Transcript Advice for Succeeding in Internal Medicine and Clerkship

Succeeding on the
Wards…and Beyond
Internal Medicine
Raymond Li
Fundamental Skills
 Developing proficiency in history
taking and physical examination is
one of the key aspects of training
 Presentation of patients is critical.
Have an organized and logical
approach. Tell a story: beginning,
middle, end.
Patients
 A greater degree of independence on IM
 Clerks assigned patients to follow and see
everyday. Sometimes you will be the one who
knows the patient best.
Patients
 Every patient is a learning opportunity!
- Know your patients well, learn their
story.
- Study their medications and orders.
Try to understand the clinical
reasoning behind them.
Ask if not sure!
- Read around your patients.
- Work backwards from investigations.
- Make your own suggestions.
Commit to decisions! Best way to
learn and retain!
Important Topics/Skills
 ECG (TO Notes, Ecgmadesimple.com)
 Chest X-Ray
 Arterial Blood Gas Interpretation
 Have a system and follow it every time!
 Look at image first before the report
???
Teamwork and Supports
 Have a good support network
 Know when you need to talk
 Work with your fellow clerks,
come to compromises
Handy Resources
Your Best Friend
on the Floors
Apps:
 UptoDate
 Medscape
 Epocrates
 ABG Expert
 MD on Call
 Qbank (USMLE World)
 MD Calc (website)
Not Him Obviously
NBME Exam Prep
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More about breadth than depth
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USMLEWORLD Step 2 CK
Qbank
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Start early and study
consistently
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Lots of other prep books: First
Aid, Case Files, PreTest, Blue
Prints, Step Up, etc.
!!!!
NBME Exam Tips
 Read the last line first/ Read the
question first
 Identify and follow the clues!
 Learn to recognize what is
important and what is filler
 Time Management! (100 qs in 3
hours for all exams)
 Pick the best answer
Things that will make you sad but are NORMAL
 Patients changing stories
 Different staff preferences
 Too much to learn/ I know so little
 UWorld Questions
 NBME
 Making mistakes
Additional Tips
 Don’t make things up. Okay to say: “I forgot/ I did not ask.”
 You learn the most on call. Ask for opportunities!
 Be organized and follow through on the tasks that you
commit to.
 Work on being thorough first and then work on speed.
 Work hard and be engaged.
One45 Evaluations
Please fill out One45
evaluations for your
residents and staff to
improve the learning
experience for others!
Psychiatry
Chris Earle
[email protected]
709 682 0143
Psychiatry Rotation Breakdown
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6-week rotation
o 3 weeks HSC, 3 weeks Waterford
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Clinics throughout
o Child, Geriatric, ACT, START, Hope, HMP, CL, ECT
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1-in-4 home call for the PAU
A Typical Day
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9 a.m. – Handover/Night Report
Weekly Interdisciplinary Rounds
Meeting with patients with staff/residents/alone
Writing notes, ordering meds/consults, planning
discharge
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Academic sessions, clerk teaching
AM/PM Clinics as scheduled
Call 1-in-4 from home until midnight
Grading
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Evaluation cards: weekly and clinic cards
MidPoint Witnessed Interview
IPE Workshop
Final Oral Exam
NBME exam grade
ITERs
** Members of the interprofessional team are asked to
contribute feedback for your ITERs**
Tips For Psychiatry
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Psych is a break with regards to work demands/hours
but can be stressful in other ways
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Develop an approach to the psychiatric interview for oral
exam
o Most clerks use grids and mnemonics
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Be proactive - make an effort to broaden your
exposure/knowledge
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Offer to help, to present at rounds, ask questions, don’t
disappear, let staff/resident know if you’re interested in
something
Useful Books for Psychiatry
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Good Coverage: First Aid, Case Files, Toronto Notes
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Reference: DSM, Introductory Textbook of Psychiatry
For Questions: USMLEworld, Pre-Test, ANKI decks
online
Clerkship Guide from Student Affairs
Find a book series that suits your learning style
Get books used from classmates/online/free
Dr Hearn’s lecture for the Oral Exam
General Clerkship Tips
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Show up on time, don’t leave until you’re told.
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Your job is to make your residents’ lives easier and to
improve patient care.
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Read a little, every day.
Be courteous, respectful, and a team player.
Don’t lie - admit it if you forgot to ask something.
