Year 6: Final Year Advice

This is literally it. A few more months. The final push…

to become a

d o c t o r.

Final year somehow manages to be both one of the hardest and simultaneously easiest years at Med School. Conceptually, and content-wise, it’s all material that theoretically you will have covered at some point already in your life. Know how to treat an MI? That’ll score you points in your writtens (and save a life, next year). Know how to assess an unwell patient? That’s likely a whole PACES station in itself sorted out.

The trouble with final year, therefore, is that there’s so much other stuff to do alongside revision for your finals exams. You’ll have to think about job applications, which may or may not include AFP application and preparation. You’ll also be sitting your SJT and PSA exams (more on this later). Back in my day, we also had to think about elective planning, which was a mammoth task in itself, but this is an ever-changing situation in light of the global pandemic.

I graduated in the class of 2019, and in those one-and-a-half years, a LOT has changed with the global state of healthcare. Nonetheless, I’m going to try to provide you with some helpful advice, pearls of wisdom, and general goodiness to make your final year a breeze.

Allow me to begin with a couple of pre-warnings. This is a really long blog post – I wanted it to be as comprehensive as possible. Apologies in advance for the length of the post, but I hope that it is something that some of you find useful.

I would also like to say that we are living in unprecedented times. It’s all too easy to forget that you are living in the midst of a global pandemic, and graduating on to the front line. Some of you may feel overwhelmed, scared, unprepared, and anxious. Some of you just can’t wait to be able to make a difference. All of these are normal feelings that are shared by your colleagues.

There is increasing evidence that this pandemic has had a detrimental effect on the population’s mental health, and this applies to the students and doctors working throughout all of this. It is okay to feel down, and it is okay to need to talk about it.

Be kind to each other. Support one-another. Whilst Imperial medics have historically been exceptionally able and rather competitive, do not forget that we are all part of the same big Imperial Medical family; we all succeed a little more when we do so together.

Finally, do not forget what the end-game is for this year: to become a responsible Doctor who will always endeavour to do what’s right for the patients they look after (this can be all too easily forgotten when you’re memorising the multiple different glomerulonephritis’s).

Academic Stuff

Let’s get the boring but essential stuff out of the way first. You’re not going anywhere if you don’t pass your finals, so this is a pretty important part of final year. The good news? Almost everyone passes first time around (from an anecdotal evidence point of view, nobody I know didn’t pass their finals first time around, which cannot be said about years 1 – 5 of med school exams).

For your core curriculum, you’ll sit two kinds of exams: PACES and writtens. The preparation strategy for success for both of these sets of exams differs slightly.

PACES

You’ve already done these before, so you know the deal. In many ways, the final year PACES are easier than those from Fifth year, and this is in part due to the fact that you won’t be asked to recall specific RCOG guidelines, but rather broader, safe principles.

My top tips for PACES prep are as follows:

  • Preparation in groups is key to success – you can’t practice PACES on your own! Find a group of 3-4 final years you get on well with, and meet up once or twice a week to practice
  • Structure, structure, structure – it’s easy to have a mind blank when you’re asked a question in your PACES exam, especially when you’re stressed out. Having a structure is beneficial because it helps you remember things, and also shows that you are logical (and ultimately, therefore, safe). Some key structures that I would commit to memory include:
    • Assessment of a patient: Airway, Breathing, Circulation, Disability, Everything else
    • Investigations: Observations, Bedside investigations, Bloods, Imaging, Special tests
    • Management of patients: Conservative, Medical, Surgical
  • Smile and wave. Your examiners are ultimately people, and therefore will respond positively to you if you smile and introduce yourself when you enter the room.
  • Feeling like you’re not ready is completely normal. Imposter syndrome is something all of us will experience at some point in our careers, and feeling like you’re not ready to be a doctor or not ready for PACES is totally normal. You have been training for over half a decade of your life though – I promise you’re ready.

There are a few key resources you can use to prepare for PACES. Alasdair Scott’s PACES notes remain highly popular, and for good reason, since they are comprehensive and succinct.  If you prefer less condensed notes, and notes which provide more of an explanation, then my colleague Dr Athif Ilyas has produced a terrific set of notes which can be accessed here.

Other people in my year used the Cases for PACES book, by Andrew Fry. This is once again an excellent resource, but in my opinion is aiming at a post-graduate level. Final year is incredibly strapped for time, which is why I think many people struggled to get round to working through this book, although if you do find the time to go through this book then it’ll put you in good stead.

My own personal preparation method was to go into hospital with a couple of colleagues in the afternoons and evenings and examine patients and practice presenting, in addition to performing preparation on our own, away from the wards. The former helped by showing me common pathologies and clinical signs (Cardio – Hammersmith, West Middlesex, Neuro – Charing Cross, Respiratory – any etc) whilst the latter helped by going through the motions of PACES and getting used to being VIVA’d.

