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below average vs average vs above average clerk


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7 hours ago, cotecc said:

Wanted to know in your opinion what differentiates the Below average, the average and the above average clerk.

People seem to say to show initiative, to be a good team player, to be able to help etc, but ain't those things everybody does?

How to step up, as a 1st year clerk?

I agree that you would think among a group of smart, keen medical students, that everybody would display those qualities, but no, everybody does not do that at all.

I think being a strong clerk is 80-90% attitude and 10-20% knowing your stuff. I can't say its 100% attitude because honestly, you should know some medicine and be able to talk about the content of your rotation, but attitude certainly makes up the bulk of what residents/staff are looking to work with.

Show up early, work hard and complete your assigned tasks, take interest in what you're doing and take responsibility for your patients (don't assume, "I'm a medical student so others will just correct my mistakes". Try to take each opportunity as a chance to pretend this is your patient), ask questions when appropriate, learn from your mistakes (i.e. don't keep doing the same wrong thing over and over again), and be polite to nurses, other clerks, residents, staff, and patients. Do those things and you'll never have a problem.

The knowledge will come with time and reading. It's important to learn and become a better physician as your training progresses, but knowing everything about a specialty will not make up for lack of above.

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below average = significant deficiencies in knowledge, poor attitude or other glaring errors/omissions.

average = mix of minor ups and downs, nothing bad to say, blends in the crowd.

If you are starting clerkship, the first step is not to sink, so during your first month play safe and get to know your environment first, get the basic skills down (eg. how to write a consult note, how to consult somebody), and try to figure out how the hospital works. Once you are few weeks into clerkship, you can start to think about stepping up more.

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11 hours ago, cotecc said:

People seem to say to show initiative, to be a good team player, to be able to help etc, but ain't those things everybody does?

well truth is all of that actually isn't as easy as it sounds. In theory it sounds like something everyone will do but most people have never experienced anything close to clerkship before. For many med students this is the first time as adults where most of their schedule and the vast about of their time is not under their control. You have to be where and when they tell you do. Overnight shifts, weekends, early and late days and most of the time for many not in a field they are interested in (say you know what you are hoping to become in the end - well most of clerkship won't be that or related to it for most). A year of that can be quite draining and cracks often appear - and I have seen that show up in surprising ways even from people you wouldn't expect it from. As a student if you are having an off day or fall behind on something you can normally just move things around. You have no flexibility as a clerk - that is hard for a lot of people.  

Plus it is a year of you not really feeling like you know quite often what you are doing, and like anyone learning you will often mess up, be confused, tired and frustrated at times. That is to be expected but still a challenge. Some people can shut down a bit (survival mode!), and avoid moving out of their comfort zone even if that is really the only time you are learning and just try to blend in. Plus there is an real strategy in focusing even in clerkship less on the current rotation and more on their primary goal in CARMS. if you are going all out in a rotation that is unrelated to your interests you cannot be doing as much on other things - there is a real cost there. You only have so much time and energy. The practical side of medicine is also a lot different from book learning in preclerkship. 

 

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Clerkship will always bother me.

 I came out of the gates strong, did very well in initial electives with excellent/stellar English-speaking electives (and obtained generally strong letters) because I did everything 'right' (i.e. attitude/work-ethic/knowledge/learning/..).  Initial electives are generally disadvantageous but I managed to overcome that fairly handily - so much so that a local admin thought the sky was literally the limit for matching.

But, when I came back to my 'home school' I saw the other side of clerkship and suffered the consequences.  Unquestionably, I had some communication issues in French and was a lot less efficient initially especially - so despite my strongest efforts my performance really suffered.  But, I also saw that evals came down to many subjective factors - that staff too have their own biases and prejudices.  

While my English-speaking electives were all strong, I realized that partly maybe I just came across a lot better (which was confirmed by several staff that took the time to evaluate in both languages with an open mind)- while sometimes having obvious difficulties in French just sometimes made me a bad clerk.  It wasn't a question of effort.  Some preceptors would emphasize/de-emphasize communication issue (or would go at pains to emphasize it wasn't “just” communication), but on the whole just comparing English vs French rotations it was literally black/white.

I mean I understand - staff are busy, impatient etc..  I just felt there was little I could do to modify my ability to function fully in French (couldn't switch medical schools either), so it was beyond infuriating for me too - I had lifetime consequences by this so-called "language barrier".. and all the excellence I had shown was basically nullified and thrown down the drain (and other things like research).

 Obviously comes CaRMS time, no one has time for "stories" (as I mostly overcame the deficit), evals get translated, so it made everything much much harder that what should have been a relatively open path (actually one concession on the Dean's letter eventually was mentioning that challenges seem to have come from French).  It’s pretty obvious looking at politics how divisive the language issue is - I sort of wonder if the 'bilingual' CaRMS is partly about promoting national unity to a valuable demographic.  

Anyways, the whole experience rubbed salt in the wound on what were some of the worst years of my life in medical school.  