Clerkship isn’t about being smart or having the right
answer. What’s important is being trustworthy and
having a thorough approach.
Most rotations: one book, and UWorld
Sit/eat/sleep wherever/whenever you can.
What I Keep in my Backpack
• Lots of pens
• Clipboard (white coat clipboard)
o Your list, loose paper, extra radiology reqs
• Pocket notebook for each rotation
o Half day notes, common algorithms, med dosages,
etc.
• Costco snacks; Water
• Tools of the trade: ID, pager, stethoscope, reflex
hammer, pen light
• Study books
Apps I use everyday at work…
MD On Call
WhatsApp
MedCalc
UpToDate
Anki
Required Viewing for Clerkship by Rotation
Internal Medicine
Surgery
Obstetrics
Family
Pediatrics
Psychiatry
Obstetrics/Gynecology
Ashley Power
Ob/Gyn Rotation Breakdown
• 2 weeks Obstetrics
– wards, OR, clinics,
consults
• 1 week Gynecology
– wards, OR, clinics, consults
• 1 week Gyne Oncology
– wards, OR, clinics,
consults
• 1 week Case Room
• 1 week Clinics
• ITER – 35%
– completed by staff and
residents
• NBME – 30%
– 100 MCQ in 3 hours
• ORAL – 30%
– 2 case scenarios, 15 mins
each, OSCE style
• MIDTERM – 5%
– 40 questions (MCQ, short
answer, fill-ins, matching)
A Typical Day
• usually start 7am, 9am on
clinic week
• round on patients on the floor
(5NB) in the morning except on
clinic week
• handover in the case room at
7am (Janeway 3rd floor)
• case conference/grand rounds
at 8am (Women’s Health)
• …to the OR, back to the
wards, clinic, case room
• some days you get lunch or
down time to read (obs/onc)
and some days you don’t
• usually leave around 5pm
• academic half-day Wed 8-1pm
• WARDS
– see your patients, write notes
and orders, follow up on
investigations with residents
• OR
– 2-8 cases per day with staff and
residents
– retract/hold/cut sutures…
• CLINIC
– HSC/Major’s path 9-12:30 and
1-4:30 with staff and residents
– 5 mandatory
– paps, colpo, biopsies…
• CASEROOM
– Triage, active patients and C/S
with (mostly) residents
– pelvic exams (routine & labor),
spec exams, FHR, deliveries…
Call
• Usually 1 in 4 (min 1 in 5)
– your template gets together
to make your own call
schedule and submit it
– generally very flexible
• 1 or 2 clerks
– weekends can be split,
works out to 4-5 weekend
shifts
• Responsibilities in the case
room (same as case room
week) working with resident
on call
– great for getting to do
procedures on your own
• ER consults covering for
obs/gyn/onc
• Post-call days
– home before 12 = no post
call day 
– stay over night = post call
day  (?) usually home
after 9am
– beware: academic half day
post call = not a great time
Expect to get no sleep and
you will be better off
Surviving Ob/Gyn
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Bring lots of food, and eat as much as you can, whenever you
can
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there is toast and cheese whiz/peanut butter/jam in the
caseroom
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If a resident tells you to go to bed…go to bed
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seeing the 37th triage patient of the night in false labor will
not significantly enhance your medical education BUT
sleeping will keep you sane
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Wear shoes that are waterproof and that you can wipe off
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…and by waterproof, I mean blood/urine/amniotic fluid proof
Overall
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For studying, read around your patients and pick one of:
o Pretest
o First Aid
o Toronto Notes
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Good luck trying to study the recommended texts
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Case Files and Q-Bank are excellent resources for testtaking/prep
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Don’t complain, be on time, and work hard – it’s only 6
weeks, you can do anything for 6 weeks!
Family Medicine
Ashar Pirzada
Family Medicine Rotation Breakdown
 8 weeks (rural)
 50% Final ITER
20% Final Exam
20% Academic half day presentations (2)
10% FM cases
Major Locations
How to get Experience
 Experience varies – ask us!
 Don’t be late
 Don’t be late
 Don’t be shy
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IV practice? Ask a nurse
ABG practice? Ask RT
NL slang practice? Go to the bar
Benefits
 Reference letter – usually 1 preceptor for 8 weeks
in many clinical settings.
