rowan 121

Wolfe, Stewart 44

women doctors

difficulties facing 20–1

doctor’s retainer scheme 114

opportunities for 12–13

representation in specialties 106

work 70–1

work experience, medically-related 48

young doctors, leaving medicine 93–4

INDEX

149