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13 hours ago, rmorelan said:

well truth is all of that actually isn't as easy as it sounds. In theory it sounds like something everyone will do but most people have never experienced anything close to clerkship before. For many med students this is the first time as adults where most of their schedule and the vast about of their time is not under their control. You have to be where and when they tell you do. Overnight shifts, weekends, early and late days and most of the time for many not in a field they are interested in (say you know what you are hoping to become in the end - well most of clerkship won't be that or related to it for most). A year of that can be quite draining and cracks often appear - and I have seen that show up in surprising ways even from people you wouldn't expect it from. As a student if you are having an off day or fall behind on something you can normally just move things around. You have no flexibility as a clerk - that is hard for a lot of people.  

This 100%.

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1 hour ago, cotecc said:

What amount of knowledge from preclerkship they except us to know. There seems to be so much

A lot of preclerkship is full of inessential details which aren't useful during clerkship.  Try to understand the big picture and practical applications - e.g. knowing how biochemical markers and lab values are used (what are the associated ddx?), how to read ECGs/basic X-rays,..

For every rotation, it's important to know the common presentations, be able to formulate a ddx as needed, have an idea of treatment.  It's more about doing - i.e. seeing patients and taking a good history+physical exam (with some ddx), charting, reviewing, putting in simple orders, etc..  

That being said, during medical rotations, knowing more of the pathophysiology or more developed ddx could help you shine.

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For surgical rotations:

Below average - asks to leave early without reason, can't read the room in the OR and asks so many questions that the staff have to tell them to shut it, told to read up on something and doesn't read up on it, asks questions that show they have not been paying attention

Average - shows up on time, does what they are told, knowledge as expected for a clerk and asks appropriate questions

Above average - asks insightful questions that show they are reading, eager and volunteer to help the team, has a team focused mentality and gets along with the team, diligent and conscientious does what they are told well enough that little supervision or correction is needed

 

A lot of it is about having good EQ, good social/working skills, knowing how to help out, catching the little things others may miss and bringing it up in a way that doesn't make any one team member look bad. If you can nail these things and have decent knowledge you will do great. Throw in good work ethic and staying late for interesting cases and you'll get a letter easily. 

Most clerks i've run into have been great, it really isn't that hard. I think the clerks that do the best are people who've had real work experience before ideally in a job that requires some sort of pace/repetition and people who socially fit in well with others. 

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15 hours ago, Edict said:

For surgical rotations:

Below average - asks to leave early without reason, can't read the room in the OR and asks so many questions that the staff have to tell them to shut it, told to read up on something and doesn't read up on it, asks questions that show they have not been paying attention

Average - shows up on time, does what they are told, knowledge as expected for a clerk and asks appropriate questions

Above average - asks insightful questions that show they are reading, eager and volunteer to help the team, has a team focused mentality and gets along with the team, diligent and conscientious does what they are told well enough that little supervision or correction is needed

 

A lot of it is about having good EQ, good social/working skills, knowing how to help out, catching the little things others may miss and bringing it up in a way that doesn't make any one team member look bad. If you can nail these things and have decent knowledge you will do great. Throw in good work ethic and staying late for interesting cases and you'll get a letter easily. 

Most clerks i've run into have been great, it really isn't that hard. I think the clerks that do the best are people who've had real work experience before ideally in a job that requires some sort of pace/repetition and people who socially fit in well with others. 

I would say this pretty much applies for internal medicine as well (and probably other specialities as well) 

one thing I will add specifically for internal medicine. Most clerks will be either average or below average from a knowledge when starting out, and that is OK. A lot of clerks stress out about the knowledge expectation given the breadth of topics and complexity of internal medicine. I try to relieve their anxiety by letting them know that the knowledge expectations are very very low for a clerk… unless they want to do internal medicine. The whole reason for  them to do an internal medicine rotation is to *learn* medicine, the rotation would be pointless if they already knew everything.

 

That being said even though the knowledge expectation is very low in the beginning, we do expect that you will learn and gain knowledge through the rotation, ie it won’t look good if you still don’t know how to manage CHFe or COPDe at the end of the block. This will happen naturally if you put in a normal amount of effort in (as you would for any rotation.)

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I will join the chorus of saying that it doesn't matter if you don't know anything about my specialty when you start, that's the point, you're there to learn. But if i go over a basic topic at clerk level that would be testable on NBME to teach you and then you struggle with that topic, then that doesn't look good. It's also totally fine if you don't want to do my specialty, I will try and tailor your rotation around your interests.

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7 hours ago, bearded frog said:

I will join the chorus of saying that it doesn't matter if you don't know anything about my specialty when you start, that's the point, you're there to learn. But if i go over a basic topic at clerk level that would be testable on NBME to teach you and then you struggle with that topic, then that doesn't look good. It's also totally fine if you don't want to do my specialty, I will try and tailor your rotation around your interests.

That's quite commendable.

I had a number of excellent preceptors that looked for progress/attitude/effort/ as described..  

unfortunately one or two seemed happy to fixate on any deficit and highlight any weakness even from the earliest moments of a 4+ week long rotations.  

 

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