The Perfect Clerk

[FailureToThrive]

How would one become the perfect clerk in terms of medical knowledge?

Is it really important to master every detail of pre-clerk years (and all the fundamental science that comes with it) or is it more than enough to master the pure clinical content in book' s like Toronto Notes, Pocket Medicine, Case Files, etc.?

[ZBL]

Bottom line: be keen, friendly and work hard. Most specialties don’t care how much you know. All do care if you’re more burden than help. There’s nothing you can do now to prepare for clerkship other than pass your pre-clerkships and bank sleep whenever possible. 

[Lactic Folly]

It may vary by person, but I do remember my internal medicine preceptors routinely attempting to assess students' knowledge bases through quizzing and discussions during rounds. A student with a stronger background should be able to write more relevant notes and present better targeted plans. I thought Case Files were great for integrating background knowledge into clinical scenarios. I found the format in Toronto Notes more difficult to learn from as a primary resource; likewise, Pocket Medicine is more of a portable reference on the wards.

[goleafsgochris]

Its a bit hard to see when youre in the thick of it, but if I could go back in time and do clerkship, I would just read the case files book at the beginning of each rotation.  Its short-ish, easy to read, and if you get through it you actually can have a lot of knowledge for a clerkship level.  

[jlkhhylyiluh6]

eh, case files is good for knowing WHICH cases to read around but its pretty superficial in terms of content...great starting point and easy to read, but you should definitely know more detail around the more common cases in there

[1D7]

Only on IM was I really ever assessed thoroughly on knowledge. On this rotation I was often quizzed on basic sciences knowledge because some preceptors assume that's what medical students should know.

In all your other rotations, if you did above average in your first 2 years, chances are you can do well working hard, studying during the rotation during off hours, and understanding what your team & attending want from you. The last item is key to doing well on all rotations. Generally if you are providing value to the team and preceptor, you will be appreciated, but occasionally you might have to talk around to understand what you need to impress.

In retrospect there's 25-35% of useless knowledge in preclerkship. The rest of it will either be directly or more often, indirectly useful. You will need to understand the language of medicine and what to search for on DynaMed/UpToDate. Sometimes knowing the basics will allow you to verbally reason through a problem enough that a preceptor will not care that you do not know the actual answer.

[Edict]

I would say: 

Be keen - say yes, don't argue or talk back, respect that there is a hierarchy and this varies by specialty with surgery being the most hierarchical and family medicine being less so. 

Work hard - If you want a letter, you need to stay late, always be on time or early, (for electives, you should work weekends, do extra call (varies by specialty)). Never leave work for others unless they absolutely insist on doing it for you/doing it themselves. (if you want to be a superstar on an elective, take on work for residents (in a tasteful and appropriate way), residents don't need to impress in the same timeframe you do, most will recognize your effort and they will return the favour)

Be knowledgeable - Know your clinical stuff, the knowledge you need for Step 2 CK is more important than knowledge you learn in Step 1.

Be socially aware - This is important. Medicine is teamwork, always pay attention to those around you. If you are in rounds and you start some 10 minute long discussion about which ACEi to use with your staff, look around, your fellow teammates may be rolling their eyes, falling asleep or shaking their leg.

Be friendly/nice/sociable - This I find is often very innate, some have no trouble others do, however the most important thing in my mind is don't be the opposite. As long as you are polite, can make some conversation and can laugh at a preceptor's jokes (even if you it was an awkward joke and it wasn't that funny) you will do fine in this category. This is a category you just need to be okay at, excelling is the icing on the cake but not the base. 

 

Two important mindsets to apply during clerkship: 

1. Function at the level of a junior resident - As you advance through clerkship, watch your junior residents closely, watch what they do, how they act. Pick the one you think does the best job in your eyes and try to work, think and act like them. Try to start doing responsibilities that they do. Try to have as much knowledge as them. 

2. Put the team first - On a rotation you want to impress in, think about the team first. Make sure the team's job is done or accounted for before you go home each day. Be willing to "take one for the team" and eventually "the team will take one for you". 

