Progress Notes: Clinical Clerkship Confessions (Medicine)

Three doctors on their stories, lessons they treasured the most, and things they wish they knew before clerkship.
Part 1 of 2.

clinical clerkship medical school blog

Julian Arguilla

(Philippine General Hospital)

clinical clerkship medical school blog

 

Clinical clerkship is every medical student’s first taste of hospital life. For many, it is a trial by fire of sorts. Your life will revolve around a three-day cycle: pre-duty, duty and from duty.

Personally, the five things I can’t live without in a duty day are:

  • My vital signs kit. Stethoscope, MANUAL BP app, pulse oximeter, and thermometer. Being the clerk, you will be the eyes and ears of the medical team. If the patient’s condition worsens, you have to be the one to catch it first.

 

  • Micropore tape. Packing a fresh roll in your pocket daily makes a lot of difference, trust me. Micropore tape has a multitude of uses—from labelling syringes, to affixing your IV line, to attaching monitoring sheets—the list just goes on and on.

 

  • Comfy shoes. The lightweight, high tech runners of today are good not only for looks, but for enduring long hours of walking and doing your rounds as well. Pick one that’s comfortable, with an ample heel cushion, and one that’s not white—you don’t want your nice kicks spattered with blood and other nasty fluids.

 

  • A rigid, durable folder. As a clerk, you will write a lot. And you can’t always do that sitting comfortably, You will write while walking, firing questions as your patient is wheeled for an emergency OR. You will write in a crowded ER when even benches are used as stretchers for toxic patients. So make sure you have your trusty folder at all times.

 

  • A trusty wristwatch.

clinical clerkship medical school blog

 

You will realize the value of good timekeeping when you start your clerkship. If you must, pick one in stainless steel (will scratch less) and has water resistance (medical school taught us to wash our hands a lot). Personally, I prefer automatics because I can correlate the sweeping hands with the patient’s respiratory rate or heart rate by the second.

 

My easiest/most memorable rotation in clerkship

would have to be emergency medicine. I say easy because despite the heavy workload, endorsements are few and the management is straightforward. It is where I got to perform the most procedures—IV insertion, extraction, NGT and catheter insertion and intubation.

It is also where I saw before my eyes the sorry state of our healthcare system: patients that could have been easily managed in their localities had there been affordable and accessible care.

 

In contrast, my hardest rotation would still have to be internal medicine. Here, both your medical knowledge and your work ethics have to be top notch. You will be questioned everyday—by your seniors, your colleagues, your subordinates, your patients, sometimes even by your own self.

 clinical clerkship medical school blog

 

A valuable lesson I can share during clerkship is this:

I am by no means religious nor always pleasant, but I have to remind myself everyday to be humble, patient and compassionate because if by chance it was God who disguised himself and walked into the triage with a chief complaint, then I’d make sure to treat Him with humility, patience and compassion.

 

There’s only one thing I wish I’d known before clerkship, it’s that relationships matter.


clinical clerkship medical school blog

 

Relationship with your colleagues, your patients, your seniors. As a clerk, dark days are ahead—toxic duties, long sleepless nights, nerve-racking rounds. Try your best to treasure your relationships, especially with your co-clerks. Remember, as Caesar in Planet of the Apes once said:

together, we are strong.

Best of luck!

 

clinical clerkship medical school blog


Katrina Torno

(Cum Laude, University of Santo Tomas Hospital)

 

clinical clerkship medical school blog


Being a clerk takes more than just knowledge from books, lectures and exams you get throughout medschool. It needs determination, patience and of course, lots of patients! Some may describe it as a point where in you get the leasts and the mosts in life. You get the least amount of sleep, hygiene breaks, family time, night outs and “me” time. On the other hand, you get the most amount of time for histories, physical exams, hourly monitoring of patients, procedures, presentations, papers, papers, and more papers!

clinical clerkship medical school blog

 It will either make or break you.
It will test your eagerness and love for Medicine but at the same time it will help and prepare you for your future practice.
During clerkship, you get the opportunity to learn from the best residents and consultants. They will guide you in doing your “first”/”milestones” whether it may be from IV insertions to more complicated procedures and assists in major surgeries.

clinical clerkship medical school blog

But as what they always say, PATIENTS are still the best teachers. So make the most out of it and see the most number of patients as possible. It might help you in handling your own patients in the future.