* Think about using this unique opportunity for a
strong reference letter!
 Get to know your community.
“You’re not from around here, are you?”
Surgery
* things no one tells you and you don’t want to ask
Stephanie Power-MacDonald
Surgery Rotation Breakdown
8 Weeks
5 weeks of General Surgery
3 weeks of Orthopedics
7 General Surgery call shifts – in-house until midnight
3 Orthopedic Call shifts – home call until midnight
Evaluations
NBME – 40 %
ITER – 2 x 15%
Witnessed History and Physical – 2 x 15%
SURGERY
Starts early:
• 6:00 or 7:00 am
• Meet as a team
• Review patients who
were admitted or had
issues
• Round on patients
• +/- teaching
Sleep is important!
To stay healthy, you will
go to bed at times you
haven’t gone to bed since
you were a child.
Surgery Rotation Breakdown
OR & Procedures
• Read up (esp Day Surgery)
• Scrub in & assist as needed
Clinics
• See patient first
• Focused H&P
• Review with staff
Wards
• Help your resident
After teaching your team
will decide who is covering
what:
• OR
• Clinic +/- Procedures
• Day Surgery
• Scopes
• Team Rounds
• Consults
Call – Consults & Cases
• Look things up before you review!
• It is always good to have a plan (it
doesn’t have to be the right one)
Keys for Success
Make sure you see it all. If there is
something you are especially
interested in, ASK!
Even if you don’t want to be a
surgeon, showing initiative and being
engaged matters!
Go where you’re needed!
Get involved!
** Always have snacks. You can’t
predict when you will get a break.
Tips for the Ward
• Start the discharge summary ASAP - this will be very helpful!
• In's and Out's:
o Eating, drinking, urinating, BMs – these are all important
• Wound Care – ask a RN or seek out the wound care nurse
• Med Changes – especially if on a service with oncology
patients; know their D/C anticoagulation therapy!
• Community Health Resources – ROS, Physio, OT – these
may hold up discharge; get to know who does what!
Tips for the OR
• Comfy shoes!
• Extra socks (if you get sweaty feet - you’ll be happy you
did this!)
• Try and read relevant anatomy (although it may not look
anything like the text book)
• If it is a simple procedure – read about the approach e.g.,
hernia repair
Resources
• Q Bank (USMLE World)
• Pre Test – this book was great
for more in-depth practice Qs
• TO Notes
• Pestanas (light reading – gym
cardio)
• UpToDate (get the phone app)
General Tips
• Show up on time
• Be interested
• Be organized
• Be dependable
The Single Greatest Resource to Survive …
Psych
Family
Peds
Ob/Gyn
Internal
Surgery
Pediatrics
Kyle Murnaghan
Pediatrics Rotation Breakdown
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4 weeks Inpatient Wards
2 weeks Pediatric Emergency
2 weeks Neonates
Mark Distribution
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Inpatient wards ITER 25%
Pediatric emergency ITER 12.5%
Neonates ITER 12.5%
Witnessed History & Physical 10%
NBME 25%
Online cases 5%
Essay 5%
Midterm examination (take home) 5%
Wards: What’s it like?
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Show up at 8:00 am
Round with your resident.
Report to the staff at 10:00 am
Round with the staff
Lunch at 12:00 noon
PM rounds in afternoon
ER: What’s it like?
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8 x 8-hour shifts. You choose when!
Lot’s of fun. You see the patient first and then discuss
your treatment plans with the staff.
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Dramatic! Know your place. If you’re worried about a
patient get staff right away. Patients come first!
Neonates: What’s it like?
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Show up at 8:00 am.
Do discharge physicals first. These are usually done at
11:00 am.
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Lunch at 11:30 am
In PM admission physicals on the newborns.
Every third day you’re on neonatal resuscitation team.
You generally observe, but be sure to know what to do!
General Tips!
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Show up on time! If you can’t, don’t show up with a coffee!
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Be nice to everyone. When you’re not around staff talk to
the other members of the team.
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Be dependable. Staff’s trust is earned. Your opportunity to
learn grows when staff trusts you.
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Understand that you are a learner. You’re going to get
questions wrong but be sure to remember the answer!
(Staff reuse questions )
Most importantly!!!
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HAVE FUN!
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Clerkship is an amazing time!
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You spend your day learning and helping people.
It’s an experience second to none.