A caveat, an introduction
To try and describe the clerkship year of medical school – the year-long, in-depth experience for students to actively participate in patient care in a clinical setting, usually in the third year – to those who haven’t experienced it firsthand is a difficult task. I steadfastly believe that medicine is an experiential endeavor, one that cannot be truly understood by someone until he has undergone it himself. The fact that each trainee has his own unique set of “critical-incidents,” to use a term from the medical education literature (1), that profoundly shapes the physician he will become makes the task even more arduous. Nevertheless, I will do what I can to try and give a good look at a day in the life of a third year student and what the experience entails.
Prior to entering the wards, medical school bears a striking resemblance to an undergraduate curriculum following a shot of anabolic steroids. The pre-clinical curriculum is designed to give an in-depth and thorough understanding of how the human body functions and the myriad of ways that functioning can go astray. The class of 2010 at St. Louis University’s School of Medicine provides a humorous but surprisingly apt analogy for this first phase of training in its “Pancakes Every Day” video.
Despite this medical knowledge being ceaselessly thrust at students for 18 to 24 months, the pre-clinical curriculum serves as a mere introduction to the real show of becoming a physician. Understanding the vocabulary with which physicians speak is one thing; translating the concerns and complaints of a live, in-the-flesh patient into those terms is an entirely different task, and using that information to arrive at a cogent treatment plan is still another. The clerkship year is focused on the latter two objectives. Through exposure to all of the general fields of medicine – internal medicine (adult medicine), pediatrics, obstetrics/gynecology, family medicine, neurology, psychiatry, and general surgery – third year students begin to develop that intangible yet critically important tool of the physician known as clinical judgment. It is this carefully curated amalgam of pattern recognition, clinical knowledge, and diagnostic reasoning that gives physicians the power to diagnose and treat patients and which is the real product of clinical training, starting in medical school.
To the wards
The particular experience on the wards a third year student has varies from clerkship to clerkship and even service to service. On surgical services, medical students serve more as assistants than surgeons as the experience is focused on spending time in the operating room rather than on the floor managing patients. Common tasks for students in the OR include retracting, or using instruments to expose the structure being operated on, and “closing,”or suturing the superficial parts of the incision at the end of the procedure. On a medical service, in contrast, a medical student may have the opportunity to directly perform small bedside procedures like placing intravenous lines, placing urinary catheters, and pulling central lines in addition to contributing to the daily care of patients.
Each attending physician – the “big boss”in charge of a medical team which otherwise includes fellows (physicians who are board certified but completing additional specialty training), residents (physicians who are not yet board certified but have graduated medical school), medical students, and other providers – will have his own expectations for the team generally and the medical students specifically. At most medical schools, the attending physicians are also the individuals responsible for assessing student performance and providing final grades. Some will seek input from other members on the team to inform their evaluations, but many do not, leaving your final evaluation based on what might be a relatively short amount of time spent with the attending that may not be reflective of the large amount of time you spend in the hospital.
Residents, too, play a large role in shaping clerkship experiences, as they are the individuals that medical students spend the most time with in the hospital. Though trainees themselves, senior residents function largely independently and are capable of managing the day-to-day care of patients while consulting the attending physician when necessary. Residents delegate the daily tasks to members of the team, see patients with medical students, and determine the students’ daily schedules. Needless to say, residents who are difficult to work with can make a rotation miserable, while student-friendly residents – those invested in the success of the students on the team and who take pride in making students shine in front of attending physicians – can make rotations fun, educational, and enjoyable.
The unpredictable nature of healthcare also adds significant variability. A student rotating on an OB/GYN service may be involved with a small number of deliveries while other students on the same service at different times in the year may perform a dozen. The cases students see are, of course, dependent upon the patients that come into the hospital. In this regard, the site of a rotation can dramatically shape the kinds of patients medical students manage and the medical problems they gain exposure to. A community hospital site, for example, might see “bread and butter” cases that are relatively straightforward, while a tertiary academic center site might see complicated patients with multiple problems and severe disease. At the latter, students might be exposed to disease that most community physicians rarely if ever manage on a regular basis, which can be a particular challenge. In short, while every clerkship will have a set of goals and expectations for the students, these are limited by what kinds of disease happen to present to the hospital during a student’s time on the service and the individual expectations and philosophies of his supervisors.