Ultimately, the more practice you have, the better you’re going to perform. Of course, you need to balance your PACES weekly socials with some bookwork, which brings us on to…

Writtens

Whilst there is a degree of overlap in the knowledge that’s being tested in PACES and Writtens, you’re probably going to use a slightly different preparation strategy in the build-up for the written exams.

Notes

Final year is a short year, and for many people there won’t be enough time to make notes, although if you do, that’s brilliant. It’s important to remember that the content covered in final year is essentially all of the general medicine, general surgery, and general practice that you’ve covered so far. In theory, you will have covered everything already at least once at some point in your training so far.

The way that I liked to think about it, SOFIA contains basically all of the conditions that you need to know about to pass finals. There are about 9 learning outcomes per condition (e.g. describe the aetiology of X, describe the epidemiology of Y etc.). The first few are about the signs, symptoms and natural history of the disease, and the latter few are about the investigations, management and prognosis of the condition. Now, in third year, you had to know about the management of about 20 or 30 conditions, and then the rest of the learning outcomes for about 200 or so conditions.

In final year, by comparison, you need to know all the learning outcomes for all of the conditions. This might sound daunting, but as long as you can identify, manage and identify common associations between conditions, then you’ll be fine.

So how do you make notes in this super short year? ICSM Note Bank has got lots of different types of notes on them to cater for a plethora of note taking styles, and you might benefit from selecting one of these and annotating it as you revise. I personally used my old Third Year Notes and supplemented it with updated management and guidelines for conditions.

Reading

Again, it’s about being efficient in final year. I personally don’t think that there’s enough time for going through Kumar and Clark or The Cheese and Onion cover-to-cover, but the same resources that work in third year work for this year too.

The key weapon in your arsenal that may have been overlooked in third year but that I think you should definitely be using in final year is NICE guideline, since a) your papers will be written based on this and b) you’ll be a boss when you say “NICE guidelines state that X should be managed by…” in your PACES.

In my opinion though, I think the best way to prepare for final year exams is to pick a Question Bank and work your way through it. The two most commonly used Question Banks used are Passmed and Pastest.

“But which one should I use?” I hear you say? My honest opinions are:

  • Passmed – Pros: Huge question bank, accessible through internet browser. Students can comment on questions which are fun to read through and reading through these comments makes revision less boring, question explanations make for good revision notes Cons: Tonnes of repetition (although this might be a positive), no dedicated app
  • Pastest – Pros: Has a great app which can download questions for offline use (great for tube commutes), website and app uses more colour (better for visual learners), questions are good-quality. Cons: slightly smaller question bank

You can’t go wrong with either. Pick one and commit, and get through it. Try to do it a second time around to consolidate your knowledge. Question banks can be worked through either with dedicated blocks of time (e.g. 1 hour every night after firms), or you can pull them out when you’ve got downtime (e.g. a quiet clinic, lunchtime, on the commute).

Firms

There’s so much to be said about firms. The most important thing to do – and this will sound cliché – is to go in. I remember people still not knowing how to examine a hernia right at the end of final year, and if you’ve ever seen even one in your life on the wards, you’ll know how to examine and differentiate hernias.

General advice regarding firms is as follows:

  • Practice performing a full clerking of at least 1 patient a week. A full clerking consists of a history of why the patient came in, their medical background, social history, and a comprehensive examination. This will help you become slicker at examining real patients
  • Examine one patient for yourself at least every day. You want to make sure you’re as slick as an Olympic swimmer when it comes to examining patients. They will not understand your instructions like your mates do when you practice PACES with them, so make sure that you get confident examining patients.
  • Go sign hunting in groups of 2 – 3 regularly
  • Get sign offs done early. The last thing you want is to be worrying about getting your catheter sign off when you could be revising Urology instead.

Each of the major final year firms also provides a slightly different learning experience. On that basis, I would provide the following advice for each firm.  

Senior Surgery

  • Go to theatre. The consultants who attend your PACES and who write your written exams will be there. They will quiz you, and this experience, although sometimes daunting, will provide you with the knowledge of the sorts of things that they regularly ask you for.
  • Shadow the F1 and the SHO. They’ll be examining patients and seeing the new patients on take respectively. This is essentially what you’re preparing yourself to do.
  • Take strategic “library afternoons”. You need time on the wards as well as time with the books. Surgery placements lend themselves usually quite favourably to the odd library afternoon…

 

Senior Medicine

  • Ask to do jobs. If you do a job or two, it’ll free up your F1 to do some teaching for you, and may even provide you with opportunities to do DOPS.
  • Clerk every new patient admitted to the ward. Be possessive. Treat the ward you’re assigned to as your ward, and when a new patient comes along, find out why they’ve been admitted. They could be a patient with the same pathology that comes up in your PACES (which means you’ll be aware of the presentation and inpatient investigation and management of that particular pathology is), and you’ll become much better at seeing new patients.
  • Make ward rounds fun (lol). For every patient you see, ask yourself i) why they are still in hospital and ii) what signs you can see that are relevant to their condition. If you can answer those two questions, then you’ll likely know enough about the patient and their condition to pass PACES.