Lastly, the most important thing about being a clerk is enjoying the whole experience and finding that sense of fulfillment you get from seeing a patient improve.

clinical clerkship medical school blog

 


Junjie Arapan

(De La Salle University Medical Center)

clinical clerkship medical school blog

 

Clerkship is the hardest thing I’ve ever been through in my life. It was during this time that I realized why they asked me “how I deal with tough times” during my interview for med school. This thing, is just a different beast. You think 1st, 2nd and 3rd year was hard? Wait till you get to clerkship. It opens your eyes to the real world of doctors.

 

clinical clerkship

 

It’s not just air-conditioned offices, checkups, smiling secretaries and patients who follow your advice. In clerkship, you’ll be rotated in steaming hot wards, procedures that drain you physically, rude co-workers and patients who challenge your diagnosis. This things happen daily, for one whole year.

One thing that is a must in clerkship is resilience.

You’re going to be put down, one way or another. Sometimes, your superiors put you down, sometimes your patients or their relatives will and sometimes, you will put yourself down. It’s not going to be like a when you fail on a test or you had a low score. It’s different in clerkship. People will use words that really hurt. Sometimes they’ll use words that cut real deep. That’s why a crying clerk is a common sight around hospitals.


And that’s completely fine. As long as you pick yourselves up and you use what happened as a learning opportunity.

You will remember that pain when you encounter that same scenario again but now, hopefully, you’re wiser.


clinical clerkship medicine medical school blog

 

The intellectual aspect of clerkship is almost the least of your problems. You’ve learned that in the first 3 years of medschool. Now, it’s time to apply that. That’s not as easy as it sounds.

 

clinical clerkship medical school blog

 

The signs and symptoms that you read on transcriptions, books and those that you hear during lectures? Sometimes those don’t show up on patients the way that they should. This is where the experiences of your seniors will help. They’ve seen this before and they know how to get things done. Not everything happens by the book. Not even how we treat patients.

 

clinical clerkship medical school blog

 

In the real world, especially in the Philippines, economics plays a big role in our health care. You might know the best treatment for a certain disease, but the question is,

can your patient afford it?

If not, what’s the next best thing?

What happens if they still can’t afford that?

What do you tell them if they can’t even afford to be admitted?

What happens if the patients question the medications or the lab tests that you ordered?

What do you say when they only choose to have certain meds and treatments done but not all of them?

clinical clerkship medical school blog


Then, when you have answers to those questions, you’ll have to figure out how to say it and for me, how you say something is more important than what you say.

 

clinical clerkship medicine medical school blog

 

Clerkship is also very demanding emotionally and physically. First, physically, because of the 30+ hours of duty. Sometimes, you literally don’t get to sleep because of surgeries, wound cleaning, monitoring patients, labor watch, whatever. That’s why it’s essential to sleep when you can. It doesn’t matter if its 2PM or 2AM, you have nothing to do, sleep. In clerkship, sleeping is more essential than eating.

You can eat on the go but you can’t sleep on the go. That’s why I always had candies in my pockets. But if you have time to eat, you should not let that pass. Just be sure to endorse your patients to your group mates who will cover for you.

clinical clerkship medical school blog

Anticipation is key.

If you know that you have a surgery at 8am, be sure to that you’re full by 7:30am. By the time you get home the next day, your body has been drained. You get to sleep. Then, in a few hours, you get to do everything all over again, and again, and again. For a whole year.


clinical clerkship medical school blog

 

Describe a typical day as a clinical clerk.

clinical clerkship medical school blog

 

A typical day depends on your rotation.

There are some rotations that are benign and others that are toxic. One thing that is common though, is that it’s tiring. Physically, mentally or emotionally.

You usually sign in at 7AM, some departments give 15 minutes grace period, and some don’t. You will really hate to be late, because that equates to makeup duties. Being late for a few minutes will turn into hours of makeup duties.

