Clinical Guide The Nerd's Guide to Pre-Rounding Table of Contents Part 6. Knowledge Management: If I Only Had a Brain… The Clerkship Binder I recommend bringing an empty binder to the first day of each clerkship, for storing the various documents you will be handed by your clerkship director’s admin. assistant. Mine has sections for "Schedules" (for daily rounds, conferences, call assignments, etc.), "Presentations and Write Ups," "Computer Info," "Academic Objectives" (such as cribsheets for the exam, or the list of what’s on the exam), "Key References," and "Misc." You should keep it in your locker or in your backpack. There’s at least two reasons to do this. 1) The mass of paper can bury you; sorting it in a binder helps you get on top of it, which makes it helpful, rather than a hindrance. That way you can find what you need, when you need it. 2) You never know when a random question about "Which student is on call tonight?" or "Is breast surgery going to be on the exam?" will come up. If you keep the stuff piled under your desk at home, it’s not going to help you when you need it. The Black Book, a.k.a. the Peripheral Brain Every student should start one of these on the first day of clerkships, in my humble opinion. Most residents and even attendings have their own peripheral brains; if you get started building one now, it’ll be that much more complete when you get to that level. At this point, I use my PB nearly every day. Also: I noticed that my medicine residents were very impressed that I already had a PB (despite its relatively scant content). They decided I was smart and meticulous—an impression that may not have been true, but which certainly helped me. So, start building a brain, if for no other reason than that it makes you look conscientious, which will help you on evaluations. What it is: The PB is a small (6") softbound binder with looseleaf paper. It is a set of organized notes and "cheat sheets" of information that you can’t quite commit to memory and which you use all the time. For example, in my own PB, I have, on the inside front cover, a list of commonly used emergency resources for patients (emergency shelters, etc.), and on the inside back cover, a table of routine weights and measures as well as metric/English conversion formulae. Inside, my first page (after a cover page with my name and phone numbers) is a list of normal lab test values, such as you get at the front of a typical ICM exam. I’ve written them using those funky short hand diagrams, such as "the fish" diagram, which is used for electrolytes: This helped me remember which values were for which test, when I encountered a note like this: I recommend asking about these "short-hand" diagrams during your orientation "information management" session. The special shorthand diagrams for other tests include: How to Organize It: The rest of my PB is organized alphabetically by medical specialities, i.e. a section for cardiology (diagnosis and treatment of acute MI, how to read an EKG, etc.), endocrine (diabetes, hyperparathyroidism, etc.), infectious disease (HIV, endocarditis, etc.), neuro (stroke, seizure management, etc. ), ortho, etc. I also have a section on "Procedures" and on "Pharmacology." The latter contains little pearls related to specific drugs or groups of drugs. Especially important (for me) is another section on "Problem-based diagnosis." In this section, I have notes on how to work-up a presenting complaint, e.g. Chest Pain, Leg Pain, Shoulder Pain, Fever, Shortness of Breath, etc. Developing differential diagnoses of symptoms or signs is a major task of third year, and having notes on presenting problems will help you do this. Thanks to endless numbers of grand rounds, formal clerkship seminars, and informal teaching on the clinics and wards, you will easily be able to fill your brain by year’s end. Make sure you jot down the article reference or name of the person from whom you got the information, so you can look it up again if the information is ever questioned. By the way, the PB also lets you record administrative information, such as your login and password codes for various hospital computer systems. You may obtain such codes at one hospital, then forget about them, only to need them again when you return to that hospital months (or even years) later. Put them in your "brain." THEN forget them. Until you need them again. How Your PB Can Make You Look Like a Mega-Genius: Personal testimony: After finishing surgery, and following a pancreatitis patient, I had a nifty little section on the diagnosis and management of pancreatitis. Later, on my medicine clerkship, we admitted a lady with pancreatitis. Now, in this country, most cases of pancreatitis are due to alcohol or gallstones. This lady had neither in her history. While my residents were scratching their