Take a moment to think about why you’re doing this year. This year is the caterpillar-to-butterfly year, at the end of which you’ll be assessing patients (without an examiner watching you), prescribing medications (and signing them with your own name), and talking to patients on your own.

Summary of academic stuff

  • Get a study group together for PACES and meet regularly
  • Get your hands on one of the question banks, and work your way through it over the course of the year
  • Go into firms
  • Be proactive
  • Behave like an F1. You should be able to clerk, examine, initiate investigations (and justify them) and start the initial management of patients on the acute medical take and in GP settings. You should also be able to assess surgical patients. All of this needs to be fluid

SJT and PSA

This is once again something that people worry about a lot in final year. Whilst both are very important exams, and there are plenty of resources available for both, I think its’ possible for one to spend too much time preparing for them.

The SJT is an exam that relies on testing your decision making skills without specifically assessing your clinical knowledge. The most important factor in scoring a high score is to actually finish the paper. This may sound very straightforward, but so many people don’t, and at that point you’re practically throwing away marks.

Some people signed up to the BMA question bank, but the most accurate resource will be the official SJT practice papers. These take far longer than you think to actually do and properly review – probably about 3 days of solid work to do and thoroughly go through the right and wrong answers. It’s important to be aware that there’s a certain style of question writing that they use in the actual paper, and subtle differences in wording will alter the meaning of the question. This is why I would stay clear of other, poorly written question banks.

I would also personally recommend reading GMC Good Medical Practice and working your way through the example scenarios they have available, for free, on the GMC website. You’d be surprised at how often their example scenarios come up in the exam papers!

I don’t think you need more than a month to prepare for the SJT – out of the people I know, people spent anything between 1 week to 2 months preparing for it.

The PSA is sat towards the end of the year, as opposed to the SJT which is sat halfway through your year. By the time you sit this exam, you’ll already have most of the knowledge you need to succeed in it. It’s a time pressured exam, so make sure you’re on top of your time-keeping skills. I would recommend you go through Pass the PSA, an excellent book, and the official paper which is available online. Be aware of common drug-drug interactions and mistakes – some of them can be as straightforward as the timing of the medication dose e.g. taking statins at night.

Other Stuff

Should I AFP?

This is a difficult question to answer, and ultimately will depend on a whole host of factors and is a really personal question that only you will be able to answer. It depends on factors such as whether or not you feel like you want to do research in your future career.

It’s important to note that an AFP gives you a 4 month protected block of research time, but this doesn’t necessarily mean that you will generate publications. It’s ultimately on you to publish in this time. The flipside of this is that you can still publish even when you’re not on the AFP, so you don’t need to do one if you want to dabble with the occasional research.

Another important thing to note about the AFP is that it relies on a slightly separate application process, which allocates points based on previous academic achievements. The points system varies from deanery to deanery, but they do not take into account your SJT score. Your SJT score is therefore only used for FPAS job applications, and not AFP applications.

I’ve made a video introducing the AFP – you can view it here – and there’s plenty of material available online. If you still have questions, please feel free to get in contact with me.

Where should I apply?

Again, this is a really personal question. Although some people say that there’s a game to be played when applying for FPAS jobs, the reality is there is no such game. All you need to do is apply to the locations that you want to spend the next two years in.

Factors that might influence your decision-making include:

  • Cost of living
  • Location of family
  • Possibility of living at home
  • Location of significant other or friends
  • Competition

Regarding the point about competition, it’s true that there are some deaneries that have a higher decile cut off, but it’s important to bear in mind that FPAS consists of two sets of rankings

The first ranking allocates people to deaneries. The second ranking ranks people within a deanery and allocates them to jobs. Bear in mind that if you just about scraped getting into a deanery, you’re not going to have the top choice in jobs. If you apply to a less competitive deanery, however, you are more likely to rank higher and therefore secure the jobs you want. Job selection might be important if you want to do a rotation in a particular specialty (although bear in mind there are alterations occurring all the time due to the Covid pandemic).

To summarise: if you’re after a particular location only, and don’t care about jobs, then rank wherever you want to go highest. If you’re after a particular job, however, think about applying to somewhere where you might rank higher within the deanery. 

My personal advice? There’s no such thing as a bad F1/F2 job. All of them are emotionally and physically demanding. The more out of your comfort zone you are, the more you’re going to learn.

Electives

This is a tough one. Traditionally I would have had lots to say about electives, but given the state of the pandemic, and the fact that case numbers are climbing and countries re-entering lockdown as I write this advice, I’m not sure you’ll have an elective, much like the year before you. My usual advice regarding how to find somewhere to do your elective, the kind of climate to travel too, and sorting out vaccinations will really depend on the trajectory of the pandemic.

So that’s it! All of final year condensed into one fairly long blog post. I hope you found some of this useful. Please feel free to contact you if you have any questions – I’ll try my best to reply as soon as I get a moment!

Dr Mohammed Fallaha

Leave a Reply