Tips for a junior clerk

[A-Stark]

Or apparently the esophagus.

[leviathan]

If you want procedures, TAKE INITIATIVE! Ask to do something rather than waiting to be asked.

 

When you're on long rounds on services where you don't have much input as a student, sometimes I felt like I wasn't learning much and started to lose concentration/focus. Then I started writing down all the little tid-bits that people were talking about and realized it does really add up to a lot. Point is, try to stay focused and active in your learning because it can be easy to tune out on some services, especially the ones where pimping is minimal.

 

And yaeh, read up on the most common problems in every discipline and know them well. Someone mentioned hyponatremia as an example...that is a really good example of something that will show up in the labwork every day on at least one of your patients in IM. If you know the differential, how to work up and identify the cause, how to correct the problem, the complications etc...you will look pro.

[Renin]

agreed with Renin

 

Thanks for you explanation

 

You welcomes.

[Julie]

I haven't found call to be a good time for practice, though. As the saying goes, eat when you can, sleep when you can... you'll be busy enough as it is.

 

I agree. I follow that saying almost religiously, and only rarely accomplish much extra studying/practice while on call. I only would if I've already eaten, have an empty bladder am not sleepy and far from feeling I need a break.

 

The other thing I would add is don't be a hero. People here are all recommending to work hard, stay late, be motivated, etc. It's all true, of course, you should do all that. But you also have to know your limits, and trying to be a hero can cause more trouble than help. In my experience, clerks are often ashamed of admitting they're sick, or feeling faint, etc. The former only results in poor performance which leads you to be sent home by your annoyed staff/resident because you're just too obviously unwell. The later often leads to fainting in the OR and your surgeon having an extra patient to manage all of a sudden. If you're a tiny bit sick, ie with a small cold, show up, of course. If you feel like a truck ran over you, have gastro and a bad pneumonia, stay home! Everyone will be better off if you rest and show up once you're healthier. Along the same lines, if you're in the OR and feel faint, don't wait until you're seeing stars and are about to contaminate the wound. You can't will yourself into not fainting, so ask to sit down and ppl will understand/be grateful you can take care of yourself.

 

... so work hard and be motivated, but within reason. Not to the point where you're about to leave medicine. Not to the point where your staff needs to send you home. Your own health is important and you need to at least take care of yourself and not become your team's patient. As everyone says, it's a marathon, not a sprint. People who take care of themselves are more pleasant to be around, imo.

[Renin]

Always stay home if you have diarrhea.

 

Just saying.

[Karma]

I agree. I follow that saying almost religiously, and only rarely accomplish much extra studying/practice while on call. I only would if I've already eaten, have an empty bladder am not sleepy and far from feeling I need a break.

 

The other thing I would add is don't be a hero. People here are all recommending to work hard, stay late, be motivated, etc. It's all true, of course, you should do all that. But you also have to know your limits, and trying to be a hero can cause more trouble than help. In my experience, clerks are often ashamed of admitting they're sick, or feeling faint, etc. The former only results in poor performance which leads you to be sent home by your annoyed staff/resident because you're just too obviously unwell. The later often leads to fainting in the OR and your surgeon having an extra patient to manage all of a sudden. If you're a tiny bit sick, ie with a small cold, show up, of course. If you feel like a truck ran over you, have gastro and a bad pneumonia, stay home! Everyone will be better off if you rest and show up once you're healthier. Along the same lines, if you're in the OR and feel faint, don't wait until you're seeing stars and are about to contaminate the wound. You can't will yourself into not fainting, so ask to sit down and ppl will understand/be grateful you can take care of yourself.

 

... so work hard and be motivated, but within reason. Not to the point where you're about to leave medicine. Not to the point where your staff needs to send you home. Your own health is important and you need to at least take care of yourself and not become your team's patient. As everyone says, it's a marathon, not a sprint. People who take care of themselves are more pleasant to be around, imo.

 

 

Thanks for the advice Julie, I was starting to freak about how I should seem to be super motivated all the time.

[Fred]

Lots of excellent tips in this thread!

 

I'll add the following, in no particular order:

 

1. Remember that you are not good at clinical stuff. Your knowledge base is ok, but you still have to learn how to use it. Don't worry, that's what clerkship is for.