After signing in, you’ll attend the morning endorsement of your department where the post duty clerks will endorse the admissions or the ER calls of the previous day. Residents and consultants attend these endorsements and sometimes, they’ll ask for the updates regarding their patients so you really have to know the latest regarding the patients decked to you. Then you go on duty.

The main bulk of what you’ll do in clerkship is monitoring the vital signs of your patients. It’s repetitive, tiring and sometimes boring but you’ll be the first one to catch any problem that your patients may encounter. Patient monitoring is a 24 hour job. If your patient is monitored Q1, then you’ll have to monitor him every hour, for the whole duty. During toxic days, groupmates usually deck the monitoring.


clinical clerkship medical school blog

 

(Ex. Clerk A will monitor the patients of clerk B and C from 8am – 12PM. Clerk B and C can rest, eat, do their papers, etc. then clerk B will now monitor for clerks A and C from 1PM – 5PM so clerk A can rest, and so on.)

During duties, you’ll usually have around 2-4 hours of sleep. Worst case scenario is that you don’t sleep at all. You have to sleep when you can. It’s a blessing if you have the skill to sleep anywhere, at any time. Don’t forget to eat too. But unlike the 1st 3 years of medschool, you don’t have a clear cut time to eat. So you’ll just have to figure out when and where you can eat.

If you’re on OB or Surgery, it is best to eat when you’re next on deck because if the patient that is decked to you is for emergency OR or for labor watch, you’ll have to go to the OR or DR immediately and you won’t be able to eat until the baby is out or the OR is done.

 

5 things you can’t live without in in a duty?

clinical clerkship medical school blog


Vital signs monitoring/PE kit – As I’ve said, monitoring will be the main bulk of what you’ll do in clerkship so if you don’t have these, you’ll be going to war without a gun.

Nurses have their own kits and might be willing to let you borrow every once in a while but you don’t want to borrow every time. They also monitor their patients and you’ll be interfering with their job.

I had a small bag which contained all my VS and PE tools so that I can just grab that bag and go to my patient knowing that everything that I’ll need is there. And if I may give an opinion, axillary thermometers are still more accurate than the forehead and ear.

Hygiene kit – You’ll be on duty for 29+ hours. You’re going to have to brush your teeth at some point. It’s your obligation to your patients to look (and smell) as presentable as you can be. No matter if it’s your 1st hour on duty or your 31st.

Smartphone – Since you’ll be the first one to notice any problems with your patients, you will have to refer those problems as soon as you can. There are also some apps which can really help speed up history taking.

Like AOG calculators, BMI calculators, etc. You’ll need to know the formula of those but during toxic times, those apps are great help.

Lights and alarm clocks help too.

Charger/Power Bank – as I’ve pointed out, you’ll need your phone. And your phone needs the juice.

A small charger with a very long cable really helped me survive clerkship. I was able to plug in my phone and still sleep beside it so that I can hear the alarm. A power bank gives you more mobility but high capacity powerbanks are usually bulky.

Pen – Basic, simple, and always not around when you need it.

Always bring multiple pens, always know where they are, and make sure that people return them to you. Even if the ones who borrowed them were your superiors.


What is your most memorable rotation?

clinical clerkship medical school blog

 

It’s probably my ER rotation for Surgery. I learned a lot, it was very tiring, it was very satisfying.

It was here where I experienced my most memorable duty in which we handled, 8 vehicular accidents, 1 of whom we suspect to be on drugs, 1 had a severe brain bleed, and 5 who came from Batangas where their jeepney rolled over.

We also had a patient who was hacked on her face with a big knife, and a patient who was shot multiple times. It didn’t only teach me about medicine, it taught me how to handle death. Most of their relatives were crying, asking me what will happen, what we can do, a parent even asked me not to tell his relative that their mother had already died on the way to the hospital.

clinical clerkship medical school blog

By morning, I was not only physically drained, I was emotionally drained too. But I had to be strong and show confidence to my patients. As one resident once told me,

“kung ikaw mismo mangangarag, pano pa yung patient or relatives mismo?”

