What to expect from CBM: 2nd year

Written by: Kathyrn Barry and Anita Adiga Third Year Medical Students

Welcome to 2nd year CBM! Green badges, stethoscopes, notebook and pen: by now, you will be familiar with how your Community-Based Medicine (CBM) days will work. The structure of CBM days in 2nd year are very similar to that of 1st year with slightly different emphasises. As you know 1st year focused on introducing you to General Practice, starting to look at the common presentations that patients may come to the GP with, and taking a history and examining patients.

2nd year CBM follows a similar structure to that of 1st year, with a similar format for the day. There is however a greater stress on examinations; notably cardiovascular, respiratory and abdominal. You are presented with more freedom in talking to patients, which is extremely beneficial in improving your history taking skills and even your general rapport building abilities. There is, therefore, less of a focus on observing consultations, and a greater expectation to get involved with your learning – this is a good stepping stone for 3rd year, where you are let loose onto wards and get the opportunity to take focused histories and perform examinations on patients.

Examinations

2nd year CBM sets the foundation for examinations; your tutors will begin to highlight the importance of examining patients in the wider context of patient care.

Make sure you have a read of the CBM clinical skills handbook on Canvas; this will also be your holy grail when prepping for OSCEs – it contains a good summary of all of the skills you are expected to be well-versed in before exams. You may notice that your GP tutors slightly deviate from the suggested order, or they may even teach you more clinical signs to look out for when examining patients but don’t worry – use this handbook as a guide for your revision. If you want to go one step further, have a skim of Macleod’s Clinical Examination textbook – it’s a detailed resource which will help you make sense of the complicated signs with confusing names. Don’t get too bogged down with the specific signs to look for, focus on the overall examination – generally if it is there, it will be obvious to you.

When doing your clinical examinations, recognise the importance of dictating everything you do to your GP tutors (and examiner in an OSCE setting!); this will definitely become apparent to you with practice. It is important that they know you are aware of what to look for, so that they can assess your ability and guide your thinking if you need some assistance. Use structures like WIPE (wash hands, introduce, position, expose) and IPPA (inspection, palpation, percussion, auscultation) to guide you.

History and Presentation Skills

Although you began to take a generalised history from patients in 1st year, in 2nd year you are expected to take this a step further. You will learn to do this with more selective questions in patients presenting with a specific complaint e.g. fatigue. With the structure of each CBM day focusing in on a specific topic e.g. renal and infection (as we have outlined in our handy table!), you will learn how to take a focused history and assemble a list of differential diagnoses in your head. With the critical thinking involved in creating a differential diagnoses list, you will start to develop independence of thought; for example, if a patient were to present to you with abdominal pain, the follow-up questions you ask will depend on their responses. After collating all the relevant information from a patient's history, you’ll slowly but surely to be able to eliminate and reorder diagnoses from your initial list.

In 2nd year CBM, you’ll notice that your tutors have incorporated more PBL learning and preparation work required for the day. These will help you develop your hypothetico-deductive (or simply, clinical reasoning) skills which will be extremely beneficial to you in the future.

PBL Learning and Prep Work

To make the most out of the PBL group learning, we cannot stress enough how important it is to put in some prep work. It may sound tedious but putting in at least half an hour before your teaching will mean that you can review your understanding with your GP tutor and learn from your peers. The PBL case studies put your anatomy and physiology learning into context and may resemble some of the patients you will see in your GP placement, so the practice is certainly beneficial.

OSCE Preparation

The biggest tip we can give you in order to be OSCE ready, is repetition! Make use of your lunchtimes at CBM and keep practising on each other. If you find that the time during CBM isn’t sufficient, go to the clinical skills suite in the Medical school with friends and make use of those facilities, (although this might be hard to do in COVID times)!

CBM is an amazing opportunity to get involved with patients, improve your clinical skills and knowledge, and have a break from lectures – so definitely make the most of it! Don’t compare your experiences at the GP practice with your friends: every GP tutor will have a different teaching style.

Enjoy the time you get to actually speak to patients: it is the most valuable part of your learning, which you definitely won’t get from reading a textbook!

Top Tips:

· Download the CBM Handbook, or even have it as your screensaver – I can guarantee you’ll read it tens of times over

· Practice examinations on your housemates, and make sure you always have an idea of the general structure in your head, this will help to refocus on what you’re doing if you ever get stuck – IPPA!

· If you're struggling with percussion, practice percussing on different materials! You’ll get more polished over time

· And finally, enjoy CBM! This is your opportunity to actually speak to patients, without any pressure

Focused Days:

The Heart of the Issue

· Quantifying risk and explaining this in lay terms to patients

· Risk factors for cardiovascular disease

Renal and Infection

· Skills – midstream urine (MSU) dipstick

Anaemia

· Understanding that causes are varied

· Categorising differentials

The Heart of the Issue

· Using surface anatomy to examine patients

· Discussing end of life

Brain and Behaviour

· Impact of diagnosis on people’s lives

· Emotional impact of chronic disease – not just organic problems

Cancer

· Dealing with uncertainty – every patient journey is different

Fertility

· Linking the biological aspects to the personal aspects

· Talking about uncomfortable topics