3rd Year ClerkshipService Unit

CPMC Medical Students

Each student is assigned to a team. At the Milstein Hospital Building, there are three teams: Hepatobiliary/Endocrine Surgery Service (RED), General Surgery/Laparoscopic Surgery (GOLD), Colorectal Surgery (BLUE), and at the Allen Pavilion, the ALLEN team. The team is composed of chief, senior and junior residents. Your intern and resident will orient you to the daily routine. You will generally spend your day with your team, except when you are in one of the student didactic or preceptor sessions.

Daily Routine

5:30 AM	Pre-rounds. Students should arrive at the Hospital at the same time as their intern, generally about 5:30 AM. During this time the student should see and examine each patient s/he is following, and gather any information about events overnight.
5:30-7:00 AM	Work rounds with the House staff. This is the time for the intern and resident to assess the patients and to make plans for the day. You will be expected to contribute the information you have gathered (reporter), your interpretation, and your ideas about what is to be done next (manager). Presentations should be made in the SOAP note format.
7:00 AM	Conference or breakfast.
7:30 AM	Go to OR for 7:30 cases and or lectures.
2:00 PM	Morning labs are available on CIS and should be recorded in each patient's chart.
Between 3:00 PM and 6:00 PM	Afternoon rounds, faster and less formal then morning rounds.
4:00 PM or 5:00 PM	Preceptor Sessions: Meet with your preceptor. These sessions take precedence over all other activities unless involved with an emergency or an operative procedure on one of your own patients.

Attending Rounds

Presentations—Presenting well is an art. A good presentation requires perspective and an understanding of the patient's problem. It also requires preparation and "rehearsal" to organize and focus the presentation, and to keep it brief (<5 minutes). Presentations are to be made without notes if at all possible. This is the "gold standard" and takes time and effort to accomplish. Your House Officers know that they are expected to help you, but you must also rehearse and practice on your own.

Follow up: be prepared to inform the attendings, when asked, about the daily progress and plans for each of the patients you are following as well as pertinent facts about your patient's disease process or operation.

NOTE: Many students experience lots of "downtime" during this rotation. Much of this can be prevented by careful planning and efficient work, but it is a good idea to have reading material available.

Be There

Be present on the ward with your intern and resident. You are responsible for the work-up of some patients each night on-call. Prepare to present patients on attending rounds. Your resident should help you with your presentation. You should follow your patients daily, and do as much of the care as possible under the close supervision of your intern and resident This should allow you to develop a cadre of 3-5 patients whom you follow with your intern, your patient load may vary, some patients are much more complex than others. In general it is best to know everything about a few patients, than try to be like the intern and carry as many as possible. Although your night on-call affords the opportunity for you to admit a patient this should NOT be the sole focus of your attention. You are urged to work with your intern as other patients are admitted and participate in the intern's activities as an "apprentice".

Regarding the work-up of new admission: Find out information for yourself! If possible, take your own history from scratch. Do not get your history from the computer; it is sometimes misleading!

You are expected to perform your own physical exam. Breast, rectal and pelvic examinations on female patients are to be done under the direct supervision of a house officer with a sex appropriate chaperone.

The Medical Record

Progress notes must be concise and legible—writing a "good" chart note takes skill and art. Use the SOAP format, include a limited, relevant exam and provide plans for the patient's main problem or problems. Don't editorialize. Do not cut and paste. Notes should be reviewed and corrected, as needed, by the residents or attendings.

Procedures

All procedures that you perform should be supervised by an appropriately credentialed resident and recorded in a formal procedure note. The procedure note should include the consent, indication, technique, and post-procedure plan.

Other Ward Responsibilities

There are many skills that must be acquired in order to take proper care of your patient, particularly in an acute setting. (See list of things TO DO and TO SEE). Despite blood drawing and I.V. teams there will still be opportunity to learn these procedures. The more skilled and confident you become in these tasks the more effective you can be in assessing and initiating treatment. Don't lose this opportunity. The intern is always busy, patients are always sick and some get sicker—suddenly—before they get well. Some routine tasks will be expected of you as you work with your intern and your patients. Days and early evenings when you are not on-call offer opportunities to help with procedures, accompany your patient to special procedures, speak with your patients and their families, etc. Help the team whenever possible. You do not need to be doing tasks on patients other than your own if you have other responsibilities (i.e. didactic sessions). Make time to read, prepare your presentations and your write-ups.