#clerking

Like, where’s the syllabus, or the overview, or the notes?

(so a few friends in 3rd med are starting clinical attachments in a couple of weeks and asked me to write a guide. i thought i’d share it here with you guys too in case anyone else find this useful) Transitioning from lecture based learning to clinically oriented teaching can be confusing and difficult if you don’t know where to start. Here is everything that I have learned through trial and error that has worked for me so far.

General

Clinical attachments are entirely different compared to traditional teaching because most of what you learn is what you take from opportunities you create for yourself. No one is going to cater to your learning needs and most people will pay you minimal to no attention unless you are a go-getter and are proactive in your own learning experience. 

Do NOT stand in the background and expect people to notice you. Not only is it slightly impolite, but most people won’t care for a random who just stands there occupying space. Introduce yourself to the team, express interest, and ask questions! 

Most of your learning from now on will be self taught. Discipline is crucial!

This goes without saying, but make sure you at least try to participate in as much as possible and offer to help the team to the best of your abilities

During your first day, ask a member of the team what their weekly schedule is like and attend accordingly. Bleep the intern to find your team on the first day of attachment. 

The most approachable person on the team is usually the intern. If they seem willing, get their digits. Text them occasionally asking them if they need help with anything, or if they have any pts with good clinical findings.

They may be extremely busy, so don’t get offended if they don’t reply.

Be nice and polite to the nurses. They can really help you out in times of need.

Important: please please please PLEASE get your annual flu shot. It’s actually really important and you should know why. Being lazy does not constitute as an excuse for not getting the jab.

Attire

As a future physician, I believe that dressing respectfully and professionally is essential to your overall image. This seems like common sense but you’d be surprised by how many people who don’t have any....Here are things to consider:

First thing’s first: wash your white coat on a regular basis. I cannot stress this enough it is disgusting and there are so many students in my year who walk around with a dirty coat and don’t wash them until right before finals..its disgusting and you’ll bring infectious diseases everywhere.

It’s easy enough for men, just wear a suit and tie + dress shoes. Tuck your tie in your shirt for hygienic purposes. 

Wear blouses with sleeves that are easy to roll up. Infection control usually has a "bare below the elbows” rule. Even if this is not a hospital policy where you’re from, I recommend doing this anyways. You wouldn’t want your nice white top to be soaked in blood while cannulating a pt.

Wear tops well above your cleavage line and skirts/dresses that is well below your ass. Pts can be giant creeps.

Loose fitting blouses can hang in very awkward ways when you bend over to do practical procedures (you will be moving about a lot), so be wary of this.

Don’t wear leggings. Please just don’t. 

For the love of God, please wear comfortable shoes. You will be running and standing around a lot. 

Invest in a good pair of scrub clogs/sneakers. There is a high chance you will get iodine/blood all over your shoes when you scrub into surgery. And clean them if they do get dirty.

If you’re attached to surgery, it’s perfectly fine to wear scrubs around the hospital unless there are specific rules against it.

Hair back and out of your face is a lot more hygienic and a lot less annoying in my opinion.

Honestly just be sensible and you should be fine.

Equipment

You will need: 

Several good black pens

Clinical notes should always be written in black. Make it a habit to use black pens and only black pens.

Tiny compact notebook/clipboard with loose papers

White coat/small bag if white coats are not allowed in certain hospitals

Tools

stethoscope

watch

tendon hammer

pen torch

tuning fork

cotton wool

neurotips

snellen chart

measuring tape 

ID badge ....etc

Handbook- most people prefer the Oxford Handbook of Clinical Medicine

If you buy textbooks online, I suggest getting them from thebookdepository, it’s usually cheaper, and free shipping worldwide, fam

The Ward Rounds

What are they? Every specialty team in a hospital goes through their pt list at a set time every morning (this varies from team to team). It is a way for every team member to get a brief history on their patients, and for senior doctors to relay what management options they want done for each pt to junior members of the team.

Your role as the med student

This is the most important part of your day for both medicine and surgery attachments. Make sure you attend them every day, especially if your team is post-call.

Ask the intern about what time they start, and help them out with list preparation. 

Get the intern to print a list for you, then ask them to go through the list with you so that you can get a general idea about all the pts. Jot notes along the way.

Show up earlier than the team. You can go through pt notes yourself and even take a brief hx before the team shows up and present your findings to the consultant/reg leading rounds. This is a way to impress them, and hopefully squeeze out a nice fat letter of recommendation.

H&Ps, writing clinical notes

Choose which pts you want to talk to from your list. You can decide either from observing the pts yourself during rounds, or talking to a member of your team. They will usually suggest pts for you, and ask you to present to them later. I highly recommend talking to as many pts as possible, it is extremely good practice for exams. 

If you are on a busy service or with doctors that involve you in team activities:

Ask to help with documentation. Usually they would let you write easy post-ward round redundant continuation notes (ie. ‘no acute issues overnight, plan as before...etc’). If they are handwritten notes black ink should be used.

documentation usually follows the “SOAP notes” format

Subjective

Objective

Assessment

Plan

Ask the intern if they need help with putting orders in for pts (labs, meds etc)

Some interns can get a lot of pages requesting consults from other services. Use this as an opportunity to take full H&Ps and present your findings back to them. Not only do you get to practice, you also help lessen the intern’s workload significantly. They will thank you for this. 

Surgical Attachment specifics

Make sure you know when your consultant has theatre. On days where they operate, show up early and check the theatre list. Get your scrub information session training over and done with well before your surgery attachment. Things you can do:

If you are able to, try and find out the list your consultant has planned for theatre day so you get a general idea of which procedures will be done. Research them yourself when you get home to get a better understanding of the procedure and prepare a list of questions you would like to ask. 

Take a hx and find out why the pt is in for surgery before they go in

Pre-op check with the intern

Be as proactive as possible. Ask the consultant if they are okay with you scrubbing in and ask questions as much as possible. Consultants/regs will generally be more than happy to explain what they’re doing as they go along provided the student seems interested enough. 

If you’re stuck standing around with poor visualization of the procedure, do other things (eg. talk to the anesthetist, ask some of the nurses if you can practice scrubbing in properly (because you won’t get other chances to do so), familiarize yourself with some of the equipment etc)

Most importantly:

If something is not beneficial to you, or if you might be more productive doing something else, don’t show up. This might contradict what I’ve been saying before but like I’ve previously mentioned, you are directing your own learning experience, spend time on things you feel you need more work on. While it is nice to show up, if you are behind on studying, stay in the library and catch up on lectures. There is no point in applying knowledge when you have little to none in the first place.

Or, If you’re attached to a busy service where most of the docs have little to no time to pay attention to you, ditch them and study on your own if that’s a better use of your time. You don’t have much of it, so don’t waste it on things that won’t help you.

Generally, no one will care whether or not you show up, there’s usually no attendance and they will not run around making sure that you’re there.