 

2. Ask a resident or attending if you can observe him/her do a couple of history/PE. I realized when I started clerkship that I had not seen a competent person do a correct history. I also realized that what I had been taught in the preclinical years wasn't really the correct way to take histories...

 

3. Never, ever lie about something you didn't ask in the history or look for in the PE. If the attending asks you: "did you ask if ..." and you didn't, the correct answer is: no, I did not. Do not make stuff up.

addendum to this rule: never chart a finding as negative if you didn't check!

This is a major red flag.

 

4. Don't be surprised/act offended when a resident or attending questions or examines your patient again.

 

5. You are still a student. Always remember that you need to cover ALL the material in a given rotation. Read about your cases, but try to cover everything else also.

 

6. The objectives of clerkship is to learn the common differentials of symptoms and diseases, the basics of investigations and diagnosis and an idea of what to do. At the end of clerkship, you'll know the doses of common drugs. Knowing the details about tests and the exact management of conditions is the main goal of residency, that's why it's 2-5 + years in one specialty.

 

 

7. Grades are subjectives...deal with it...

I know it pissed me off more than once...

[CharmingHedgehog]

if you dont know your drugs (and some never really learn).... grab a pharmacist and ask. make an effort to write semi legibly so everyone can read it.

[thebouque]

if you dont know your drugs (and some never really learn).... grab a pharmacist and ask. make an effort to write semi legibly so everyone can read it.

 

I love pharmacists (but I know my drugs pretty well)

[Student_Doctor]

If you want procedures, TAKE INITIATIVE! Ask to do something rather than waiting to be asked.

 

Definitely think this is very important. Although I haven't started my clerkship yet, during my preclerkship electives I was hesitant to ask if I could perform procedures just due to lack of confidence, and it was reflected clearly on one of my evaluations.

[Lactic Folly]

Count yourself fortunate to have received this feedback before starting clerkship. I've learned over time as well to become more vocal about asking for learning opportunities. Now it is possible to be too pushy, but it's unlikely that anyone who started out with a lack of confidence will overcompensate to this extent. It helps if you can identify what you need to learn and have prepared by reading up on the procedure beforehand and going through the steps on your own.

[Karma]

Thank you so much for some very useful info!!!

 

It's Very, very appreciated

[leviathan]

On my first core rotation I jokingly offered to put in a central line for dialysis in the ICU and the attending responded seriously and said 'absolutely'. I started asking to do a lot more after that.

[estairella]

The difference between playing the game and not playing the game is going to be mostly 7-10s/10 on your evaluation, versus mostly 6-8s with some 9-10s. (6 being 'average student') I chose not to play the game because 1) I'm not aiming for anything competitive 2) I suck at sucking up. Plus, if you play the game poorly, esp. to staff who have been around, people are going to see right through you, and THAT will reflect in your evaluations.

 

So, doing decent (not excellent, but decent) in clerkship is pretty easy. The bare minimum detailed below is ALL you need to do. Anything beyond that is gravy.

 

This may be surprising to you, but doing the bare minimum is a big problem for a lot of clerks, esp. ones who have never had a 'real job' in the 'real world' where expectations are not just there for fun but actually mean something.

 

1) Show up. On time. Do the work asked/expected of you. Don't be a ****. Don't leave early. Don't EVER lie (about clinical findings or your procedural expertise).

 

2) ???

 

3) Profit!

 

Yep, that's right, if you show up, ON TIME (don't know why this is so hard, but some students always manage to be 10-15 minutes late, whether it's a 5am start or a 9am start), you're a "team player" i.e. not a douchebag, and do your work - which, honestly, as a clerk, is barely anything - you will do fine on your evaluations.

 

I also disagree about the "seem interested" thing that everyone is glamorizing, and once again it goes back to it not being necessary to play the game. When I was doing my surgery rotation (which I have zero interest in) I did as little as possible. I never offered to suture, or retract, or put in a chest tube, only did it if they offered. I didn't ask a single question unless I genuinely didn't know and thought it might show up on the exam. (In contrast to asking questions to which you already know the answer, so if they ask you back, you can impress them).