 

 

[psychiatry2017]

I think that you will be mostly quizzed at internal medicine+ pediatrics, make sure that you read around your cases + strong knowledge base.

Otherwise, I echo at what edict said, be a strong team player. It's important to show off your knowledge sometimes, but do not spend more than 10 minutes to talk about which ACEI during morning round. 

If you are willing to stay late and help for the scut work for junior residents, they will highly appreciated and in return, help you by making you look good in front of the staff attending. I often review before the CC3 present their cases to the staff physicians, and appraise their work when staff ask me for feedback. So be extra nice to your junior & senior, they could vouch for you !

Also, respect the hierarchy in medicine, do NOT cut off your junior residents & seniors& other health professionals, and do not attempt to answer question if your senior resident could not answer, unless your staff specifically ask you.

Unfortunately, when I was a clerk, you feel that you are at the bottom of chain, and there were some difficult times, but think about what kind of physician you want to be, and take the bad time with a grain of salt

[shikimate]

Knowing the high yield things in First Aid for Step 1 and Step 2 CK would be a good idea.

[Histolytica]

On ‎3‎/‎29‎/‎2018 at 8:47 PM, Edict said:

I would say: 

Be keen - say yes, don't argue or talk back, respect that there is a hierarchy and this varies by specialty with surgery being the most hierarchical and family medicine being less so. 

Work hard - If you want a letter, you need to stay late, always be on time or early, (for electives, you should work weekends, do extra call (varies by specialty)). Never leave work for others unless they absolutely insist on doing it for you/doing it themselves. (if you want to be a superstar on an elective, take on work for residents (in a tasteful and appropriate way), residents don't need to impress in the same timeframe you do, most will recognize your effort and they will return the favour)

Be knowledgeable - Know your clinical stuff, the knowledge you need for Step 2 CK is more important than knowledge you learn in Step 1.

Be socially aware - This is important. Medicine is teamwork, always pay attention to those around you. If you are in rounds and you start some 10 minute long discussion about which ACEi to use with your staff, look around, your fellow teammates may be rolling their eyes, falling asleep or shaking their leg.

Be friendly/nice/sociable - This I find is often very innate, some have no trouble others do, however the most important thing in my mind is don't be the opposite. As long as you are polite, can make some conversation and can laugh at a preceptor's jokes (even if you it was an awkward joke and it wasn't that funny) you will do fine in this category. This is a category you just need to be okay at, excelling is the icing on the cake but not the base. 

 

Two important mindsets to apply during clerkship: 

1. Function at the level of a junior resident - As you advance through clerkship, watch your junior residents closely, watch what they do, how they act. Pick the one you think does the best job in your eyes and try to work, think and act like them. Try to start doing responsibilities that they do. Try to have as much knowledge as them. 

2. Put the team first - On a rotation you want to impress in, think about the team first. Make sure the team's job is done or accounted for before you go home each day. Be willing to "take one for the team" and eventually "the team will take one for you". 

 

 

I agree with all of this. 

A good attitude and strong work ethic is 95% of it.  If a clerk is lazy or arrogant, they will be judged poorly no matter how smart they are and how much they know.

The best med students are eager to help and learn.

Also, know what your limitations are and ask for help when you need it.

[synch]

In addition to the excellent advice that everyone here has already given, bear in mind that your senior resident may be completing your evaluations and treat them with respect and courtesy. It's also important to remember that residents often feed back their assessments of clerks to attending physicians. You may not hear a ton of gratitude when you take on extra work, but it is almost always going to make it back to somebody important. If you want to match to that particular specialty and you make it clear, then it is all the more likely that information about your performance is going to be communicated to the important people. Residents can be your best ally. The corollary is that residents can really hamper your ability to match if they feed back that you were weird, rude, or not a hard worker.

