Chapter 3
Tips for the Medicine Clerkship
Kathleen F. Ryan MD
The Internal Medicine Clerkship is the educational experience during which students are expected to gain the basic knowledge, skills, and attitudes needed to care for adult patients with medical disorders. Traditionally, the clerkship has been hospital-based and geared to the diagnosis and management of acutely ill inpatients. With changes in the delivery of health care in the United States, clerkships at many medical schools have also included some training time in the ambulatory environment. The clerkship can be an anxiety-provoking time for some students as they move from the objective evaluation system (i.e., tests and quizzes) of the preclinical years to the subjective evaluation system of the clinical years, which is based on day-to-day knowledge and care of patients. That is not to say that students will never encounter a written examination, as many schools administer the National Board of Medical Examiners (NBME) Shelf Examination in Medicine at the end of the clerkship, which may account for a significant portion of the student’s final grade. This chapter provides a few pointers to hopefully ensure success in this very exciting, but sometimes intimidating, clinical journey.
KNOW THE GOALS
There are levels of proficiency throughout medical school and during the clerkship that are usually linked to the goals and objectives. Schools either distribute the goals and objectives or have a website devoted to the clerkship where they can be found. In addition, many schools have adopted the national Clerkship Directors in Internal Medicine—Society of General Internal Medicine Core Medicine Clerkship Curriculum; the national goals, objectives, and syllabus can be accessed at the Alliance for Academic Internal Medicine’s website (http://www.im.org). These elucidate what the learner will need to master, as the goals and objectives are usually tied in some way into the final evaluation for the Internal Medicine Clerkship.
GREAT EXPECTATIONS: THE DUTIES OF A JUNIOR CLERK
Many students struggle with what is expected of them as junior clerks. It is optimal for students to discuss the expectations of their resident and attending physician early during the first week of the rotation. The following are examples of basic duties and responsibilities that are commonly suggested across a wide variety of medical schools and other clerkships.
Timeliness
Always be on time; in fact, try to be a bit early. This includes lectures, teaching rounds, and other required activities. Timeliness is a part of being a professional and working within a profession. If you need to be late or absent, you should immediately notify the attending physician, resident, and the person responsible for the clerkship at that site (director or administrator). It is also important to realize that if illness is the reason you are absent, you may need a doctor’s note to return. This is not because your supervisors don’t believe you but instead because if your absence is related to an infection, you may need to be deemed noninfectious before returning, as many of your patients may have depressed or absent immune systems such that close contact can expose them to serious illness.
Be Aware of How You Look to Others
Professional dress is a must. What may be the latest fashion trend may not be appropriate for patient care. Attire can matter from a safety standpoint: open-toed shoes may allow access of resistant organisms to your skin or even allow for an unexpected needle stick injury. Improper dress can also cause a communication barrier. Many patients encountered on the Internal Medicine Clerkship are older and may not feel comfortable opening up about their medical conditions to someone with tricolor hair. As it is critical to get the information from the patient so as to provide appropriate care, a medical clerk may have to conform to more conservative dress while involved in patient care activities. Also be aware of the rules concerning scrubs! Unlike what one sees on TV, most hospitals prefer that scrubs are worn only in the operating room and while you are on night call.
There Is No “I” in Team: Working as Part of the Medical Team
You will now be working with others for the good of the patient. The medical team consists of doctors, nurses, pharmacists, respiratory therapists, physical therapists, case managers, social workers, students, and even environmental staff. Each has duties and responsibilities in the care of the patient. Each member of the team should be treated with respect. When writing sign-out instructions or documenting information in the medical record, handwriting should be legible and the contact information of the author should clearly be visible. For the student to be kept abreast of changes in the patient’s condition, prompt answering via any communication device is a must. Many institutions have moved to the use of cell phones instead of beepers, so it is imperative that the preferred method of communication is identified on the first day of the rotation. When answering calls or pages, make sure people know who you are and what role you have on the team. Many students feel more comfortable using terms such as “medical student” or “student doctor.” It is important to realize, however, that in the eyes of the patient you are a doctor on the care team. Therefore, if a question is posed that you feel uncomfortable answering, explain that you will get an answer from a more senior member of the team. A patient’s condition can sometimes change very rapidly in the hospital, and the team will not be able to spend time looking for you. Be available to help the members of the team any way you can, even if it is not concerning one of your patients. Students sometimes underestimate how helpful they can be to the team.
