Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 2. The Job of the Medical Student Get a thorough history. Do a complete physical exam. Make a concise presentation. Write a timely progress note in the chart. Do whatever is needed to learn about your patient and ensure her well-being. If at any moment you get confused about your role, on the wards or in the clinics: There it is. It’s that simple. (Mind you, it may seem pretty intimidating at this point, but you CAN do it—even in the first week.) The Rest of Your Job. In addition to the above, on inpatient services, you will be expected to help your team with "scut," a term for "tasks related to patient care." Examples: Calling a consultant, writing orders for labs or medications, doing procedures, getting the read on an X-ray. Interns do the bulk of the team scut, but will often need your help to cover it all, especially on a busy service (see "Pre-Rounding and Scut Basics," below). In surgery, you will also be expected to "assist" on operations. Mostly this means holding a retractor (referred to as "water-skiing,"—if you don’t get it, don’t worry, you will) or suctioning blood or smoke produced by the "Bovey" (electric scalpel/cauterizer). If you’re lucky, you will help suture. You will also be asked to give "Presentations"[2] - either on your patient and her illness, or on a special topic of interest to the team (see "Presentations: Here There Be Dragons," below.) What Isn’t Your Job. Your job is NOT necessarily to know up front the full differential for every presenting sign and symptom—but you will be expected to demonstrate your knowledge, and, more specifically, that you have a systematic way of thinking about questions (see "Pimping and the Art of Self-Defense," below). This is not to say you shouldn’t try to learn as many differential diagnoses as you can ahead of time, but to emphasize that you can still do a good job despite (temporarily) not having this knowledge. Coping with "Stage Fright." If at any time you enter an exam room, and think, "I don’t know what the hell I’m doing in here," refer to the list above. You don’t have to think—just follow that list. If you feel REALLY stumped, ask a fellow student, an intern, a resident, or an attending for help. Once, when I went into an exam room, I found a patient who was there for follow-up of an elbow sprain. The first thing I thought was: "Hmm. I have no idea what’s involved in evaluating this patient." If I’d only referred to the list above! Thanks to first and second year, I should have recalled that a patient with a limb injury should be checked for range of motion of the digits, and for signs of nerve damage. A general physical would have also unveiled any additional injuries that needed attention, as well as other medical problems (which this patient had). All I had to do was 1) take the history, 2) do a full exam, and 3) present. Bottom line: You have the knowledge to at least do the basic job. While it helps if you feel like you know the 12 different things that could cause your patient’s symptoms, you don’t have to know all of what’s going on, in order to do your job. Nor are you expected to know it all, at this point. Your Mission. Don’t forget that, in addition to your "job," you also have a mission: To learn as much as possible about the various areas of medicine, to help you as you ascend in your level of responsibility for patient care. Even if you’re not going to be a surgeon, you need to know how to recognize when your patient needs a surgeon. No "Boring" Tasks, or Patients. I’ve noticed that most of our superiors, from attendings to interns, underestimate the role of "useless scut" as part of the educational experience. Presenting a patient to a consult service may be a "ten times a day" bore to an intern, but in your first months on the wards, it’s a new activity. It probably will get boring to you, after you’ve done it ten times. But initially, it’s not a bore. So be willing to help with scut, and let your team know you’re willing. Likewise, you may notice that residents will characterize a case as "boring," as in: "Sorry you had to take the patient with the abscess - I wanted to give you something more interesting." Hmmm. How many abscess patients do they think you’ve cared for, at this stage of the game? How many times have you done dressing changes, managed pain meds, or pulled housing out of thin air with the help of a savvy social worker? At this stage, it should all be fairly interesting. [2] By the way, the word "presentation" is thrown around a lot, and deserves definition. There are several types of "presentation." On daily inpatient rounds, or in the clinic, you will be asked to "present" the patient-either a quick update on their daily progress, or a quick summary of their history and physical. In addition to these "presentations," there are also "Presentations," which last about 10-20 minutes and usually involve looking up several articles on a topic or your patient's illness(es). [Back]