One hundred years of question banks: life as a medical student.

My life as a medical student, especially in the final year, was filled with question banks and OSCE textbooks. Finally, I graduated from British medical school in 2022 with honors and a deep apprehension about starting work and dealing with sick patients. Despite studying for five years, I did not feel prepared to become a doctor.

You are often told during medical school that as a newly graduated junior doctor you will always have seniors around to support you and that there is always someone you can call if the patient is unwell and you need assistance. Sure enough, if a patient is really sick there will always be someone more senior and experienced to help out. But what about all these small situations when a patient is not sick enough to escalate, and yet you have a question you need to ask seniors who are simply not there? How many times can you bother senior doctors from a different firm simply because rota coordinators left you and your fellow FY1 completely alone? What should you do if you are on surgery, you only have one registrar who is always in theatres, and nurses keep on bleeping about unwell patients you feel you need advice on? And most importantly - what should you do when the pressures on the NHS and doctors leaving the profession means that the situation will not improve for you or the new set of junior doctors starting in August?

Other than general stress levels, there was another feeling that accompanied me during these first months as a doctor. A feeling that I should have been prepared better for the scenarios I face every single day. There seems to be a general consensus that you can only become a good junior doctor by actually being a junior doctor. Nothing else you can do at the moment dear final-year medical student - just wait and hope you will not be rotated into surgical on-call nights on your first day.

However is that true? Is there truly nothing else that can be done? Does the leap between the final year and starting work as a doctor really need to be this big? Is medical education really as good as universities advertise it to be?

A little insight into my curriculum

At the time of my graduation, each UK university had its own unique curriculum, and adopted different teaching styles and there was no unified final-year exam for all medical students to compare their knowledge. My medical school used an integrated teaching style, which blurred the distinction between pre-clinical years and clinical years. As such, we had a chance to gain clinical experience from the first year through limited patient contact in the clinical setting. This patient contact included 10 afternoons in GP surgery in my first year, 10 full days in GP surgery, and 2 weeks on clinical placement in a hospital in a second year. Other than this the timetable mostly consisted of traditional-style lectures with some integrated learning activities scheduled throughout the year, which consisted of students preparing answers to a set of questions and then discussing this under the guidance of a facilitator. We also had a chance to learn about anatomy through whole-body dissection sessions every Monday and started learning practical skills like blood taking in preparation for clinical placements. My university also incorporated sessions about statistics and research interpretation during my first year, as well as some reflective practice based on our experience and contact with patients with chronic diseases.

Most of the time from the third year onwards was spent rotating to various departments for placements. There was not much medical school-organized teaching provided and instead, each hospital and department could schedule (or not) the teachings as they saw fit.

Recent changes done to the structure of placements in my alma matter showed a trend in favor of longitudinal placements where more emphasis is put on students’ engagement with teamwork and participation in things like multidisciplinary team and departmental meetings rather than on gaining knowledge and experience in multiple medical rotations. Although helpful with feeling like ‘part of the team’, inevitably it means that students will not get exposure to all medical specialties during their medical studies. Whereas it is not as much of a problem if you miss out on the more niche specialties, it becomes a much bigger issue if you never rotate into the main ‘bread and butter’ departments. As such you end up with a schedule like mine - where somehow I covered all minor specialties including 12 weeks in orthopedics, 8 weeks in ENT/ ophthalmology, and 8 weeks in breast surgery, but never, not even for one day, I got to officially rotate to cardiology, renal or respiratory. As a consequence, I finished medical school more comfortable reading bone X-rays than ECGs.

Is anyone even studying from lecture slides?

There was another interesting trend that was evident in my medical school, namely that students regarded med school-organized lectures and tutorials as pretty useless and instead chose to spend their time and money on paid resources found on the internet. The pandemic seemed to have further accelerated this trend, especially as many medical schools simply canceled placements and only offered limited teaching, if any. At the same time, many medical platforms offered regular lectures and Q&A sessions. Perhaps as a consequence, my year cohort spent most of their study time on websites like Passmed, Quesmed, or Bitemedicine rather than revising the PowerPoint slides and listening to recorded lectures provided to us by our medical school. All of these websites provide similar resources - 1000s+ exam-style questions, textbook summaries to explain the topics covered in questions, mini-lectures based on discussions about exam-style questions, and some OSCE resources with answer keys.