[noneed2live]

Okay this confuses me a lot. Everyone here is saying be very hard working and kind. But as a first year, I always thought that everyone going into clerkship would try their best to exemplify those skills. I would expect that everyone coming in has the social IQ not to be rude, or not respect the hierarchy, and that if they had the work ethic to get into med school, they should demonstrate that work ethic in clerkship. But a lot of people have been telling me the opposite - that not as many people as you think are actually hard working. Can anyone explain that to me please? 

[goleafsgochris]

22 minutes ago, noneed2live said:

Okay this confuses me a lot. Everyone here is saying be very hard working and kind. But as a first year, I always thought that everyone going into clerkship would try their best to exemplify those skills. I would expect that everyone coming in has the social IQ not to be rude, or not respect the hierarchy, and that if they had the work ethic to get into med school, they should demonstrate that work ethic in clerkship. But a lot of people have been telling me the opposite - that not as many people as you think are actually hard working. Can anyone explain that to me please? 

 

The thing about getting into med school is most people are smart enough to learn what work they have to do, and what work they do not have to do.  Once you are in clerkship, its not too hard to pass by doing the minimum required to get by.

Now, you may say "that's poor work ethic."  But its complicated.  Say you want to get into a specialty, and the clerkship rotation youre on in really unrelated.  Are you gonna put in a ton of extra hours above the minimum?  Before youre in the thick of it, you might say of course.  But what if instead you spent those hours doing reading or research for the specialty you want to get into?  What if instead, because you worked hard on electives and on the rotations needed to get into your specialty of choice, you spent the hours on the unrelated rotation finally seeing friends and family you've been neglecting?  

To the first part of your post, there is really no excuse for rudeness.  That being said, "respect the hierarchy" is also a lot easier to imagine in an abstract sense before youre in clerkship.  The time will come when you will be on one of those "unrelated" rotations I described, and the hours will be brutal, and you will be stressed, and you will have the option to not do some additional bs work even though it may look better if you did it.  Its possible you will still respect the hierarchy, but at least to me its not so absurd why someone would not. 

[rmorelan]

2 hours ago, noneed2live said:

Okay this confuses me a lot. Everyone here is saying be very hard working and kind. But as a first year, I always thought that everyone going into clerkship would try their best to exemplify those skills. I would expect that everyone coming in has the social IQ not to be rude, or not respect the hierarchy, and that if they had the work ethic to get into med school, they should demonstrate that work ethic in clerkship. But a lot of people have been telling me the opposite - that not as many people as you think are actually hard working. Can anyone explain that to me please? 

everyone thinks that going in, and probably most people try to as well. 

The problem is for most....they never really have had to do something like that before

How many med students have had a situation where they have no control at all of their schedule for an entire year, are constantly sleep deprived, constantly not knowing what is going on all the time, all in a high stress environment working most of the time with people you never worked with before or know. When it doesn't matter if you are tried, sick, or have anything else going on that is a priority - you have to be at work on time, and cannot leave until the day is over. Basically it is a grind.

This is a complete generalization but med student know how to work hard - very hard, but in a sense until then on mostly their own terms at least most of the time. Clerkship isn't like that - that is seems to me why personality issues can emerge there. You simply aren't at your best after all the all nighters, all the 5-6am roundings, all the weekends you are working,  all within the back drop of looming CARMS when you are simply dead last in the hierarchy (as my senior joked to me once the person that cleans the floors is more important  than you - if you aren't here my day is easier as it is faster if I do it myself. If he isn't here we have dirty floors).  Exhaustion can kick in and it is hard to find time to do all the things you normally would do to destress. Plus you are surrounded by other people that may also not exactly be at their best either and conflicts happen.

It is one of those things that for most part only really makes sense when you actually have to do it. 

[1D7]

In clerkship (i.e. one step closer to the real world), there is much less hand holding. But unlike the rest of the real world, you'll be thrown into new rotations/preceptors every 1-4 weeks, all with different expectations of behaviour/personality, and even knowledge base. Of course many of these expectations will be unstated and so you simply must 'know' by being observant and asking the right things. You may excel with one preceptor and be merely average with another, and sometimes there will be preceptors who simply dislike you or are very particular about what they think med students should know.