heads, trying to figure out why she had pancreatitis, I looked at the other causes of pancreatitis in my PB notes. Under one of the other causes, "medications," I had written "thiazides, steroids, tetracycline." And I realized, this lady had been on tetracycline for a sinus infection. So, there was our likely suspect. And I piped up: "Hey, she was on tetracycline, that can cause pancreatitis!" And I looked way smart. You, too, can pull off stunts like these, and ace your clerkships, simply by building a brain. Cards: Know When to Hold ’Em. Patient data cards are a common method for keeping track of important information on patients you’re following in the hospital. There are various formats; many students use the "tan-yellow-blue" cards, which were invented by a UCSF graduate and traditionally are passed down from generation to generation. Residents usually use blank index cards. I recommend using pre-formatted cards of some kind as "training wheels," until you get comfortable with the sorts of data you need to follow on your patients. I used the tan-yellow-blue cards during clerkships. In Appendix 3 of this guide, you will find a version of those cards, with revisions I made after working with them in the field for two years. There are various philosophies about using patient data cards. Some residents don’t like students using cards, because they think it’s inefficient for students to write down information twice: once on their cards, and then again on their progress notes. I maintain that, at least for me, using the cards was how I learned what to put on a progress note in the first place. My use of cards was reinforced by starting clerkships at the VA, where progress notes are computerized. I would not have been able to carry around blank progress note forms on rounds there, even if I’d wanted to. In hindsight, I’d recommend students use cards, but also carry blank progress notes during pre-rounding, and try to record their pre-round data on a progress note sheet. This will make it easier to get notes finished by noon. Be forewarned that some attendings hate students reading off their cards during rounds. I actually had an attending and resident grab my cardset out of my hands and command me to present without my notes. (Was this incredibly patronizing? Yes, it was. Did it piss me off? Yes, it did. However, I was able to present perfectly well without the cards. For more commentary on such incidents, and how to handle them, see "The Horrible Truth About the Wards," below.) To the best of your ability, you should try to present without looking at your progress note or "daily note" card, but I think it’s okay to refer to your card when reporting the exact vitals, or exact lab values. By the way: LABEL YOUR CARD SET. Use a key chain with a tag on it, don’t just put your name on one of the cards—no one who finds a lost card set is going to tab through the cards looking for the one with your name on it. Until you get used to carrying a card set, you may occasionally misplace them. If you put a nametag on them with your pager number, a kind-hearted nurse or tech who finds them can call you, and get them back to you. Otherwise, you may take a long time to find them, or never find them and have to rebuild them from scratch. Quite a pain. I misplaced my cards three times during third year, and the second two times I was called within the hour by someone who happened to find them. Useful References I’m not going to go into an exhaustive account of all the books I used on the wards. Just a few tips: The Yale Wards Handbook. Yale School of Medicine has an on-line, student-written handbook for the wards. It has a separate section of tips for each rotation, from surgery to medicine to ob-gyn. I used some of these and they were very helpful. Surgery Recall. Awesome. Saved my butt multiple times. Also written by students, for students. I don’t know about the other books in the "Recall" series, but this one is worth its weight in gold. A problem-based book. Patients do not usually enter your care with the chief complaint, "Doctor, please help me, I have new-onset congestive heart failure." They say, "I feel short of breath lately, especially at night." Rather than resorting to Current Medical Diagnosis and Treatment—which would require that I KNEW what my patient had—I often referred to Problem-Oriented Medical Diagnosis, 4th edition, by H. Harold Friedman (Boston: Little, Brown, 1987). I think it’s out of print, but the Ferri Clinical Advisor 2000 apparently has a problem-oriented section. It’s worth finding and keeping a problem-based text around, especially in third year, where the diagnosis for a patient’s sign or symptom is not obvious. Sapira’s Art and Science of Bedside Diagnosis. By Jane M. Orient (Philadelphia: Lippincott Williams & Wilkins, 2000). If you desire to