 

I just did what was expected of me - I charted the vitals, I saw whoever I was asked to see, I didn't skip out on my 1-in-3/4 calls and I was pleasant to everyone. I still ended up getting along really well with everyone and one staff (who was the director of gensurg at the hospital) asked literally about 4-5 times if I would reconsider gen surg as a CaRMS choice. My responses range from "Nope." to "Hahaha.. nope" and I think the last time "I think we both know the answer." My surgery evals were, as expected, pretty decent in the end.

[Lactic Folly]

I also disagree about the "seem interested" thing that everyone is glamorizing, and once again it goes back to it not being necessary to play the game. When I was doing my surgery rotation (which I have zero interest in) I did as little as possible. I never offered to suture, or retract, or put in a chest tube, only did it if they offered.

Just sharing my personal experiences. I worked hard and *was* trying to seem interested, but was told on one rotation that I needed to show more initiative and interest. Whether that is due to a quiet demeanor, or whether your surgeon's expectations were different than mine (as an example of what I could do to improve, they said that when I was in the OR as a surgical clerk, I should ask anesthesia to let me intubate) is unclear. Your rotation sounds pretty laid back.

[bloh]

I can echo what estairella has said as well. A number of residents/attendings have said the same thing.

 

1. Be punctual + reliable

2. BE NICE

 

Everything else is gravy and if you're going the extra mile, you're pushing yourself and trying to beat the law of diminishing returns. Ironically, by doing that you can burn out and then default on #2, which will be much more detrimental than anything else you've done. Remember that all it takes is one bad incident/outburst to put a negative mark on yourself and you need to do a ton of over-the-top great stuff for it to be noticed.

[A-Stark]

Just sharing my personal experiences. I worked hard and *was* trying to seem interested, but was told on one rotation that I needed to show more initiative and interest. Whether that is due to a quiet demeanor, or whether your surgeon's expectations were different than mine (as an example of what I could do to improve, they said that when I was in the OR as a surgical clerk, I should ask anesthesia to let me intubate) is unclear. Your rotation sounds pretty laid back.

 

I find this sort of thing is extremely staff dependent. On my ICU rotation, one of the four staff who was on during that month said I was "quiet" and she wasn't sure whether I was "engaged" as I didn't (supposedly) say much on rounds. (I don't think I was significantly different from the other housestaff in that respect.) It was generally a fairly frustrating evaluation and - as ever - evidence that these things can be subjective and, frankly, unfair and/or unjustified. Unfortunately for me, she was also the anesthesia program director...

[leviathan]

I find this sort of thing is extremely staff dependent. On my ICU rotation, one of the four staff who was on during that month said I was "quiet" and she wasn't sure whether I was "engaged" as I didn't (supposedly) say much on rounds. (I don't think I was significantly different from the other housestaff in that respect.) It was generally a fairly frustrating evaluation and - as ever - evidence that these things can be subjective and, frankly, unfair and/or unjustified. Unfortunately for me, she was also the anesthesia program director...

 

We can't talk too much or we look like know-it-alls...we can't talk too little or we look bored or like we don't know anything. And everyone's definition of too much or too little is different, so you never know precisely where to strike that balance. This is why med school drives people crazy!

 

I also hate how 90% of the time that I feel like I've done something wrong, it was from making decisions where either option will get you in trouble. Alastriss has a point though...asking for feedback early is a good way to find out if you're doing everything the 'right' way.

[Karma]

This is where I have to say you need to "actively" ask for feedback every once in a while. Even asking how the learning dynamic is going and if there is anything you can improve on can identify the point of view of others early so you can rectify the problem. It also makes you look amenable to constructive criticism, so that looks good.

 

I've been doing it for some time now in clerkship and in my previous jobs and it's true that it's helpful to ask if there are things that I can improve.

[Karma]

We can't talk too much or we look like know-it-alls...we can't talk too little or we look bored or like we don't know anything. And everyone's definition of too much or too little is different, so you never know precisely where to strike that balance. This is why med school drives people crazy!

 

I also hate how 90% of the time that I feel like I've done something wrong, it was from making decisions where either option will get you in trouble. Alastriss has a point though...asking for feedback early is a good way to find out if you're doing everything the 'right' way.