Another point to consider is that people aren't as young anymore. There are some who are already married and many who are in long term relationships trying to sustain them. Some may even have children. Parents are older and start to have health problems -- some student themselves may have health problems. Former close friends are often busy in the 'real world', or at another medical school. There are many priorities to juggle, with fewer social supports than ever.

Lastly, on tougher rotations you will have to pick multiple things to sacrifice. Will it be your relationship? School performance? Sleep? Exercise? Finances? Diet? Hobbies? If you're not planning to become a surgeon on your surgical rotation, you're probably going to prioritize your long term relationship and physical health first, or at least on the same level as performance.

[Edict]

1 hour ago, noneed2live said:

Okay this confuses me a lot. Everyone here is saying be very hard working and kind. But as a first year, I always thought that everyone going into clerkship would try their best to exemplify those skills. I would expect that everyone coming in has the social IQ not to be rude, or not respect the hierarchy, and that if they had the work ethic to get into med school, they should demonstrate that work ethic in clerkship. But a lot of people have been telling me the opposite - that not as many people as you think are actually hard working. Can anyone explain that to me please? 

It is a lot harder to pull what I mentioned above off in clerkship compared to pre-clerkship. If you manage to do that, you are one of fewer than you probably think. 

[rmorelan]

14 minutes ago, Edict said:

It is a lot harder to pull what I mentioned above off in clerkship compared to pre-clerkship. If you manage to do that, you are one of fewer than you probably think. 

Plus I mean for most people - do you really have to be the perfect clerk in all fields? Perfect is a bit strong ha. You only have so much time and so much energy. Unless you are going for something that requires perfect in everything and your MSR actually shows everything it can be a bit pointless. I didn't get into radiology by mastering obstetrics - I didn't slack off but I also didn't show up an hour early to preround and prep every chart in advance either. 

[Arztin]

1 hour ago, noneed2live said:

Okay this confuses me a lot. Everyone here is saying be very hard working and kind. But as a first year, I always thought that everyone going into clerkship would try their best to exemplify those skills. I would expect that everyone coming in has the social IQ not to be rude, or not respect the hierarchy, and that if they had the work ethic to get into med school, they should demonstrate that work ethic in clerkship. But a lot of people have been telling me the opposite - that not as many people as you think are actually hard working. Can anyone explain that to me please? 

In addition to everything else people said, then there is the fact that you are always rotating, sometimes after 1-2 weeks. Change of hospital, teams, floors, and you feel like a total noob again on that new service.

People tend to get tired/fed up after a few months of clerkship for all these reasons.

One advice I would give to anyone who is starting clerkship is: even if you don't care, at least try to care, or in the worst case, pretend to care. People really hate students who give the impression they don't want to be there.

[noneed2live]

This is very great insight. Thanks, everyone! 

[The Ace of Spades]

On 3/29/2018 at 9:08 PM, psychiatry2017 said:

...do not attempt to answer question if your senior resident could not answer, unless your staff specifically ask you.

Although sometimes it's more useful to pretend you don't know either. Really have to read the room on this one.

[Lactic Folly]

The danger with always being careful not to show up anyone else is that you may receive evaluations stating that you need to read more, lack confidence, etc.

Rather than pretending that you don't know, it may be better to say that you were just taught that info by someone else, came across it in your reading around a patient, etc.

[ellorie]

In my mind the solution is to answer questions that were directly asked to you or asked to the room at large, but not questions that are asked to someone else. Seems to strike a good balance. 

[Snowmen]

37 minutes ago, ellorie said:

In my mind the solution is to answer questions that were directly asked to you or asked to the room at large, but not questions that are asked to someone else. Seems to strike a good balance. 

And I'm guessing that if your resident was just torn a new one for not knowing something, you absolutely shut the hell up.

[Lactic Folly]

1 hour ago, ellorie said:

 but not questions that are asked to someone else. 

Yes, never answer a question that is directed towards someone else. The more grey zone is what to do with questions that are asked to the entire group - you can see quite a range of behaviours among students in this instance.

[ellorie]

Ideally yes