improve your physical exam skills, GET THIS BOOK. Bates is to Sapira’s as See Spot Run is to The Brothers Karamazov. An endless trove of clinical exam tips and pearls. Go from physical exam "dud" to "stud" in 600 pages. Harrison’s vs. Current Medical Diagnosis and Treatment. Now, I have to confess, I have a sentimental soft spot for Harrison’s, and keep a 1998 edition by my bedside. However, by real-world experience, I have to say CMDT is much easier to use. I recommend it. www.medscape.com. It’s free, and offers regular, up-to-date practice guidelines, articles, quizzes, images in medicine, etc. A good way to kill time, or find helpful reviews. Being Prepared for Specific Medical Cases: the Review File. I recommend, as much as possible, collecting a handful of review articles on common problems likely to be seen during your particular rotation ahead of time, and keeping them in a binder in your locker for quick reference. The Yale Ward Handbook can give you a list of "hot topics" for particular rotations, as can any specialty-specific textbook, e.g. Ob/Gyn Secrets, Handbook of Pediatrics, etc. Why do this? It may help you a lot. Personal testimony: I kept a set of such articles, including one on the management of acute stroke, for medicine. One call day, my intern flagged me and said, "Meet me in the ER in 15 minutes, we’re admitting a patient. I think it’s stroke." Aha! So, I went to my locker, pulled out an excellent review from American Family Physician on stroke management, and read up. When I went down to the ER, I was able to make a couple of solid suggestions for managing the patient—including points that my intern wasn’t even aware of! Which made me look way smart. Obviously, you can’t do this for every problem. But if you pick, say, five things that are likely to come up, you may have a chance to "sneak a peek" at a crucial moment—before heading down to the ER for the admit, before the impromptu teaching session at attending rounds, etc.-- and wind up coming off very well. Even if at breakfast that very morning you wouldn’t have been able to spell the diagnosis, much less explain it. Creating a review file requires comfortable use of Medline. If you’re not comfortable with it, find a friend who is, and get tutored. As a quick hint: You can search specifically for review articles. Use the "publication type" category and select "review." Use the "title word" category and enter a few basic entities you’d want to know about, e.g. stroke, otitis media, PID, etc. And, by the way, I strongly recommend American Family Physician as an excellent source for review articles. Pager Etiquette When you page someone, punch in the call-back number, star, and then your personal pager number. The latter allows the recipient to know who is paging them, and, if they’re delayed in calling you back and miss you, they can page you later even if they don’t recognize who you are. When I was paged the first time on the wards, I was baffled by receiving two numbers: I didn’t know which to call. I tell you above to save you a sense of cluelessness the first time you are paged. Also: "2222" or repeated numbers means your team’s getting dinner - call them! Another tip: I used the Pac Bell PCS wireless service. For $80 for a year, and a free pager, it was a cheap deal. BUT… I had many technical snafus, including receiving many "return pages" from people I had never paged! When I complained to PCS, they offered to replace the pager—which did not fix the problem. So, I don’t recommend them. I don’t think it matters, by the way, whether you have the "719" Airtouch (now Verizon) prefix, or another pager number. Since most residents’ pagers are 719, people refer to their pager numbers by four digits, the 719 being assumed. "Her pager’s 4567" means 719-4567. If you have a 719 pager, you will be able to use this shorthand when giving out your pager number. Caution: SFGH now has an "in-house" pager system; for those, you dial "7777" THEN the four digits. Thus, at SFGH, you must now ask, "Is that in-house, or 719?" Palm Pilots and the Like Over 20% of all M.D.’s use handheld computers[15], and a sizeable minority of med students use Palm Pilots, Visors, or the like on the wards. I am not one of them, so I can’t offer any advice. I am considering getting one, but I have some trepidation: I used a Sharp Wizard before med school, and it up and died on me one day for no good reason, losing years of data. I suppose the advantage to Palm Pilots is that they’re backed up on a home computer, so this can’t happen. Still, Pilots can go on the blink and throw your day into chaos. They can also be misplaced. Or simply stolen. Replacing a set of lost paper cards is much cheaper. [15] Chasin MS. "How a palm-top computer can help you at the point of care." Family Practice Management, June 2001, p. 50. [Back]