 

 

Same here, I feel almost all the time that either I'm totally useless or that I'm actually actively making someone's work harder, or annoying someone... hopefully it will pass.

[Maxime]

Best thing is to look interested (man I hate working with a clerk who doesn't seem like he gives a damn. I will make it stand out if the attending asks me what I think of the clerk -- Although the attending will probably know what I think without having to ask me. Even if you suck, at least you're interested, and things will work out for you...). However, don't look too interested, I hate that too. I remember a clerk sticking his head right next to my pen every time I was writing F/U notes (to get a clearer image of what I'm writing? I'm just writing F/U notes. What's so interesting? My notes are unreadable anyways! Seriously, he was getting on everybody's nerves, just too interested... It happens. You need to adjust you're interest level to the interest level of the case, and if you're unsure (a case of veno-occlusive pulmonary disease in a 28 year old patient who will be receiving a pulmonary graft? don't know how to react? Don't know that the hell veno-occlusive disease is? If your attending and senior resident are excited, you better be too, but not too much, because you don't know what veno-occlusive disease is, and if you're too excited, people will start asking questions..

 

Also, don't hesitate to point out positive contributions your team members brought to the ward, especially good differentials that wound up being the diagnosis. Don't over do it, but just sliding it in at the right time will make you very much appreciated by your team members (and senior residents), often resulting in a good evaluation by the attending.

[A-Stark]

Clerkship grades are insanely subjective. It helps if you are a sociopath of the Dexter variety.

 

The flipside is that she thought I was a really hard worker and worked very effectively with the team and knew the patients pretty well. It was also my third week of continuous rounding so by the end I was thoroughly exhausted.

[cardiomegaly]

The subjectivity of preceptors / how they don't know you whatsoever drives me crazy sometimes. I wish senior residents could have formal impact on your evaluations.

 

Things I've noticed so far in my first rotation:

 

1. If you say you're going to do something, DO IT. NOW. Not at 5 pm that day. The charge nurse will hate you if you try and discharge someone at 4:30 with follow-up appointments to book and home care consults.

 

2. It's all about an organized approach. Asked about your differential for dyspnea? Go systematically, if you have 7 organized answers it's much better than rattling off 20 in a haphazard fashion.

 

3. Don't show up your residents and fellow students. No one likes a know-it-all

 

4. This relates to item 1, but your preceptor won't care if you got his minute pimping question wrong. He will, however, remember if you neglected to follow-up a patient's lab work or fill out discharge summaries. The key to being a good clerk is to not cause extra work for your staff/senior resident. If you help them reduce their amount of scut, they will be happy.

[Lactic Folly]

I wish senior residents could have formal impact on your evaluations.

 

In most of my rotations, the chiefs had significant input - either writing the interim or final evaluations directly, or providing feedback to the course coordinators. But as with attending evaluation, this can also be subjective, even if they have spent more time observing you.

 

1. If you say you're going to do something, DO IT. NOW.

And if you can't get to it right away, make sure whoever is waiting is aware. Communication is key to preventing mistakes and misunderstandings.

[Bobby42]

The subjectivity of preceptors / how they don't know you whatsoever drives me crazy sometimes. I wish senior residents could have formal impact on your evaluations.

 

Things I've noticed so far in my first rotation:

 

1. If you say you're going to do something, DO IT. NOW. Not at 5 pm that day. The charge nurse will hate you if you try and discharge someone at 4:30 with follow-up appointments to book and home care consults.

 

2. It's all about an organized approach. Asked about your differential for dyspnea? Go systematically, if you have 7 organized answers it's much better than rattling off 20 in a haphazard fashion.

 

3. Don't show up your residents and fellow students. No one likes a know-it-all

 

4. This relates to item 1, but your preceptor won't care if you got his minute pimping question wrong. He will, however, remember if you neglected to follow-up a patient's lab work or fill out discharge summaries. The key to being a good clerk is to not cause extra work for your staff/senior resident. If you help them reduce their amount of scut, they will be happy.

 

sorry! but what is exactly, i am not understand.

And in this you mentioned one point which is relevant to fashion, i don't know but i hope you are talking about fashion tips. If i am right or not kinda reply me...