Speak No Evil: What Happens in the Hospital Stays in the Hospital
Since the 5th century BCE Hippocratic Oath, patient confidentiality has been an integral part of medicine. Students experience many privileged conversations and hear test results of their patients. It is imperative that patient information not be shared in public venues such as the cafeteria, hallways, or elevators. In addition, one must be aware that pictures and stories regarding patients should never be shared on public forums such as Facebook. Even if the patient’s name or other identifying information is excluded, any posted information or photos will be in violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA; http://www.hhs.gov/ocr/privacy).
LEARNING EFFECTIVELY ON THE CLERKSHIP
One of the most exciting aspects of the Internal Medicine Clerkship is that now the world is your classroom! Learning will mostly be “on the fly,” and your patients and your team will be your teachers, although there may be some foundation lectures that will be part of your clerkship experience. Also a larger portion of learning will be moved to the student and become self-directed. Carving out time each night to read about your patients and their medical conditions is very important. When approaching topics, always cover the basics, as follows:
3. What do they look like on examination?
4. What other conditions are commonly confused with this one?
5. How does one diagnose and treat it?
When you are on teaching rounds, keep track of the types of questions that arise, as it is likely they will come up again. Make sure you look them up. Use an evidence-based approach applying practice guidelines that have the support of the literature. One should strive to practice medicine founded upon sound scientific evidence. You should know the most about your patients. You will generally be following from two to four patients at any given time, and your other team members will have considerably more than that. You will be an integral member of the patient care team and have important contributions to make in the care of your patients. This will allow you to actively participate on teaching rounds, which will foster evaluation of your performance.
FEEDBACK: ASK AND ASK OFTEN
Since the evaluation process on the clerkship is very subjective, it is very important that you obtain useful feedback to improve your performance. This concept is sometimes tricky for attending staff and residents to convey to medical students. Be wary of simple phrases such as “You are doing great!” or “There is no need to improve.” One always can improve on something, and this is especially true when a student is first starting on clinical rotations. One of the ways students can ask for feedback, without seeming to nag, is by approaching a supervisor more directly, as follows:
“Hi, Dr Smith! I was wondering if you had time to give me some feedback? Could you tell me in what areas I might improve on the clerkship?”
This phrasing makes it more difficult to give one-word or simple-phrase answers and may allow Dr. Smith to give meaningful feedback to the student. If you are provided feedback but are not sure what the person is speaking about, ask for an example. Always be courteous and thank the person offering feedback—even if it is difficult for you to accept what he or she is saying. Feedback is an opinion, and it is important for you as the learner to know the opinions of others. You may not believe it, but if you start to see patterns of similar feedback from different people, you need to consider what you are doing to make multiple persons observe the same behavior. Remember that the goal of feedback is to assist you in improving your performance to the best that it can be. It is also not inappropriate to get weekly feedback from both the resident and the attending physician. At the very least, you should inquire about feedback by the halfway mark of working together to ensure that you have time to make any necessary changes in your performance.
The Internal Medicine Clerkship is one of the most important you will experience, because what you learn will be applicable to patients regardless of your eventual area of focus. Patients with diseases such as hypertension and diabetes mellitus will be encountered in many different disciplines. Therefore, you should take advantage of all of the learning opportunities and use this time to hone your clinical and deductive reasoning skills. Enjoy yourself and cherish your patients, as they truly are your greatest teachers.