Overall it certainly felt like the focus on studying was on passing the exams, which in my medical school were all multiple-choice questions. These encouraged going through multiple question banks in order to memorize facts and keywords pointing to diagnosis, rather than focusing on a deeper understanding of the subject. Multiple guidelines created for pretty much any clinical scenario in the UK were also used as study resources which promoted memorization over understanding the topic and relevance to clinical practice. In fact, a lot of my peers did not attend parts of their placements, and could instead be found in a library or at home doing Passmed questions, or practicing OSCE scenarios with peers in the doctor’s room.

Why is everyone so tired?

Study methods and lack of teaching during placement years were not the only problems I noticed during my studies. Burnout was prevalent with many of my peers being unsure of whether they wanted to continue their medical career after graduating and many struggling with mental health during their studies and after.

Many of us moved from home towns or other countries at an objectively young age to then start studies in a completely new environment surrounded by completely new people. When we started placements we constantly kept changing the wards, teams, hospitals, and other students we were placed with, which I felt never allowed me to feel like I belong to a certain team and never allowed me to get to know people I was rotating with particularly well either.

Moreover, being rotated to hospitals away from medical school and not owning a car often meant travelling for more than an hour one way to get to placements, which not only consumed my energy but also money - as medical school allowance did not cover the entire cost of traveling. There were no scholarships for excellent performance on exams in medicine at my university, whilst some of my friends studying other courses were given grants for getting excellent grades. Some courses also organized study sessions, paying the students further along in their studies for teaching the younger years. Medicine did not offer any money - teaching others was expected of us and is an essential part of our portfolio when applying for training later on and therefore was done for free in our free time. Many of my peers had to take part-time jobs to support themselves on weekends or evenings. The amount of content meant attending 9-5 placements and then going home to continue studying. Unlike other courses, we were expected to be up to date with the medical guidelines, which sometimes meant having to relearn the same topic based on new guidelines as we progressed through our studies.

Some of us also took a year out to get a bachelor's/master’s in a different area of study, which normally would have given extra points when applying for foundation training. Getting the points for an extra degree was scrapped suddenly and without prior warning halfway through that very extra year for the people from my cohort. I guess good thing most of us did not do it just for the chance to be allocated to a dream job in our dream deanery.

The final year

The final year and the way the application to the foundation program is structured only further exacerbated my own burnout. You feel like the application process is stretched out across the entire year without a moment of rest - first the pharmacological exam which medical school does not prepare you particularly well for, then the situational judgment test which is worth more than all of the medical exams you take during medical school combined, and finally the painstaking process of ranking deaneries, waiting for an allocation and then ranking 400+ different programs in given deanery all just before final exams. If having to pick whether the registrar inserting a cannula onto a screaming patient is ‘not inappropriate’, ‘a bit inappropriate’, ‘very inappropriate’, or ‘extremely inappropriate’, knowing it will be a decisive factor about where in the UK I will be placed did not give me the last push to burn out, then having to drag and drop 450 programs certainly did.

Congratulations, you graduated! Now what?

All of the above left me so tired after medical school that I barely had a chance to recover my energy and enthusiasm over the short summer holidays. However, a bit under 2 months we were given allowed me to reflect on my studies and career choices. I felt resentment after graduating. I remember being mesmerized and enthusiastic about medicine during my earlier years, spending time reading more about the topic in my free time out of sheer curiosity or spending it chatting with patients curious about their journey and experiences. By the end of my fifth year, I just felt tired. It was not only due to reduced holidays in comparison to other courses, with some clinical years only having 8-10 weeks off during the entire year, full-day placements and the need to study and work part-time afterward, and minimal teaching from medical school during clinical years. Going through the Covid pandemic, being expected to get involved in audits, research projects, and quality improvement projects for free in my free time and the stress of applying for jobs only added to the burnout. When I graduated I was not proud or happy. I did not want to meet with my friends and celebrate. I did not want to tell others I am a doctor. I just wanted to sleep.

Now

A few months into my foundation training I feel more confident and relaxed in the hospital and when faced with unexpected clinical scenarios. However, I constantly identify new knowledge gaps which exist either because I started forgetting content I learned for medical school finals, or because I never properly understood the basic pathophysiology behind certain topics.

With my evenings being off for the first time in 5 years, I have managed to rebuild some of my curiosity and enthusiasm for medicine. With this comes finally actively and regularly working on my project, the idea for which was first conceived 3 years ago. A project where I not only want to try to reimagine a new approach to studying medicine but also allow myself to freely and creatively mix my passions for medicine and art. Come for a journey with me where I try to explore the impossible in practice but possible in imagination and enjoy this new world with its exciting environments and characters I am slowly creating. And perhaps watch it come into use as an educational resource one day!