I had to show them that we were in control and were doing our best. I was even surprised that at one point, I didn’t even feel tired anymore. Or maybe I was already numb.

 

What is your toughest rotation?

For me, the toughest rotation was OB because you don’t know what kind of case you’ll be handling. It ranges from a simple in-patient admission to Cesarean Section. You don’t know if you’ll be assisting in a VSD or a CS. Sometimes you’re expecting the patient to have a VSD then all of a sudden, it can be converted to a CS.

You don’t know if after a surgery, you’ll just have to monitor at the RR or you’ll have to follow your patient to her room to monitor her bedside. Labor watch can be as short as 2 hours but it can be as long as 24 hours.

I think I just don’t like not knowing what to expect.

clinical clerkship medical school blog

What is your easiest rotation?

That would probably be Commed. It was a fun rotation. There were no patients to interview. No toxicities, no ORs to assist in. All you have to do in be immersed in the community, learn their ways, bond with your groupmates and your foster parents and of course, do your CDx. It’s fun doing the groceries with your housemates, learning about their habits, talking to them and making fun of each other.

 

clinical clerkship medical school blog

 

You also have to rotate in the Family Medicine OPD which is like a less toxic version of IM OPD. It was great because there’s a lot of you to interview patients. You don’t have to see 5+ patients in a day. TB DOTS was also fun because you get to see and talk to patients who are undergoing TB treatments. You see their struggle and their will to get better.

Lesson you learned you treasured the most during clerkship.

  • My patients are humans. They have emotions and I have to deal with that.
  • I should not be afraid of my patients
  • Be confident.
  • I don’t know everything. Ask for help.
  • There’s no “I” in team. Learn to thrive without hurting your groupmates.
  • The main point of clerkship is to teach us how to care.

clinical clerkship medical school blog


Things you wish you knew before clinical clerkship.

 

  1. That it would be a lot like nursing. Only 100x harder.
  2. I wish I knew more diseases and;
  3. That no orientation, no endorsement, no article, no book would prepare me from clerkship. It’s something that you have to experience to know what it really is.

 


clinical clerkship medical school blog


———————————————–
This has always been a part of my bucket list when I first started blogging. But it will still take me two years to write my personal stories, on my experience on Clinical Clerkship.
I got really happy that 3 distinct and astounding doctors helped me fulfill this content, not only for my future reference but for everyone who can have access to  this.
As what Kuya Junjie had said, clerkship is something that you have to experience to know what it really is.
But once in a while,  it is also nice to find a treasure like this and have an eye-opener, that can help the clerks in the present and future. Kaway kaway future doctors! 🙂
Thank you so much for reading!

It means the world to me if you share this content. You probably all know that it  has grown to be my advocacy, to spread out knowledge and awareness, to open to the world, the unsung parts of medicine.
Like me, I hope you enjoyed the glimpse on the life of being a clinical clerk.
Stay tune on part 2!!

 Stay inspired!
xo,
chloramphenicolemd


clerkship confessions

 Dr. Julian Arguilla is a Clinical Clerk from University of the Philippines- Philippine General Hospital. Dr. Katrina Torno and Dr. Junjie Arapan are Post graduate Interns, rotated as Clinical clerks at University of Santo Tomas  Hospital and De La Salle University Medical Center respectively.

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  • Jacqueline 💙

    Hi! I’ve been reading your blog for quite a while now and if it’ll make you a bit more fulfilled and jubilant, I am immensely grateful to have read this entry. Indeed a comprehensive one! Excited to read your own take on this, future M.D. ☺ Thank you for sparing your time writing for us. Break a leg! ❤

    • Dear Jacqueline! Thank you so much for your sweet comment! It took me ages to reply, because I can’t put to words how I appreciate what you’ve said. And today I’m having a rough time, but I stumbled upon again to this content. Recalling na that I haven’t replied to you yet pa. huhu
      Please know that you have made my day! You are the inspiration I’m needing on these days. Thank you!

      love,
      Chloramphenicole