Regardless of the clerkship, most in-patient services follow a similar structure. The day begins with “pre-rounds,”during which the members of the team see their assigned patients and begin to develop treatment plans for the day. Medical students receive a number of patients commensurate with their ability and depending upon the number of patients being cared for by the team. On most services I was expected to carry two to four patients, though on more difficult rotations, like intensive care services, this dropped to one or two patients. In addition to seeing and examining patients, other important tasks include gathering diagnostic data, including lab and imaging results, and reviewing overnight notes and speaking with the night team to learn about any important events that may have happened while the team was away from the hospital.
Using this information, you begin to write your note for that patient. Most notes are written using the SOAP format: Subjective information, or what the patient tells you about his illness and current condition; followed by Objective information, or what you find in your physical exam and see on diagnostic tests; followed by the Assessment, which includes a quick summary about the patient and a tentative diagnosis of their condition; and finally the Plan, which includes the clinical problems you have identified with the patient and how you are addressing each of them. The process of writing a note helps students solidify their understanding of the patient’s disease and the treatment plan while the note itself helps students for the next, and perhaps most important, part of the day: rounds.
The infamous rounds
Rounds consist of the daily event of visiting every patient on the service – or “rounding”- with all members of the providing team to discuss each patient’s case and the treatment plan for the day. For attending physicians, this may be their only time on the floor visiting patients and is critical for receiving updates and making decisions related to the patients’ care; for fellows and residents, this is an opportunity to ensure that their proposed management plans are reasonable and in-line with the physician’s plan; and for medical students, this serves as an opportunity to practice delivering a concise patient presentation, generating a treatment plan and defending that plan to the other providers, and demonstrating their clinical knowledge by answering questions from the attending physicians, known colloquially as “pimping.”As with other aspects of the clinical experience, the style of rounds varies widely among services and attending physicians. Speaking generally, surgical services tend to engage in shorter rounds with highly focused presentations and treatment plans and little supplemental teaching. With particularly quick attending physicians, our team could round on 8-10 patients in less than an hour. In contrast, medical services tend to have longer rounds which include discussions of the patient’s conditions as well as the medical knowledge underlying the disease and its treatment. Rounds that last a few hours would not be uncommon on a busy in-patient medicine service.
Discussion of a particular patient follows a highly choreographed and standardized format which quickly becomes second nature after some time on the floor. The trainee assigned to a patient first gives a presentation roughly following the SOAP note format above for previously admitted patients, starting with a brief, one sentence summary of the patient’s condition. This is followed by any overnight events, changes in medications that have occurred, pertinent exam findings, and newly obtained diagnostic data. Finally, each medical problem and the plan for addressing it are discussed. This last portion of the presentation usually includes pimping, which is designed to assess the presenter’s knowledge while ensuring that treatment decisions are made thoughtfully, the current management plan is effective, and alternate diagnoses are being considered. Newly admitted patients are treated in a similar manner, though the first presentation for that patient is typically more in-depth and includes information related to the patient’s past medical history, currently prescribed medications, and other facets of the patient’s health status prior to hospitalization. Delivering an effective, concise presentation is a key goal of the clerkship year but is a deceptively difficult task. Apart from remembering all of the components of the presentation and recognizing what information is relevant or extraneous, each attending physician has his own preferences for how presentations are delivered, sometimes down to the order in which labs are presented. Thus, a well-done presentation requires a thorough history and physical exam to know as much about the patient as possible, a wide base of medical knowledge to understand the information being presented, and the flexibility to provide that information as the attending physician prefers.
Rounds are decried by some as an antiquated practice and an inefficient use of provider time, but they are, in my view, what each student makes of the experience. Paying careful attention to the residents’ presentations and the feedback they receive can help you improve your own presentations and become an efficient presenter. Listening to the “why” behind treatment plans can develop your fund of knowledge and that elusive clinical judgment mentioned previously. Taking the opportunity to examine every patient along with the residents and attending physician hones your ability to identify abnormal exam findings and understand their relevance. Pimping – whether through fear of negative evaluations or seizing the opportunity to rise to the occasion and impress your superiors – provides a powerful motivating force to always be reading up on patients and studying as much as possible. Since rounds may be the only time students spend with the attending physician, the importance of making a positive impression cannot be overstated.
Come back Wednesday to read Part II!
(1) Branch W, Pels RJ, Lawrence RS, and Arky R. Becoming a Doctor —Critical-Incident Reports from Third-Year Medical Students. N Engl J Med 1993; 329:1130-1132. October, 7 1993.